Fillable Add, Change, and Termination Form (CalOptima)

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Add, Change, and Termination Form (CalOptima)

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  • 91 check-boxes
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Add, Change, and Termination Form
CalOptima Addition, Change, Term Form
Revised 4/30/15, 8/23/17, 7/2/18
This form must be completed to report any additions, changes, and/or terminations to a provider’s network affiliates.
A separate form must be completed for each contracted provider terminated or whose status is being changed.
Health Network Name:
Line of Business
(Check all that apply)
Medi-Cal OneCare PACE OneCare Connect
PROVIDER INFORMATION
PROVIDER STATE LICENSE # PROVIDER TIN #
TYPE 1 NPI (National Provider ID #) PROVIDER ID MEDICARE # MEDI-CAL EFFECTIVE DATE
PROVIDER NAME (Last) (First) (Middle Initial)
PRIMARY TAXONOMY SECONDARY TAXONOMY TERTIARY TAXONOMY ORDERING, REFERRING, PRESCRIBING
(ORP)
YES NO
AREA OF FOCUS PRIMARY SPECIALTY SECONDARY SPECIALTY
GROUP NAME PROVIDER TELEHEALTH INDICATORS
Telehealth Only No Telehealth Both Telehealth and In-person
GROUP/TYPE 2 NPI (National Provider
ID #)
GROUP ID GROUP TIN
SERVICE ADDRESS FOR AFFILIATION (See Page 2 for address changes and
additional locations)
CITY STATE ZIP
REMIT ADDRESS CITY STATE ZIP
OFFICE MANAGER PHONE NUMBER FAX NUMBER PUBLIC E-MAIL ADDRESS
ADMINISTRATION EMAIL ADDRESS WEBSITE URL ADDRESS SPECIAL SERVICES CCS CHDP CPSP
HOSPITAL / FACILITY AFFILIATIONS AND
ADMITTING PRIVLEGES
1. _____________________________________
NONE ACTIVE ASSOCIATE STAFF
HONORARY CONSULTANT
COURTESY LIMITED PROVISIONAL
SENIOR ATTENDING SURGICAL
SUSPENDED
2. ____________________________________
NONE ACTIVE ASSOCIATE STAFF
HONORARY CONSULTANT
COURTESY LIMITED PROVISIONAL
SENIOR ATTENDING SURGICAL
SUSPENDED
3. _____________________________________
NONE ACTIVE ASSOCIATE STAFF
HONORARY CONSULTANT
COURTESY LIMITED PROVISIONAL
SENIOR ATTENDING SURGICAL
SUSPENDED
ATTESTATION: I affirmatively confirm authorization to display my provider office
e-mail in CalOptima’s provider directory. The email address provided is only intended for
patient communication, is regularly monitored and maintained in a manner consistent
with state and federal healthy privacy laws.
Signature ________________________________________________________
A provider’s office email address shall be displayed only with the written
permission of the provider, and only if the provider has affirmatively
verified that the email address is intended for patient communication,
regularly monitored, and maintained in a manner consistent with state
and federal health privacy laws.
ACTION REQUIRED (Check all that apply)
NEW ADD OR
AFFILIATION
REQUIREMENTS: The PR Rep must complete this form, including credentialing information, for each provider being added as a provider
affiliate. In addition, a copy of the recitation and signature pages from the provider contract and a W-9 form must be attached. If copies
are not attached, the form will be rejected by PDMS and returned to the PR Rep.
Effective Date (required): Date Credentialing Completed (within the last 3 years) Current Facility Site Review Date (within last 3 years)
PROVIDER TYPE
ANCILLARY/ALLIED HEALTH
Open Panel / Closed Panel
Accepting new patients
Accepting existing patients
Accepting new patients through referral
Accepting new patients through a hospital/facility
Not accepting new patients
PCP
SPECIALIST
REQUIREMENTS: Panel changes are effective the date of processing.
CHANGE IN
PANEL STATUS
PROVIDER TYPE
(If applicable, check both)
PCP
Open Panel / Closed Panel
Accepting new patients
Accepting existing patients
Accepting new patients through referral
Accepting new patients through a hospital/facility
Not accepting new patients
SPECIALIST
TAX I.D.
CHANGE
REQUIREMENTS: The health network must attach a copy of the provider notification indicating the change of tax ID AND a new W-9 form.
Effective Date of New Tax I.D. (required): Previous Tax I.D. New Tax I.D.
ACTION REQUIRED cont. (Check all that apply)
TERMINATION
REQUIREMENTS: Complete this form for each provider being terminated from its provider network affiliates. If the termination is requested by
the provider, a copy of the request from the provider must be attached. If a copy is not attached, the form will be rejected by PDMS and
returned to the PR Rep.
Effective Date (required): PCP SPECIALIST ANCILLARY
Date CalOptima received the termination notice:
Exceptions: Review found that the termed specialist is exempt from providing continued access based on the exemption checked below.
Provider not available
Provider Retired
Contract not continued
Other: ____________________
Provider Deceased
Provider unwilling to accept member / payment terms
Termed due to review action
PCP Termination: Assign member to new PCP: ____________________________________________
Name of new PCP
ADDRESS/PHONE
CHANGE OR
ADDITIONAL
LOCATION
REQUIREMENTS: For all address changes, select [TERM] to remove an old/prior address, and select [ADD] to add the new location. For
additional location, select [ADD] to add the additional location. If PCP site, a Facility Site Review is required. A copy of documentation
submitted by the provider AND a new W-9 form must be attached, if applicable. Note: The form contains three (3) address sections, allowing
multiple changes to be entered for one provider on the same form.
SERVICE ADDRESS
Check one: [ ] ADD [ ] TERM
Effective Date (required): SITE TELEHEATH INDICATORS
Telehealth Only No Telehealth
Both Telehealth and In-person
Address City State Zip
Phone Number Fax Number Office Hours After Hours Phone Number
Office Manager E-mail Address
SERVICE ADDRESS
Check one: [ ] ADD [ ] TERM
Effective Date (required): SITE TELEHEATH INDICATORS
Telehealth Only No Telehealth
Both Telehealth and In-person
Address City State Zip
Phone Number Fax Number Office Hours After Hours Phone Number
Office Manager E-mail Address
LANGUAGE
Languages Spoken by Staff
1. _____________________________ 2. ________________________________ 3. __________________________________
Languages Spoken by Provider
2. _____________________________ 2. ________________________________ 3. __________________________________
OTHER
Comments:
I certify that the above information is true, accurate and complete to the best of my knowledge and that I am authorized to execute this document on behalf of the
applicant. I understand that incorrect or inaccurate information may affect the applicant’s eligibility to receive CalOptima reimbursement and that the applicant must
report changes in the above information to the CalOptima Provider Enrollment Unit. I hereby further declare that the applicant listed above and its agents (a) have
not been convicted of a criminal offense related to health care in the past seven (7) years; and (b) have never been suspended, excluded or otherwise ineligible to
participate in Federal and/or State health care programs based on a mandatory exclusion under 42 U.S.C. § 1396a-7(a).
I hereby further certify that the applicant listed above and its agents will comply with all applicable laws including, without limitation, Medicare and Medi-Cal laws and
regulations, and CalOptima’s Compliance Program. I acknowledge and agree that CalOptima may recoup reimbursement paid to any ineligible provider.
PROVIDER RELATIONS REPRESENTATIVE
(Please print)
CCN PROVIDER SIGNATURE DATE
CCN PROVIDER NAME
(Please print)
SIGNATURE DATE
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Add, Change, and Termination Form (CalOptima)

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Completed 11 March 2021

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