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INSTRUCTIONS PLAN PARTICIPATION CHECKLIST VERY IMPORTANT INFORMATION

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5608 Malvey Ave
Ste 200
Fort Worth, TX 76107
Ph: (817)484-6274 Fax: (817)420-9661
INSTRUCTIONS
PLAN PARTICIPATION CHECKLIST
VERY IMPORTANT INFORMATION
Please take careful consideration before filling out the Plan Participation Checklist. Once you have made your selections,
and sent the document to us, our Provider Relations team will submit the information to the payors. It generally takes
30 - 180 days to be loaded to the payors. If you are adding a provider to your group, PLEASE refer to the PPCL the
established providers use. Please utilize the PPCL of the established providers as a guide for the new provider’s PPCL. If
not, it can cause inconsistencies in plan participation within the group. Subsequently, PPCL corrections are often
submitted too quickly after the initial PPCL has been processed, which causes issues and backlogs in the loading process.
It is important to wait a minimum of 6 months before making changes to plan participation by sending us another
PPCL. To avoid this, take the time to make careful selections on the initial PPCL, keeping a selection template at the
practice level, and reading all checklist instructions, bylines, and participation criteria thoroughly.
If you are pending a Medicare PTAN and/or Medicaid TPI but plan to accept Medicare Advantage and Medicaid managed
care plans in the future, please make your selections for these plans on your initial checklist. Once we receive your
Medicare PTAN and/or Medicaid TPI we will automatically enroll you in the plans you selected.
To establish valuable organization with the networks, and maintain your revenue cycle we recommend you make
minimal changes. For this reason, we are limiting our members to a maximum of 2 plan changes per fiscal year October
1 – September 30. If you need to change your plan participation more than 2 times in a fiscal year, there is a $350
charge to process each additional change. Please note this does not include new plan offerings when we send out opt-in
forms with solicitations.
I have read, and I understand the information above.
Group Name
Provider Name
Group Admin or
Provider
Signature
Date
Last edit 01.31.2022
Page 1 of 8
PLEASE NOTE CHANGES AS MARKED
PLAN PARTICIPATION CHECKLIST
Pro
vider Name: ________________________________________ Provider NPI: _________________________
Provider CAQH#: ________________________ Provider Specialty: _____________________________________
Gr
oup Association: _____________________________________________ TIN: _________________________
Please select Opt-in or Opt-out on all options listed below and return with your application.
If a plan does not have an Opt-in/Opt-out box checked it defaults to Opt-out and will not be sent for enrollment.
COMMERCIAL PRODUCTS
• Aetna Commercial Plans (All or nothing)
Includes, but not limited to – Choice POS, Elect, HMO, Open Choice PPO, Meritain Health, & Walmart.
(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.
(Must be enrolled under the commercial plans with TIOPA to qualify)
Opt In
Opt Out
• Blue Cross and Blue Shield of Texas
(Must have BCBS Record ID associated with the current TIN to participate)
Provider BCBS Record ID # ______________
Opt In – Blue Choice PPO (Includes EPO, Federal Employees Benefit Plan, POS, and TRS ActiveCare)
Opt In – Blue Essentials HMO (Includes Blue Essential Access, Health Select, and TRS ActiveCare)
Opt In – Blue Advantage HMO (Exchange product)
Opt In – Blue Premier
Opt Out
• Bright Health Management Inc.
(Must complete & return Bright Health Hospital Letter – Uses Medical City & Methodist Facilities)
Opt In –Texas Standard Plan
Opt Out
• ChoiceCare PPO Humana
Opt In
Opt Out
• Cigna Healthcare of Texas, Inc (All or nothing)
Includes, but not limited to – HMO/OAS/Network, PPO, Open Access Plus. Providers cannot just enroll in Local Plus.
(Must complete & return CIGNA Election to Participate addendum & Cigna Hospital Letter).
Opt In
Opt In – Local Plus – (Narrow network at discretion of Cigna for enrollment, no guarantee.)
Opt Out
• Cigna Healthcare North Texas Provider Select Plan
Opt In – Tier I – Network participation at discretion of Cigna for enrollment, no guarantee.
