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Joining the Network

Cook Children's Health Plan's credentialing process is designed to meet National Committee for Quality Assurance (NCQA) and state requirements for the evaluation of Providers who apply for participation.

Network Development Can Help You With:

  • Credentialing
  • Provider contracts
  • Name change
  • Address change
  • NPI update
  • TPI number

To Start the Credentialing Process, You Must:

TMHP Enrollment and Demographic Information Update

To Providers: Please update your enrollment and demographic information with TMHP (Texas Medicaid & Healthcare Partnership).  TMHP is HHSC’s provider enrollment administrator and serves as the authoritative source for HHSC Providers’ enrollment and demographic information.  Once you update your enrollment and demographic information with TMHP, your data will be reconciled with the demographic information on file with the MCOs. The TMHP Provider Enrollment information may be located by visiting the web page titled “Provider Enrollment”.

To make updates to your current enrollment (e.g., new practice locations or change of ownership updates), please access the web page titled “Provider Enrollment and Management System (PEMS)” which also includes a step-by-step guide.

Additional Provider enrollment help can be found by visiting the web page titled “Provider Enrollment Help”. Otherwise, you can contact TMHP directly at 800-925-9126 for assistance.

Once You Have Submitted the LOI, Cook Children's Health Plan will:

  • Once reviewed and approved, Network Development will submit your information to the credentialing verification office (CVO), Verisys.
  • Verisys will contact the Provider to initiate the credentialing process, accept the credentialing application, and conduct primary source verification (PSV).
  • Facility and Ancillary Providers will use Availity to complete the credentialing application.
  • Upon receipt of a completed application and any requested documentation, the credentialing process will be completed within ninety (90) days.
  • Providers will sign and return all contract documents, including a Form W-9 (Rev.03-2024); older versions will not be accepted.
  • Upon complete credentialing and full execution of contract documents, the Network Development Department will send a welcome letter with the effective date of participation, along with the fully executed contract.

Re-Credentialing Process

  • For existing Providers the re-credentialing process will occur every three (3) years or as determined by Verisys through the Texas Credentialing Alliance (TCA).   Re-credentialing must be completed to continue participation in the Cook Children's Health Plan network.

Expedited Credentialing for Physicians in a Medical Group

  • If an applicant physician meets the qualifications for expedited credentialing, the physician will be treated as a participating Provider for Cook Children's Health Plan for payment purposes under the terms of the medical group's current participating Provider contract.
  • Be enrolled with Texas Medicaid and have a valid Texas Provider Identifier (TPI) attested to the participating group.
  • Submit all documentation and other information required by the health plan to begin the credentialing process within thirty (30) days.
  • Agree to comply with the terms of Cook Children's Health Plan's current participating Provider contract with the established medical group. If deemed eligible, the physician will be authorized to collect copayments from Cook Children's Health Plan enrollees and will be paid in accordance with the terms of the medical group's current participating Provider contract.

An applicant physician will not be included in the Cook Children's Health Plan Provider Directory or any list of participating Providers, and will not be eligible for selection as a Primary Care Provider by enrollees, unless and until the physician is credentialed as a participating Provider.

 

In addition to verifying credentials, the Health Plan will consider Provider performance data, including Member complaints and appeals, quality of care, and utilization management.

Phone: 1-888-243-3312
Fax: 1-682-885-8403