T
5608 Malvey Ave, Suite 200
Fort Worth, TX 76107
Ph: (817)484-6274 Fax: (817)420-9661
Provider Name: ________________________________________________________________________
Provider NPI: ____________________________________CAQH #:______________________________
Group Association: _______________________________________TIN:__________________________
Please select Opt-in or Opt-out on all options listed below and return with your application.
|Managed Care Organization Selections |
❖ Aetna Commercial Plans
Including but not limited to Managed Choice POS, Elect, HMO, Open Choice PPO, & Meritain All or nothing
(Must sign & return enclosed Individual Provider Addendum)
← Opt In
← Opt Out
❖ Aetna THR Joint Venture EPO (Narrow Performance Network)
Requires specific hospital privileges or return covering letter for NP/PA.
← Opt In
← Opt Out
❖ Blue Cross and Blue Shield of Texas
Must have BCBS Record ID number to participate.
Provider BCBS Record ID # ______________
← Opt In – Blue Choice PPO (Includes POS and EPO)
← Opt In – Blue Essentials HMO (Includes Health Select)
← Opt In – Blue Advantage HMO (Exchange product)
← Opt Out
❖ Choice Care PPO Humana
← Opt In
← Opt Out
❖ Cigna Healthcare of Texas, Inc
HMO\OAS\Network, PPO, & Open Access Plus All or Nothing plan
(Provider must sign & return attached CIGNA Election to Participate addendum.)
← Opt In
← Opt In – Local Plus – (Narrow network @ discretion of Cigna for enrollment)
← Opt Out
❖ Coventry/First Health – PPO
← Opt In
← Opt Out
❖ EVRY – PPO
← Opt In
← Opt Out
❖ Family Healthcare (fka Texas Bluebonnet Health Plan)
← Opt In – PPO
← Opt In – HMO
← Opt In – EPO
← Opt Out
❖ Galaxy Health Network
All or nothing – Includes: PPO, Medical Savings Card, Medicare Supplement
← Opt In
← Opt Out
❖ Healthcare Highways Healthplan PPO
← Opt In
← Opt Out
❖ Healthscope Benefits, Inc - DART- (All Commercial)
← Opt In
← Opt Out
❖ Healthsmart Preferred Care
← Opt In – ACCEL
← Opt In – GEPO
← Opt In – HPO (Health Payors)
← Opt In – PPO
← Opt Out
❖ Imagine Health – PPO
(Requires privileges at a Baylor facility)
← Opt In
← Opt Out
❖ Independent Medical Systems (IMS) – PPO
← Opt In
← Opt Out
❖ Molina Healthcare – Exchange Network
← Opt In
← Opt Out
❖ Multiplan Network
← Opt In – PPO
← Opt Out
❖ National Preferred Provider Network (NPPN) – PPO
← Opt In
← Opt Out
❖ Nexcaliber PPO
← Opt In
← Opt Out
❖ Oscar EPO
← Opt In
← Opt Out
❖ Prime Health Services, Inc.
← Opt In – Group Health
← Opt Out
❖ Private Healthcare Systems, Inc. (PHCS)
← Opt In – PPO
← Opt Out
❖ Provider Select, Inc. – PPO
← Opt In
← Opt Out
❖ Scott & White Health Plan
Must have privileges at a BSW facility OR Complete & Return the attached BSW admitting letter stating what BSW facility you will send patients to before approval. Includes - HMO, PPO, POS & ASO
← Opt In
← Opt Out
❖ Superior Ambetter Exchange
← Opt In
← Opt Out
❖ Three Rivers Provider Network – PPO
← Opt In
← Opt Out
❖ Tricare (Humana Military)
(Complete & return the enclosed Opt In/Out form.)
← Opt In
← Opt Out
❖ United Healthcare Commercial
(All commercial products, including but not limited to, UMR & GEHA)
← Opt In
← Opt Out
❖ USA Managed Care Organization
← Opt In – PPO
← Opt In – LoneStar Athletic Injury Network PPO
← Opt Out
|Worker’s Compensation Products |
← I ACCEPT WORKERS COMPENSATION PATIENTS
← I WISH TO OPT OUT OF ALL WORKERS COMPENSATION PLANS
❖ CareWorks fka Rockport Healthcare Group
(DOES NOT Accept PA\NP)
← Opt In – Worker’s Compensation
← Opt In – NWI (Non-Subscriber Work Injury)
← Opt Out
❖ Corvel Healthcare
Includes Worker’s Comp, Auto, and NWI All or nothing
← Opt In
← Opt Out
❖ Coventry/First Health
← Opt In – Auto
← Opt In – Worker’s Compensation
← Opt Out
❖ Galaxy Health Network – Non-Subscriber Work Injury
← Opt In
← Opt Out
❖ Healthsmart Preferred Care – Worker’s Compensation
← Opt In
← Opt Out
❖ Prime Health Services, Inc.
← Opt In – Auto
← Opt In – IME
← Opt In – Worker’s Compensation
← Opt Out
❖ The Reny Company – Non-Subscriber Work Injury
← Opt In
← Opt Out
❖ Texas Healthcare Foundation – Non-Subscriber Work Injury
← Opt In
← Opt Out
❖ Three Rivers Provider Network – Worker’s Compensation
← Opt In
← Opt Out
❖ USA Managed Care Organization – Worker’s Compensation
← Opt In
← Opt Out
|MEDICARE ADVANTAGE PRODUCTS |
MUST submit a Medicare/PTAN enrollment letter to TIOPA before being submitted to any Medicare plan. Providers must apply for and maintain PTAN initial enrollments and revalidations. Unless you opt to have TIOPA obtain and maintain the PTAN for you at an additional fee.
