Managed Care Primary Medical Provider Panel Limit Or Panel Hold Update Form printable pdf download

Managed Care Primary Medical Provider Panel Limit Or Panel Hold Update Form

Managed Care

Managed Care Primary Medical Provider Panel Limit or Panel Hold Update Form

Advantage

Anthem

MDwise

Managed Health Services (MHS)

Date Submitted:

Please select applicable Program

Mail to: EDS Provider Enrollment

Managed Care

For questions,

Risk Based Managed Care(RBMC)

P.O. Box 7263

call (877) 707-5750

Care Select

Indianapolis, IN 46207-7263

Instructions

Complete every field on this form and submit the provider’s panel update request. Submit the completed form and required

documentation to EDS. Incomplete forms and documentation may be returned and may delay the PMP’s panel size update.

Information

1. MCE Contact Name:

2. MCE Contact Phone Number:

3. MCE Contact E-mail:

4. Provider Name:

5. MCE Fax Number:

6. IHCP Provider Number:

7. Provider NPI Number:

8. Group Number:

9. Group NPI Number:

10. Provider Specialty: (Other is utilized for Care Select only)

Family Practitioner

Pediatrician

OB/GYN

General Practice

Internist

Other_______________________________

11. Practice Type:

12. Current Panel Limit:

13. Current Actual Panel Size:

14. Requested Panel Limit:

Solo

Group

15. Panel Hold Status (Hold/Open):

16. Number of Service Locations:

17. County of Service Locations:

18. Justification of Variance:

Panel Change Request

19. Panel Limit Decrease:

19a. Place Panel Limit at:

Yes

20. Panel Limit Increase:

20a. Place Panel Limit at:

Yes

21. Panel Hold:

21a. Effective Date:

Yes

22. Panel Hold Remove:

22a. Effective Date:

Yes

21. Comments:

For Completion by EDS Staff Only

Date Received:

Date Processed:

Date Quality Checked:

Care Select Primary Medical Provider Panel Limit or Panel Hold Form

Version 2.0, April 2007

Managed Care Primary Medical Provider Panel Limit Or Panel Hold Update Form

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