Become a Participating Provider

All providers must maintain a physical practice location within the Health Plan’s geographic service area to be considered for in network participation. In addition, all practice locations are expected to be accessible to our members and may be subject to an office site visit conducted by the Health Plan. Providers offering telehealth services only will not be credentialed or contracted with the Health Plan.

Providers requesting enrollment due to the COVID-19 Pandemic will not be credentialed with the plan. Upon the expiration of the applicable Executive Orders (EO), on which your temporary participation was approved, you will be required to meet all our network requirements, including our contracting, credentialing and enrollment criteria, for continued participation in our network.

Application for Practitioner Enrollment (Credentialed and Non Credentialed)

See credentialing requirements for all specialties

To enroll a new practitioner with the Health Plan, complete the Application for Practitioner Enrollment Open a PDF for the following practitioner types.

To add an additional Tax ID number, complete the Practitioner Demographic Changes form.

Acupuncturist [LAC]
Anesthesiologist
Audiologist [AuD]
Certified Diabetic Educator (affiliated with Physician Group or Hospital)
Certified Diabetic Educator [CDE] (Independent)
Certified Nurse Midwife – Home Birth [CNM]
Certified Nurse Midwife [CNM]
Certified Registered Nurse Anesthetists [CRNA]
Clinical Psychologist [PhD; PsyD]
Doctor of Chiropractic [DC]
Doctor of Optometry [OD]
Doctor of Podiatry [DPM]
Doula
Emergency Medicine
Enterostomal Therapy
Genetic Counselor
Hospitalist
Licensed Behavioral Analyst [ABA]
Licensed Clinical Social Worker [LCSW]
Licensed Marriage & Family Therapist [LMFT]
Licensed Mental Health Counselor [LMHC]
Locum Tenens
MD/DO - Psychiatry only (all other MD/DO specialties, see below)
Medical Doctor [MD/MBBS/BMED]
Nurse Practitioner, Primary Care [NP]
Nurse Practitioner, Psychiatry [PMHNP]
Occupational Therapist [OT]
Oral Maxillofacial Surgery [DMD]
Osteopathic Doctor [DO]
Pathologist
Physical Therapist [PT]
Radiologist including Tele-Radiologist
Registered Dietician (affiliated with Physician Group or Hospital)
Registered Dietician [RD] (Independent)
Speech Pathologist [SLP]

Application for Non-Physician Health Care Practitioner

See credentialing requirements for all specialties

For the following practitioner types, complete the Application for Non-Physician Health Care Practitioner Open a PDF to:

Enroll a new Non-Physician Health Care Practitioner with the Health Plan under the supervision of physician
Update the demographic information (Tax ID, address, etc.) for a currently enrolled non-physician health care practitioner
Update collaborating/supervising physician for a currently enrolled non-physician health care practitioner

Non-Physician Health Care Practitioners