To be reimbursed for services rendered to Medicaid managed care members, providers must be enrolled in Texas Medicaid, complete the initial credentialing process, and have a duly executed contract with PCHP.
PCHP’s credentialing process is consistent with guidelines set forth by the National Committee for Quality Assurance (NCQA), Texas Department of Insurance (TDI), Texas Health and Human Services Commission (HHSC), and health plan requirements. To participate in the Medicaid (STAR) and CHIP networks, PCHP requires full credentialing of office-based health care professionals, including but not limited to:
- Doctor of Chiropractic (DC)
- Doctor of Dental Surgery (DDS)
- Doctor of Dental Medicine (DMD)
- Doctor of Osteopathy (DO)
- Doctor of Podiatry (DPM)
- Medical Doctor (MD)
- Audiologist (AD)
- Nurse Midwife (CNM)
- Nurse Practitioner (NP, APN, ARNP, CNS)
- Optometrist (OD)
- Occupational Therapy (OT)
- Physical Therapy (PT)
- Physician Assistant (PA)
- Speech & Language Pathology (SLP)
To see PCHP members for behavioral health issues starting Sept. 1, 2025, providers must be credentialed and contracted directly through PCHP.
Practitioners must submit all requested information necessary to complete the initial credentialing or recredentialing process. Each practitioner must cooperate with PCHP as necessary to conduct initial credentialing and recredentialing in accordance with PCHP’s policies and procedures.
PCHP utilizes Verisys, a Credentialing Verification Organization (CVO), for all initial credentialing and recredentialing requests. Verisys will collect all initial credentialing or recredentialing applications, forms, licenses, and other relevant documents needed to validate a practitioner’s credentials. The process of validation is called primary source verification (PSV). Verisys will notify PCHP upon completion of the PSV process. A final determination will be made by PCHP whether to approve or deny the practitioner’s participation. A written notification of the final decision will be sent by PCHP to the practitioner.
During the initial credentialing or recredentialing process, PCHP affords practitioners the following rights:
- Review information submitted in support of the initial credentialing/recredentialing application
- Correct any erroneous information
- Receive status of initial credentialing/recredentialing application.
PCHP ensures that information gathered during the primary source verification stage is duly reviewed and validated. Practitioners are notified of any discrepancies noted between the credentialing information provided by the practitioner and those obtained from other sources. Practitioners must respond to information requests in writing and address all identified discrepancies. PCHP staff will make up to three attempts to notify practitioners of discrepancies, after which the practitioner will be either denied or terminated.
Upon successful completion of the initial credentialing process, the practitioner will be effective in the claims system no later than 90 calendar days following the receipt of a completed initial credentialing application.
In accordance with Texas Insurance Code Chapter 1452, Subchapters C, D, and E, PCHP allows certain practitioner types to request an expedited credentialing process. Practitioners eligible for expedited credentialing include physicians, podiatrists, and therapeutic optometrists. Additionally, as required by Texas Government Code § 533.0064, PCHP allows applicant practitioners to provide services to members on a provisional basis for the following provider types: Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, and Psychologists. To qualify for expedited credentialing the practitioners must:
- Be a member of an established health care provider group that has a current contract in place with PCHP
- Be Medicaid enrolled
- Agree to comply with the terms of the contract between PCHP and the health care provider group
- Timely submit all documentation and information required by PCHP as necessary for PCHP to begin the credentialing process
If the practitioner qualifies for expedited credentialing, PCHP will consider the practitioner as a network provider upon submission of a complete application. The claims system will process claims from the practitioner no later than 30 days after receipt of a complete application
At least once every 36 months, PCHP will review the credentials of all licensed practitioners that are participating in PCHP provider network. In addition to credentialing standards, the process will also evaluate provider performance data including member complaints and appeals, quality of care, and utilization management data.