Opt In – Tier II – Rolled into the OAP product, if opted into.
Opt Out
• Coventry/First Health – PPO
Opt In
Opt Out
Last edit 01.31.2022
Page 2 of 8
• Evry PPO
Opt In
Opt Out
• Friday Health Plan – Exchange PPO
Opt In
Opt Out
• Galaxy Health Network (All or nothing)
Includes – PPO, & Medical Savings Card
Opt In
Opt Out
• Healthcare Highways Healthplan PPO
Opt In
Opt Out
• Health EZ – The City of Crowley Employee Benefit Plan
For Johnson & Tarrant Counties
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
Opt Out
• National Preferred Provider Network (NPPN) – PPO
Opt In
Opt Out
• Nexcaliber PPO
Opt In
Opt Out
• Oscar --- All Products
Oscar will only except ODs if you are Therapeutic Optometrists
Uses Medical City & Methodist Facilities
Opt In
Opt Out
Last edit 01.31.2022
Page 3 of 8
• 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 -- BSWQA NOT INCLUDED
Includes – HMO, PPO, POS, ASO, Medicare Advantage, & TRS.
(Must have privileges at a BSW facility OR complete & return the attached BSW admitting letter..
Opt In
Opt Out
• Stone Mountain Risk PPO
Must complete & return Stone Mountain Hospital letter
Uses Dallas Medical Center & Dallas Regional Medical Center
Opt In – Hospital Narrow Network PPO
Opt Out
• Superior Ambetter Exchange
Opt In
Opt Out
• Three Rivers Provider Network – PPO
Opt In
Opt Out
• Tricare (Humana Military)
Includes – Champ VA, Life, Prime, & Select
(Must be Tricare Certified, and complete & return the Opt In/Out form)
Opt In
Opt Out
• TriWest
(Must have BCBS Record ID associated with the current TIN to participate)
Provider BCBS Record ID # ______________
Opt In
Opt Out
• United Healthcare Commercial
Including, but not limited to – Charter, Choice, Core, Navigate, Nexus, Select, UMR & GEHA
Opt In
Opt Out
• USA Managed Care Organization
Opt In – PPO
Opt In – LoneStar Athletic Injury Network PPO
Opt Out
Last edit 01.31.2022
Page 4 of 8
WORKERS’ COMPENSATION PRODUCTS
I WISH TO OPT OUT OF ALL WORKERS COMPENSATION PLANS
• CareWorks (fka Rockport Healthcare Group)
Opt In – Workers’ Compensation
Opt In – NWI
Opt Out
• Corvel Healthcare (All or nothing)
Includes – Auto, Non-Subscriber Work Injury, & Workers’ Comp
Opt In
Opt Out
• Coventry/First Health
With the enrollment in Coventry you will automatically be enrolled in the following networks: Caramor Network (DBA: Avidel
Medical Management); Conduent Care Solutions TX HCN; First Health TX HCN; Genex/American Airlines Group Network; Genex
Health Care Network; Hartford Workers Compensation Health Care Network.
ALL OTHER SUB-NETWORKS REQUIRE ADDITIONAL STEPS TO JOIN THE NETWORK AS DETAILED ON THEIR SEPARATE WEBSITES, INCLUDING BUT NOT LIMITED TO: AIG
TX HCN, AIG Productivity Edge TX HCN-CHCWC, Broadspire, Coventry Workers’ Comp Network, Employers Managed Provider Network, Gallagher Bassett, Liberty
Health Care Network, Sedwick, Texas Star Network, Travelers, United Airlines TX HCN-CHCWC, Zenith Health Care Network, & Zurich Services.
Opt In – Auto
Opt In – Workers’ Compensation
Opt Out
• Galaxy Health Network – Non-Subscriber Work Injury
Opt In
Opt Out
• Healthsmart Preferred Care – Workers’ Compensation
Opt In
Opt Out
• MultiPlan – Workers’ Compensation
Opt In – Auto
Opt In – Workers’ Compensation
Opt Out
• Prime Health Services, Inc.
