Applying to Homestate Health
- Complete all steps with MMAC and receive your acceptance email
- Create an account on Availity (see notes)
- Fill out the HSH Contract Request Form.
- Gather all documents to submit to HSH (see notes)
- Liability Insurance
- MMAC letter
- w9
- Doula Certificate
- Practicioner Data Management (see notes)
- Schedule C for Providers (see notes)
- Disclosure of Ownership
- Monitor your email for any further requests, and a contract.
Notes
- Availity is not required for applying to HSH, but you will use it for submitting claims.
- We recommend preparing your documents first, so as soon as you submit the application you can email everything.
- Download blank disclosure of ownership form here
- Download blank w9 here
- Download Schedule C for Providers here
- Download Practitioner Data Management here
- For the Practitioner Data Management spreadsheet:
- There are 3 pages in the file. Click on “Full Roster”
- Fill out EVERY cell on line 4
- If a cell does not apply to YOU, enter “n/a”
- Make sure all your documents are accurate, and signed/dated properly.
- You will submit documents to Clark Miner. Let us know when you are ready and we will get you his contact information.
- We do have contacts who can help you with questions on claims or making changes to your roster or practice information. Please let us know if you need these.
- See our other guides:
Healthy Blue • Homestate Health • United Healthcare
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