Fillable Optima Health Provider Update Form Instructions

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Optima Health Provider Update Form Instructions

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1 | Page
Optima Health Provider Update Form
Instructions
The Provider Update Form is to be utilized by Providers that are currently contracted with Optima Health
and have had a change to provider/practice information or practice roster (i.e. address change, adding new
providers to group, and terminations).
If you are a non-participating provider (tax ID) interested in participating with Optima Health, please
complete the “Request for Participation” form available at Join our Network on www.optimahealth.com.
If you have any questions regarding this form, or need to inquire about your provider record or
participation status, please contact your Network Educator at (877) 865-9075.
Please follow these instructions and submit to: ProviderUpdates@optimahealth.com
Change Requested
Description
Required Fields
Add Provider to Existing
Group/Tax ID*
A new provider joining an existing/already
participating group/tax ID. Submission of
this form will initiate the practitioner
credentialing process if the provider is not
already credentialed with Optima Health.
• All Fields are required (unless N/A for
provider type.)
• Member Matching Form
*Please see Page 3 for additional instructions for
this request type
Changing Practice
Practitioner is leaving one participating
practice and joining another participating
practice. Fields should be completed
with the new practice information
• Effective Date
• Provider Name
• Individual NPI
• Panel Status per product at new practice
• New practice Name
• New Tax ID Number
• New Group NPI
• P
rimary Address (Add’l address as applicable)
• R
equestor’s Name
• Requestor’s Email
• Member Matching Form
Additional Practice
A practitioner currently practicing with a
participating practice is joining
another/additional participating practice
(tax ID).
• Effective Date
• Provider Name
• Individual NPI
• Panel Status per product and add’l practice
• Additional Practice Name
• Tax ID
• Primary Address (and Add’l address if
applicable)
• Requestor’s Name
• Requestor’s Email
• Member Matching Form
Primary Address
A practitioner has a new primary
service address.
• Effective Date
• Provider Name
• Individual NPI
• Practice Name
• Practice Tax ID
• Group NPI
• Primary Office Address (all fields)
• Requestor’s Name
• Requestor’s Email
• Member Matching Form
2 | Page
Change Requested
Description
Required Fields
Billing Address
Any billing address changes for the
practitioner/group. A W-9 may be required
• Effective Date
• Practice Name
• Practice Tax ID
• Group NPI
• Billing Office (all fields)
• Requestor’s Name
• Requestor’s Email
Additional Address (for
current practice)
A Practitioner or Practice* is
adding an additional service
address.
*If new address for the Practice,
attach list of provider name and
NPI for each provider who will
render services at that address.
• Effective Date
• Provider Name (if applicable)
• Individual NPI (if applicable)
• Practice Name
• Practice Tax ID
• Group NPI
• Additional Office Address (all fields)
• Requestor’s Name
• Requestor’s Email
• Member Matching Form
Phone/Fax/Email
A practitioner or practice has had a
change to a phone/fax number or
email address.
• Effective Date
• Provider or Practice name (as applicable per
change)
• Individual/Group NPI
• Tax ID
• Applicable Phone, Fax, or Email for change
• Requestor’s Name
• Requestor’s Email
Provider Name Change
A practitioner’s name has changed due to
marriage/divorce/other. (Practice/Group
legal name changes should be submitted
directly to the Optima Health Contract
Manager.)
• Effective Date
• New Practitioner Name
• Individual NPI
• Provide previous name in comments
• Requestor’s Name
• Requestor’s Email
• Attach: VA License with new name
Panel Status Change
A change to the provider’s panel status or
ability to accept new patients.
Please note: Status of accepting new
patients is required for both PCPs and
Specialists.
• Effective Date
• Provider Name
• Individual NPI
• Practice Name
• Tax ID
• Check products for panel change
• Select panel status PER PRODUCT
• Requestor’s Name
• Requestor’s Email
Termination
Provider is leaving current practice and/or
terminating from the Optima Health
network
• Effective Date
• Provider Name
• Individual NPI
• Termination Date
• Termination Reason
• Practice Name
• Tax ID
• Requestor’s Name
• Requestor’s Email
Please note: Requests for Tax ID Changes should be initiated directly with your Contract Manger to
determine if any contract changes or amendments are needed.
3 | Page
*Add Provider to Existing Group/Tax ID
If the new provider is not already credentialed with Optima Health, submitting the Provider Update
form will initiate the Optima Health practitioner credentialing process.
Please follow the instructions below;
omitting required fields or required documents/at tachments
will cause the request to be returned to you for correction and will delay the credentialing process.
Submission Instructions:
1.
Complete the Provider Update form (all fields are required unless not applicable to provider
type)
2. Complete the Member Matching form
3. Submit both forms to ProviderUpdates@optimahealth.com.
