Credentialing
Credentialing and recredentialing
Anyone who provides services covered by Dell Children’s Health Plan may apply to be contracted. However, applying does not always mean you will receive a contract. All requests are reviewed by the Network Oversight Committee to ensure our members can work with quality providers.
If you are interested in becoming a contracted provider, please reach out to our Network team for more information on what services we are contracting for and to assist with your contracting questions. Email the contracting inbox at shpnetworkdevelopment@seton.org or call 512-324-3125, option 5.
Non-contracted Behavioral Health providers requesting network participation for Dell Children’s Health Plan CHIP and STAR, please contact Magellan at 1-800-424-1764.
To be reimbursed for services rendered to Medicaid managed care members, providers must be enrolled in Texas Medicaid. Providers are not considered participating with us until they have enrolled in Texas Medicaid and have been credentialed with a duly executed contract with us.
Providers must submit all requested information necessary to complete the credentialing or recredentialing process. Each provider must cooperate with us as necessary to conduct credentialing and recredentialing pursuant to our policies and procedures.
Dell Children’s Health Plan uses a Credentialing Verification Organization, Verisys (formerly known as Aperture), to conduct the primary source verification on our behalf. You can expect Verisys to reach out by email, mail, and phone. Any requests for missing information must be submitted directly to Verisys.
To check on the status of your credentialing application, please email TXcredentialing@
As an applicant for participation in our network, each provider has the right to review information obtained from other sources during the credentialing process. Upon notification from us of a discrepancy, the provider has the right to explain information obtained from another party that may vary substantially from the information provided in the application and to submit corrections to the facts in dispute. The provider must submit a written explanation or appear before the credentialing committee if deemed necessary.
We will complete the initial credentialing process and our claims system will be able to recognize a newly contracted provider no later than 90 calendar days after receipt of a complete application. If an application does not include required information, we will send the applicant written notice of all missing information no later than five business days after receipt of the application.
At least once every three years, we will review and approve the credentials of all participating licensed and unlicensed providers who participate in the Dell Children’s Health Plan network. The process will take into consideration provider performance data including member complaints and appeals, quality of care and utilization management.
Expedited credentialing
If a provider qualifies for expedited credentialing under Texas Insurance Code 1452, Subchapters C, D, and E, regarding providers joining established medical groups or professional practices already contracted with us, our claims system will be able to process claims from the provider as if the provider was fully contracted, no later than 30 days after receipt of a clean and complete application, even if we have not yet completed the credentialing process.
Dell Children’s Health Plan will provide expedited credentialing for certain provider types and allow services to members on a provisional basis as required by Texas Government Code §533.0064 and our state contract with HHSC. Provider types included are licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists and psychologists. The provider must meet the following criteria:
- Be a member of a provider group already contracted with Dell Children’s Health Plan
- Be Medicaid-enrolled
- Agree to comply with the terms of the existing provider group contract
- Submit all documentation and other information required by us to begin the credentialing process
Credentialing committee
The credentialing committee’s purpose is to credential and recredential all participating physicians according to plan, state and federal accreditation standards. Committee responsibilities include:
- Conduct reviews for all providers who apply for participation in the network
- Review all participating providers for recredentialing purposes, including the review of any quality or utilization data/reports
- Approve or deny providers submitted by a delegated credentialing entity
- Review and update credentialing policies and procedures
- Report physician corrective actions and sanctions imposed based upon recredentialing activity to the Quality Improvement Committee (QIC)
- Approve or deny providers for participation in the network and report decisions to the QIC
- Oversee delegated credentialing relationships
Credentialing decision appeal process
If an adverse initial credentialing or recredentialing decision is made, Dell Children’s Health Plan will notify the provider of unsuccessful credentialing within 10 business days. The notification shall include the reason for the adverse decision, a request for additional information (if applicable), and the right of the provider to request a hearing within thirty (30) business days.
Adding a new provider to existing group contract
Please use the Add a Provider to an Existing Group Contract form to add a provider to an existing contracted group. This is the first step of the credentialing process for providers across all lines of business with Seton Health Plan. Please provide the information below to start the process of credentialing to the PR inbox at shpproviderservices@seton.org.
