Dual Special Needs Plan (DSNP) and Managed Long Term Care (MLTC) Combined Credentialing Application

For Certified Home Health Agency (CHHA), Durable Medical Equipment (DME), Prosthetic and Orthotics, Skilled Nursing Facility (SNF), and Licensed Professional Services (Audiology; Podiatry; Outpatient Occupational, Physical and Speech Therapy)

Complete the Combined Credentialing Application using the online form below, or download and complete the Combined Credentialing Application PDF.

Completed applications may be submitted by:

Questions: Call (315) 477-9280

Dual Special Needs Plan & Managed Long Term Care Combined Credentialing Application
  • Requirements
  • General Information
  • Accessibility and Service Lines
  • Licensure
  • Practitioner Roster
  • Attestation and Certification
    • Review Application
    Please include the following documentation with your DSNP and MLTC Credentialing Application. Submission of all applicable items is required for the application to be considered complete.

    Requirements to Participate

    • Business Associate Agreement (required for DME providers)
    • Current signed and dated Services Agreement
    • Current Medicaid ID (Pending Medicaid is not acceptable)
      • Medicaid Approval Letter including Medicaid Number (TPI) and effective date (if applicable)
    • Current Medicare Number (Pending Medicare is not acceptable; not required for Supplemental benefit provider)
    • Current State Operating License/Business License/Certificate of Need for applicable locations
    • Current Accreditation Letter and/or Certificate (JCAHO, NCQA, URAC, DNV, or CHAP – if applicable)
      • *If not accredited, the most recent NYS Department of Health (NYSDOH) State Survey and Plan of Correction(CHHA and SNF)
    • Copy of Patient Satisfaction Survey (CHHA)
    • *Incontinence Products Verification (required only for DME providers offering incontinence supplies)
    • *Current General Liability & Professional Liability Insurance with limits of $1M / $3M or State Law Requirement ACORD Form (Certificate Holder: Nascentia Health, 1050 West Genesee Street, Syracuse, NY 13204)
    • Completed IRS Form W-9 including legal name and remit-to address
    • Signed and dated Attestation for each service location
    • *Current Provider Roster including Medicaid ID and CAQH identifiers (required for Licensed/Certified Professionals)

    *Submit updated documentation for any changes, renewals, or new inspections as they occur.

    Maximum file size: 134.22MB

    Provider Compliance Certification

    Provider Compliance Certification is required for Certified Home Health Agencies (CHHA). Provider Compliance Certification may be required for Durable Medical Equipment (DME) providers and Licensed or Certified Professional Service providers, as applicable. Refer to page 8 for more information.

    Note: Applications will not be considered complete until all applicable documentation has been received and reviewed.

    Last Updated on August 11, 2026