Anthem Medi-Cal Managed Care Network Request Form
This form is designed for individuals and organizations wishing to participate in the Anthem Blue Cross Medi-Cal Managed Care Network in California. It includes details about submission and participation criteria. Ensure to complete all required sections accurately for successful submission.
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How do I fill this out?
Filling out this form involves several key steps. Begin by providing your specialty and agreement type accurately. Next, complete the demographic and contact information sections to ensure efficient processing of your application.
How to fill out the Anthem Medi-Cal Managed Care Network Request Form?
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Step 1: Complete sections A and B of the form.
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Step 2: Prepare necessary documents such as IRS Form W-9 and Medi-Cal enrollment verification.
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Step 3: Email your completed form and documents to the relevant Anthem contact.
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Step 4: Wait for a review of your submission, which may take up to two weeks.
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Step 5: Respond to any requests for further information or clarifications from Anthem.
Who needs the Anthem Medi-Cal Managed Care Network Request Form?
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Community-based adult services (CBAS) providers need this form to enroll in the Medi-Cal network.
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Doulas must fill out this form to become part of Anthem's approved provider network.
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Street medicine providers use this file to apply for participation in the network.
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Telehealth providers need this form to register for coverage under the Medi-Cal program.
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Healthcare facilities require this form to establish agreements for services provided to Medi-Cal recipients.
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What are the instructions for submitting this form?
To submit this form, email your completed request along with all required documentation to the appropriate Anthem contact based on your specialty area. For CBAS providers, use CAMedicaid_FFSContracting@anthem.com, whereas doulas and street medicine providers should send their submissions to SpecialPrograms_Contracting@anthem.com. Ensure that your documents are clearly labeled and professionally formatted to expedite the review process.
What are the important dates for this form in 2024 and 2025?
Important dates for submitting this form include deadlines for enrollment submissions each quarter in 2024 and 2025. Review the specific timelines based on Anthem's enrollment cycles. Ensure your applications are submitted in advance to avoid any last-minute complications.
What is the purpose of this form?
The primary purpose of the Anthem Medi-Cal Managed Care Network Participation Request Form is to facilitate the enrollment of eligible healthcare providers within Anthem's Medi-Cal network. It establishes a systematic approach for providers, like CBAS and doulas, to apply for participation and ensure they meet the required standards. This form not only enhances the accessibility of healthcare services but also promotes collaboration between Anthem and community-based service providers.
Tell me about this form and its components and fields line-by-line.
- 1. Specialty and agreement type: Indicates the type of provider and their operational format.
- 2. Demographic and contact information: Gathers essential contact details to establish communications.
- 3. Provider name and title: Specifies the legal name and designation of the provider.
- 4. Tax ID: Required for taxation purposes and identification.
- 5. Type 1 National Provider Identifier (NPI): Unique identifier assigned to healthcare providers.
What happens if I fail to submit this form?
If you fail to submit this form, you will not be considered for participation in Anthem's Medi-Cal Managed Care Network. This could lead to missed opportunities for providing Medi-Cal services and potential loss of income. Therefore, ensure all sections are filled and the necessary documents are attached.
- Incomplete application: An incomplete application may result in delays or denial of participation.
- Missing documentation: Failure to include required documents such as IRS Form W-9 may hinder submission.
- Invalid information: Submitting incorrect or outdated information can lead to disqualification.
How do I know when to use this form?
- 1. New Provider Enrollment: For providers seeking to enroll in Anthem's Medi-Cal network for the first time.
- 2. Change in Provider Status: When an existing provider wishes to update their participation agreement.
- 3. Network Participation Compliance: To ensure compliance with Medi-Cal standards and agreements.
Frequently Asked Question
How do I fill out the Anthem Medi-Cal Request Form?
Begin by providing accurate information in sections A and B. Ensure you have necessary documentation like IRS Form W-9 ready for submission.
What documents do I need for submission?
You need IRS Form W-9, Medi-Cal enrollment verification, and the completed request form itself.
How long does the review process take?
The review process may take up to two weeks before you receive a notice of the outcome.
Where do I submit my request?
Email your completed form and documents to the relevant Anthem provider contracting team based on your specialty.
Can I edit my form after submission?
Currently, you can only edit the PDF before submission using PrintFriendly's editing tools.
What if I forget to include required information?
Incomplete applications may delay the review process, so ensure all sections are filled accurately before submission.
Is there a contact number if I have questions?
For inquiries, you can reach out to Anthem's provider contracting team via email.
Do I need a license to participate?
Yes, you must provide your license number as part of the demographic information.
What happens after I submit my form?
After submission, Anthem will review your request and notify you of the outcome.
Can I track my submission status?
Currently, submission status tracking is not available, but you can follow up via email.
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