Optima Credentialing – Fill Out and Use

Optima Health Credentialing Packet

Thank you for your interest in becoming a participating provider in the Optima Health Network. Please review the following instructions to ensure acceptance of your application for processing:

1.Please inform Optima Health directly of the Provider’s intent to participate in the Optima Health Network by contacting your assigned Network Educator at 877-865-9075.

2.Visit www.CAQH.org to complete an application. Optima Health uses the online Council for Affordable Quality Healthcare (CAQH) application exclusively for all Providers. Please contact the CAQH Provider Help Desk (1-888-599-1771 or caqh.updhelp@acsgs.com) for assistance with the CAQH application.

3.Once your CAQH application is complete, with all supporting documentation attached, please complete and submit this packet, which includes the following:

•Optima Health Provider Information form

•Optima Health Application Checklist – please review and complete to confirm your CAQH application contains all required information. (Optima Health Credentialing will not accept or process an incomplete application. Omission of any information or supporting documentation will result in your application being returned to your office for correction.)

•Optima Health Authorization and Release

PLEASE EMAIL PACKET TO:

Hampton Roads, Eastern Shore, NC: Linda Winebrenner - LKWINEBR@SENTARA.COM

All other areas: Ebonie Grady - ELGRADY@SENTARA.COM

Complete applications are forwarded to the Optima Health Credentialing Department for review, verification, and presentation to the Medical Director and Credentialing Committee for final determination. The credentialing process typically takes between 60-90 days upon receipt of a complete and correct application.

Upon approval by the Optima Health Credentialing Committee, Providers will be notified by their assigned Network Educator of their Optima Health participation effective date. Providers should not begin scheduling or treating Optima Health members on an in-network basis until they are notified of their Optima Health effective date.

If you have any questions about the Optima Health credentialing process, please contact Provider Services at 800-648-8420. We look forward to working with you.

OPTIMA HEALTH CREDENTIALING

PROVIDER INFORMATION FORM

(All fields are required.)

Provider Name: ___________________________________ CAQH Number _____________________

Individual NPI: ______________________________

Provider Type: ___________	Provider Specialty:___________________________________________
If Family Practice, Geriatrics, Internal Medicine, or Pediatrics, will provider be a PCP with
members attached?	Yes	No

If yes, please select panel status listed below:

0Provider is open and accepting members

1Not accepting new patients; will continue providing services for existing patients, siblings, and spouses

switching plans with verification from physician’s office

3Not accepting new patients; accepting newborns and siblings.

4 Age restriction: Provide ages: _____________

5 Non MD: Membership should be paneled to valid MD in practice 7 Covering physician only

Practice Name _______________________________________________________________________

Tax Id # _____________________________ Group NPI # ___________________________________

Vendor Number(s) to be Attached to Provider (if known) : ____________________________________

Practice Address

Phone________________________ Fax_____________________

Practice Email _______________________________________

Office Credentialing Contact: ________________________________________

Credentialing Contact Phone: ________________________________________

Credentialing Contact Email: ________________________________________

OPTIMA HEALTH CREDENTIALING

APPLICATION CHECKLIST

Provider Name: ________________________________________________

Please initial to confirm each of these items has been completed:

Provider		Optima
Office Use
______		_____ All questions answered on CAQH application
______		_____ Optima Authorization & Release Form with signature date no more than 6
		months old at the time Optima receives all required documents
		_____Seven years of malpractice insurance history in CAQH application (Two years for
		NPs, PAs, CNMs)*
______		_____ Explanation for gaps in malpractice insurance noted in CAQH*
______		_____ Copy of current malpractice insurance face sheet showing
		$2,200,000 per incident/$4,400,000 per aggregate for Virginia or
		$1 million/$3 million minimum for other states.
______		_____ Explanation for any malpractice suits noted in CAQH
______		_____ Education history, including applicable internship/residency/fellowships noted in CAQH
______		_____ All past and current state licenses and DEA information noted in CAQH
______		_____ ECFMG number noted in CAQH (if applicable)
______		_____ Board Certification information or date when taking boards noted in CAQH
______		_____ Hospital Privileges listed in CAQH (if applicable)
______		_____ Covering colleagues or partners/associates noted in CAQH
______		_____ Work history for past 10 years noted in CAQH
______		_____ Explanation of work history gaps > 6 months noted in CAQH*
______		_____ Professional references from 2 providers with contact
		phone number noted on CAQH Application*
______		_____ Copy of Curriculum Vitae or Resume in month and year format attached to CAQH
______		_____ Foreign languages spoken noted in CAQH
______		_____ Completed W-9 form (for newly contracted practices only)
______		_____ National Provider Identification Number

Provider Office Representative (Print Name) _____________________________ Date _______

OPTIMA HEALTH USE ONLY:
CA/Reviewed by _______________________________	Date _______
_____ Medicare Opt Out List	Date _______
Credentialing Department _______________________	Date _______

Comments ____________________________________________________________________

* Information not included on North Carolina CAQH application and must be supplied separately.