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.
Question | Answer |
---|---|
Form Name | Optima Credentialing |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | core credentialing, company that helps with credentiallingfor mental helath providers, how to credential providers, format for credentialising |
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
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
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
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
If you have any questions about the Optima Health credentialing process, please contact Provider Services at
OPTIMA HEALTH CREDENTIALING
PROVIDER INFORMATION FORM
(All fields are required.)
Provider Name: ___________________________________ CAQH Number _____________________
Individual NPI: ______________________________
Provider Type: ___________ |
Provider Specialty:___________________________________________ |
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If Family Practice, Geriatrics, Internal Medicine, or Pediatrics, will provider be a PCP with |
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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 |
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Office Use |
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______ |
_____ All questions answered on CAQH application |
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______ |
_____ Optima Authorization & Release Form with signature date no more than 6 |
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months old at the time Optima receives all required documents |
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_____Seven years of malpractice insurance history in CAQH application (Two years for |
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NPs, PAs, CNMs)* |
______ |
_____ Explanation for gaps in malpractice insurance noted in CAQH* |
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______ |
_____ Copy of current malpractice insurance face sheet showing |
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$2,200,000 per incident/$4,400,000 per aggregate for Virginia or |
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$1 million/$3 million minimum for other states. |
______ |
_____ Explanation for any malpractice suits noted in CAQH |
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______ |
_____ Education history, including applicable internship/residency/fellowships noted in CAQH |
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______ |
_____ All past and current state licenses and DEA information noted in CAQH |
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______ |
_____ ECFMG number noted in CAQH (if applicable) |
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______ |
_____ Board Certification information or date when taking boards noted in CAQH |
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______ |
_____ Hospital Privileges listed in CAQH (if applicable) |
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______ |
_____ Covering colleagues or partners/associates noted in CAQH |
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______ |
_____ Work history for past 10 years noted in CAQH |
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______ |
_____ Explanation of work history gaps > 6 months noted in CAQH* |
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______ |
_____ Professional references from 2 providers with contact |
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phone number noted on CAQH Application* |
______ |
_____ Copy of Curriculum Vitae or Resume in month and year format attached to CAQH |
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______ |
_____ Foreign languages spoken noted in CAQH |
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______ |
_____ Completed |
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______ |
_____ National Provider Identification Number |
Provider Office Representative (Print Name) _____________________________ Date _______
OPTIMA HEALTH USE ONLY: |
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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.