Paper Credentialing
If you are not registered with the Council for Affordable Quality Healthcare (CAQH)* and would prefer to join the Keystone First CHC provider network via our paper process, complete and return the documents linked below. If you have any questions, please call 1-800-642-3510, option 1.
*CAQH credentialing does not apply to HCBS and LTSS providers. HCBS and LTSS providers should complete our paper application process.
Forms
HCBS and LTSS providers
HCBS and LTSS provider requests for a contract can be sent to CHCProviders@keystonefirstchc.com. Please include a copy of your W-9, counties that you cover, and services that you provide. A completed contract is required in order to start the credentialing process.
- Application for home- and community-based services and LTSS providers (PDF)
- HCBS/LTSS provider application checklist (PDF)
Physical health practitioners
- Credentialing application (Pennsylvania Standard Application) (PDF)
- Application checklist for practitioners (PDF)
Fax all applicable items on the application checklist, including IRS Form W-9 (PDF), to 1-877-759-6221. Or, you may scan your signed documents and submit them by secure email to credapps@keystonefirstpa.com. Please be sure to scan the application checklist and fax or email it along with the documents.
Organizational providers
- Organizational provider credentialing application (PDF)
- Application checklist for organizational providers (PDF)
Completing and/or submitting the Keystone First CHC credentialing application does not guarantee participation in the Keystone First CHC provider network.
Note: If you are joining an existing Keystone First CHC participating group or health care facility and you would like to become a participating provider, please use the credentialing application (Pennsylvania Standard Application) (PDF).