4. Prior to submission, please ensure the practitioner’s Council for Affordable Quality Healthcare
(CAQH) application is complete and up to date.
o Optima Health requires the CAQH application contain the following information:
Board Certification information or date when taking boards
All past and current state licenses and DEA information
Explanation for any malpractice suits
Explanation for gaps in malpractice insurance
Education history, including applicable internship/residency/fellowships
Work history for past 10 years
Explanation of any work history gaps greater than 6 months
Professional references from 2 providers with contact phone numbers
Covering colleagues or partners/associates
Foreign languages spoken
Listing of hospital privileges (if applicable)
ECFMG number (if applicable)
o The following must also be attached in CAQH:
Copy of Curriculum Vitae or Resume in month and year format
7 years of malpractice history (2 years for midlevel providers)
Copy of the Nursing Board Certificate (ANCC, AANP, NCC, PNCB) when
applicable
OPTIMA HEALTH
Provider Update Form
Change Requested
:
Primary Address Phone/Fax/Email Termination
Changing Practice Billing Address Provider Name Change Other (please use comments)
Additional Practice
Additional Address Panel Status Change
(for current practice)
Effective Date:
Provider: Name SS#
NPI Taxonomy Specialty
License Type: License#: Degree
Board Status: Cert
Elig Grandfathered
VA MCD#
MCR#
DEA#
CAQH ID
Panel Status:
HMO/POS
PPO
Medicare
OFC/Medicaid
OHCC/CCC+
DSNP
Provider Termination Date: Termination Reason
Practice: Name *Vendor #
Group NPI
State Zip
Fax Y N
Tax ID
Credentialing Contact::
Primary Office Address:
City
Phone
Billing Office Address (or "Same as Primary")
City State Zip
Phone
Fax
Additional Office Address:
City State Zip Phone Fax
If there are multiple additional addresses, please include an attachment with all required address information
Comments:
Provider/Requestor Name
Provider/Requestor Signature
Date
Panel Status
Panel Status
Panel Status
Panel Status
Panel Status
Panel Status
Is this a confidential fax line?
AUTOFAX
Credentialing Email
Provider Email
Add New Provider to Existing Group/Tax ID
(Optima use only)
Please email to:
ProviderUpdates@optimahealth.com
Please complete (with Member Matching attached) and submit to:
ProviderUpdates@optimahealth.com.
You may validate the completion of your request 30 days after submission by viewing the provider record
on the Optima Health Provider Directory on www.optimahealth.com. Thank you.
Select Panel Status
Select Panel Status
Select Panel Status
Select Panel Status
Select Panel Status
Select Panel Status
Select termination reason
click to sign
signature
click to edit
V: 0520
MEMBER MATCHING INFORMATION
This information will appear on your provider profile in the Optima Health Provider Directory. Please complete entirely; any
omitted information will be blank on the directory and may exclude you from a member's "Find a Provider" search
Provider Name: NPI: Tax ID:
1. Office Hours: These hours should be inclusive of your availability at all locations you may have with this practice tax ID.
Office Hours
Start
End
Start
End
Monday
Friday
Tuesday
Saturday
Wednesday
Sunday
Thursday
2. Office Accessibility:
Wheelchair Accessible Public Transportation within one mile Use of TDD
3. Languages Spoken in the office:
English
Spanish
German
French
Vietnamese
Korean
Navajo
Tagalog
Portuguese
Italian
Arabic
Dakota
Yupik
Polish
French Creole
Other:
4. Gender and Ethnicity: (It is our experience that patients often express preferences for providers of a particular ethnic background or gender.
Providing this information will include you in the search list for these categories on our website.)
Gender: Ethnicity:
Male African-American Caucasian
Female American Indian/Alaska Native Hispanic
Asian Other:
5.
Cultural Competency Attestation
Has this provider completed Cultural Competency Training?
Yes No
6. Populations Seen (Behavioral Health only)
Younger Children (0-5 years) Women Gay / Lesbian Phillipine
Older Children (6-12 years) Family In-Patient Child/Adolescent Training/Fellowship
Adolescents (13-18 years) Couples Korean Child/Adolescent Board Certified MD
Adults Geriatric Hispanic
Men Step Families Vietnamese
7. Treatment Categories (Behavioral Health only, please check all that apply)
Addictions ECT-Outpatient Outpatient Treatment
ADHD Family/Victim Violence Phobias/Habit Disorders
Anger Management Forensic Evaluation Physically Impaired
Anxiety Disorders Grief Psychological Testing
Autism Spectrum Disorders Head Injury Patients PTSD
Bipolar Disorder Hearing Impaired Separation/Divorce
Blind/Visually Impaired HIV/AIDS Sexual Disorders
Christian Focus Hypnosis Sexual/Physical Abuse
Chronic Pain Inpatient Treatment Substance Abuse
Crisis Intervention Intellectually Disabled Terminally Ill
Depression Medication Management Therapy – Family
Development Disability Mood Disorders Therapy – Group
Eating Disorders Neuropsychological Testing Therapy – Individual
ECT-Inpatient Therapy - Marital/Couple
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Optima Health Provider Update Form Instructions

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Completed 17 May 2021

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