Opt In – Auto
Opt In – IME
Opt In – Workers’ 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 – Workers’ Compensation
Opt In
Opt Out
• USA Managed Care Organization – Workers’ Compensation
Opt In
Opt Out
Last edit 01.31.2022
Page 5 of 8
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.
Individual PTAN(s) associated with TIN ________________________ ________ 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 – Medicare Advantage
Opt In – Prime Medicare Advantage
Opt Out
• Amerigroup Medicare Advantage (Amerivantage)
(Includes, but not limited to – Amerivantage HCOP—Texas Medicare Advantage Dual Coordination Plus, HMO – Traditional HMO, HMO SNP –
Chronic Care Medicine, ISNP – Care To You, PPO – Choice PPO Medicare Network, SNP – Special Needs Plan)
Opt In
Opt Out
• Blue Cross Medicare Advantage
(Must have/keep CAQH updated before enrollment approval)
Provider BCBS Record ID # ______________
Opt In – Medicare Advantage HMO
Opt In – Medicare Advantage PPO
Opt Out
• Bright Health Management Inc.
(Must complete & return Bright Health Hospital Letter – Uses Medical City & Methodist Facilities)
Opt In – Medicare Advantage
Opt Out
• Care N Care Medicare Advantage – HMO and PPO
HMO include Southwestern Select HMO for Tarrant and Johnson Counties
Opt In
Opt Out
• Choice Care Network by Humana – Medicare Advantage
Opt In – Medicare Advantage HMO (For Specialists only NO PCPs)
Opt In – Medicare Advantage PFFS
Opt In – Medicare Advantage PPO
Opt Out
• Cigna Medicare Advantage (fka HealthSprings)
Pediatrics not eligible for CHS MA
HMO Counties Currently – Collin, Dallas, Denton, Johnson, Parker, Hood, Wise, and Tarrant
PPO Counties Currently – Collin, Dallas, Denton, Johnson, Tarrant
Opt In – Medicare Advantage PPO
Opt In – Medicare Advantage HMO
Opt In – Traditional Medicare PPO (No Gatekeeper)
Opt Out
• Global Health HMO Medicare Advantage
Opt In
Opt Out
• Imperial Insurance Company of TX – Medicare Advantage
Opt In
Opt Out
• Molina – Medicare Advantage Options
Opt In
Opt Out
Last edit 01.31.2022
Page 6 of 8
• Scott & White Medicare Advantage HMO
(Must have privileges at a BSW facility OR complete & return the attached BSW admitting letter.
Opt In
Opt Out
• WellCare by Allwell
Opt In
Opt Out
• United Healthcare Medicare Advantage
** At this time, UHC is not enrolling PCPs in the Medicare Advantage products. We are not sure when this will change. Please to
continue to opt-in if this is a product you are interested in because geographical regions are also considered. Including, but not
limited to - Dual Complete, Care Improvement Plus, AARP, WellMed.
Opt In
Opt Out
Last edit 01.31.2022
Page 7 of 8
MEDICAID 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.
Individual TPI(s) associated with TIN ___________________________ I WISH TO OPT OUT OF ALL MEDICAID & CHIP PLANS
• Aetna Better Health 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
• Cook Children’s Health Plan
Open to Existing Groups ONLY, and limited to the following counties: Denton, Hood, Johnson, Parker, Tarrant, & Wise. Any
enrollments in other counties are at the discretion of Cook Children’s Health Plan. (Must have/keep CAQH updated before
enrollment approval)
Opt In – CHIP
Opt In – Star
Opt In – Star Kids
Opt Out
• Cigna Star Plus (fka Healthspring)
This plan has transitioned to Molina Star Plus, and Molina Star Plus MMP as of 1/1/2022
You will need to opt into Molina to continue seeing these patients.
• Molina Healthcare
Opt In – CHIP
Opt In – Star
Opt In – Star Plus
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 Plus + MMP (Medicare/Medicaid Dual)
Opt Out
• United Healthcare Medicaid
At this time UHC Medicaid is closed, enrollment is solely at the discretion of UHC
Opt In
Opt Out
Last edit 01.31.2022
Page 8 of 8
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Completed 4 April 2022

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