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Add Behavioral Health Provider to Group

If adding a large number of providers, you can instead utilize use the Behavioral Health Roster Template. Please email the completed roster to CONTRACTING@coordinatedcarehealth.com.


Practitioner Name

Is this a whole new location to the group (not just new to the practitioner)?

If 'Yes' to New Location selection above: Proceed in enrolling practitioners here and then navigate back to go through the Add an Additional Location form.

Used only for when members want to have a specific ethnicity of doctor.
HCA requires that providers who contract with Managed Care Organizations register in the state’s ProviderOne (Washington state’s Medicaid Information System). Practitioners either need a Core Provider Agreement or register as a non-billing provider.
Example: CRNP or RN
DEA certificate #s that indicate a Certified Substance Abuse Medication Prescriber would have a number showing as an “X” factor and/or Business Activity on the DEA certificate: DW 30, DW 100 or DW 275. EXAMPLE: XW8788549
Multiple languages should be separated with a comma and are intended to reflect the individual practitioner rather than office or clinic staff language ability The response must provide enough information for an enrollee looking for a provider to know whether he or she speaks the enrollee’s language or how to access interpreter services.

Specialties

Specialties should be determined by, and consistent with Taxonomy and/or the disciplines (Family Medicine, Geriatrics, OB, Surgery) in which you are actively practicing.
Assign appropriate Taxonomy based on practitioner type. Do not assign a location/clinic/center Taxonomy to an individual practitioner.
Indicate the board status of the practitioner as it relates to their secondary specialty/taxonomy.
The organization that provided board certification for the practitioner in this specialty.
Specialties should be determined by, and consistent with Taxonomy and/or the disciplines (Family Medicine, Geriatrics, OB, Surgery) in which you are actively practicing.
Indicate the board status of the practitioner as it relates to their secondary specialty/taxonomy.
The organization that provided board certification for the practitioner in this specialty.

Locations

This should be the name registered/affiliated with the Group NPI as reflected on the facility application or other contracts/licensure documents.
Appears on the provider directory. This is the main, general office phone number for the location that members and other practitioners will call. Please provide only one phone number for each location. Including multiple phone numbers in the directory will likely search for on the provider directory for this address.
Default is Yes unless contractual or extenuating circumstances apply.
Any Per Diem, Float, Hospitalist or Inpatient only provider would NOT carry a panel (be available for ongoing outpatient vs episodic or inpatient only) care.

Secondary Location

Tertiary Location

If you are adding more than three locations, please use the Behavioral Health Roster Template and email to CONTRACTING@coordinatedcarehealth.com

Examples: Female Only, Male Only, None, Pregnant Women Only

Age Restrictions *

Practitioner Panel Status *
Indicate whether practitioner provides services to members/patients via telemedicine. Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store
For More details - please reference the Washington Administrative Code: WAC 182-531-1730 and HCA guidance: Telehealth includes arrangements to extend provider networks past their geographic bounds (for example, by connecting rural and urban providers together to deliver dermatology or behavioral health services). Technologies such as Store and Forward; Ehealth includes electronic modes of communication that help extend the reach of network providers through electronic chat, triage, and so on. On line Client Portals, Instant messaging, virtual clinics; Telemedicine, or more broadly telehealth technologies, allows healthcare services to be delivered when the provider and patient are in different places, in real time. Technologies such as Skype and Face Time (video conferencing services).

Hospital Affiliations



Practitioner Primary Hospital Privilege Type
If yes, please complete Hospital Information on attached enrollment form.


Cultural Competency Training Completed?
Cultural competency, or the ability of health care providers to work effectively with colleagues and patients in cross-cultural situations, is a vital component of professional competence.

A brief description of skills or experiences that would support the cultural or linguistic needs of its Enrollees (e.g., “served in Peace Corps,Tanzania; speaks fluent Swahili.”)

For the next five categories, please select all that apply. 

Types of Services*
Certifications*
Settings/Populations Treated*
Treatment Modalities/Approaches*
Disorders/Issues*

Final Comments and Contact Information