Provider PTAN(s) associated with group __________________________________________
← I WISH TO OPT OUT OF ALL MEDICARE PLANS
❖ Aetna – Medicare Advantage HMO and PPO
(Must sign and return enclosed Individual Provider Addendum.)
← Opt In
← Opt Out
❖ Amerigroup Medicare Advantage
← Opt In – HMO
← Opt In – SNP (Special Needs Plan – Medicare Advantage)
← Opt Out
❖ Blue Cross Medicare Advantage PPO
(Must have/keep CAQH updated before enrollment approval)
Provider BCBS Record ID # ______________
← Opt In
← Opt Out
❖ Care N Care Medicare Advantage – HMO and PPO
← Opt In
← Opt Out
❖ Choice Care Network by Humana – Medicare Advantage
← Opt In – Medicare Advantage PPO
← Opt In – Medicare Advantage HMO (For Specialists only)
← Opt In – Medicare Advantage PFFS
← Opt Out
❖ Family Healthcare (fka Texas Bluebonnet Health Plan)
← Opt In – Medicare Advantage
← Opt Out
❖ Global Health HMO Medicare Advantage
← Opt In
← Opt Out
❖ Healthcare Highways – Mutual of Omaha Medicare Advantage
Complete & Return Joinder Agreement
← Opt In
← Opt Out
❖ Healthspring - Medicare Advantage
Open to Existing Groups ONLY
Please note: The PPO product is not available in Rockwall, Ellis, Wise, Parker, Hood or Johnson counties.
← Opt In – Medicare Advantage PPO
← Opt In – Medicare Advantage HMO
← Opt Out
❖ Imperial Insurance Company of TX- Medicare Advantage
← Opt In
← Opt Out
❖ Molina – Medicare Advantage
← Opt In – SNP (Special Needs Plan – Medicare Advantage)
← Opt Out
❖ Scott & White Medicare Advantage HMO
Must have privileges at a BSW facility OR Complete & Return the attached BSW admitting letter stating what BSW facility you will send patients to before approval.
← Opt In
← Opt Out
❖ Superior Health Plan – Medicare Advantage HMO
← Opt In
← Opt Out
❖ TexanPlus (fka Universal American)
← Opt In – TexanPlus Medicare Advantage HMO
← Opt Out
❖ United Healthcare Medicare Advantage
(All Medicare lines, including but not limited to, - Secure Horizons, Care Improvement Plus)
← Opt In
← Opt Out
❖ Wellcare – Medicare Advantage HMO
← Opt In
← Opt Out
|Medicaid AND cHIP PRODUCTS |
MUST submit a Medicaid/TPI enrollment letter to TIOPA before being submitted to any Medicaid plan. Providers must apply for and maintain TPI initial enrollments and revalidations. Unless you opt in to have TIOPA obtain and maintain your TPI for you at an additional cost.
Provider TPI(s) associated with group _____________________________________
← I WISH TO OPT OUT OF ALL MEDICAID & CHIP PLANS
❖ Aetna Medicaid
Must sign & return enclosed Individual Provider Addendum
← Opt In – CHIP
← Opt In – Star
← Opt In – Star Kids
← Opt Out
❖ Amerigroup Texas, Inc.
← Opt In – CHIP
← Opt In – Star
← Opt In – Star Plus
← Opt In – Star Kids
← Opt In – Star Plus + MMP (Medicare/Medicaid Dual)
← Opt Out
❖ Blue Cross & Blue Shield of Texas Medicaid
← Opt In – CHIP
← Opt In – Star
← Opt In – Star Plus
← Opt In – Star Kids
← Opt Out
❖ Children’s Medical Center Health Plan
← Opt In – Star Kids
← Opt Out
❖ Cook Children’s Health Plan
Open to Existing Groups ONLY
(Must have/keep CAQH updated before enrollment approval)
← Opt In – CHIP
← Opt In – Star
← Opt In – Star Kids
← Opt Out
❖ Healthspring Star Plus
← Opt In
← Opt Out
❖ Molina Healthcare
← Opt In – CHIP
← Opt In – Star
← Opt In – Star Plus
← Opt In – Star Kids (Dallas County)
← Opt In – Star Plus + MMP (Medicare/Medicaid Dual)
← Opt Out
❖ Superior Health Plan
← Opt In – CHIP
← Opt In – Foster Care
← Opt In – Star HMO
← Opt In – Star Plus
← Opt In – Star Kids
← Opt In – Star Plus + MMP (Medicare/Medicaid Dual)
← Opt Out
❖ United Healthcare Medicaid
← Opt In
← Opt Out
Group Name:
_____________________________________
Provider Name:
_____________________________________
Group Admin or Provider Signature:
_____________________________________
Date:
__________________
Updated June 6, 2019
❖ For Internal Use Only
← Physical/Office Address Change
← Billing Address Change
o Updated W-9
← Mailing Address Change
← TIN Change
← Medicare Enrollment Letters
← Medicaid Enrollment Letters
← BCBS Record ID
← Specialty Add or Change
← Board Certification
← Hospital Privileges Added
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