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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 3901-1-58 | Standard credentialing form for physician and non-physician providers.


(A) Purpose

The purpose of this rule is to prescribe the standard credentialing form to be used when credentialing or recredentialing providers. For purposes of this rule, the term "providers" has the same meaning as in division (P) of section 3963.01 of the Revised Code.

(B) Authority

This rule is promulgated pursuant to the authority vested in the superintendent under sections 3901.041, 3901.21, and 3963.08 of the Revised Code.

(C) Form

All credentialing and recredentialing of physicians and non-physician individual providers identified in division (P) of section 3963.01 of the Revised Code is to be performed using the credentialing form available from the council for affordable quality healthcare (CAQH) in electronic or paper format. The CAQH credentialing form is referred to as the department of insurance part A credentialing form. Copies of this form may be obtained electronically from CAQH or from the department of insurance. The department of insurance part B credentialing form is used to credential hearing aid dealers, home health agencies, hospice care providers and all other providers, with the exception of hospitals, that are not individuals. Copies of this form may be obtained from the department of insurance. The credentialing forms prescribed by this rule may be reproduced as needed and may be amended from time to time.

(D) Severability

If any portion of this rule or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the rule or related rules which can be given effect without the invalid portion or application, and to this end the provisions of this rule are severable.

Last updated November 16, 2023 at 8:29 AM

Supplemental Information

Authorized By: 3901.041, 3901.21, 1753.09
Amplifies: 3901.20, 3901.21, 1753.03, 1753.04
Five Year Review Date: 8/31/2028
Prior Effective Dates: 1/14/1999, 1/14/2002, 5/30/2009