Optima Credentialing PDF Details

Optima Credentialing Form is a browser-based application that enables healthcare professionals to easily submit credentialing and privileging information. The intuitive, easy-to-use interface expedites the process, making it simple to track the status of each submission. With Optima Credentialing Form, you can be confident your application is complete and accurate. Plus, our team is available to support you every step of the way.

You can find information about the type of form you intend to complete in the table. It can tell you the length of time you will require to finish optima credentialing, exactly what parts you need to fill in, and so forth.

Form NameOptima Credentialing
Form Length5 pages
Fillable fields69
Avg. time to fill out15 min 7 sec
Other namesprovider credentialing 101, caqh credentialing form pdf, carebridge eap credentialing aplication, optima packet

Form Preview Example

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


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.



(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?



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: ________________________________________



Provider Name: ________________________________________________

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



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 _______



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.

How to Edit Optima Credentialing Online for Free

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Step 1: Click the orange button "Get Form Here" on the page.

Step 2: You're now free to edit carebridge eap credentialing aplication. You possess plenty of options with our multifunctional toolbar - you can include, remove, or change the content material, highlight the selected components, and undertake many other commands.

For each segment, add the details required by the software.

optima credentialing blanks to complete

Include the necessary details in the Provider, Name, CA, QH, Number Individual, NP, I Provider, Type, Provider, Specialty and Yes segment.

stage 2 to filling out optima credentialing

Point out the most significant data the Practice, Name TaxI, d, Group, NP, I Practice, Address Phone, Fax Practice, Email Office, Credential, ing, Contact Credential, ing, Contact, Phone and Credential, ing, Contact, Email box.

Finishing optima credentialing step 3

Inside of paragraph NPs, PAs, CN, Ms state the rights and obligations.

step 4 to completing optima credentialing

End by looking at these fields and filling out the required information: ECF, MG, number, noted, inCA, QH, if, applicable Work, history, for, past, years, noted, inCA, QH phone, number, noted, on, CA, QH, Application and Foreign, languages, spoken, noted, inCA, QH

step 5 to filling out optima credentialing

Step 3: Once you have selected the Done button, your file is going to be available for upload to every electronic device or email address you identify.

Step 4: Be sure to keep away from possible difficulties by creating at least a couple of duplicates of the file.

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