How To Become Carefirst Provider

How to become CareFirst Provider?

We provide a health plan that blends personalized care with world-class medical care. The advantages include a broad provider network and great customer service, as well as access to one of America’s finest healthcare systems.

Who qualifies for Health Choice?

The Health Choice Program is required for all eligible who qualify, which covers the vast majority of Medicaid beneficiaries. Health Choice enrolls around 75% of all Medicaid eligible. Any participant who applies for credentialing through our connection must also apply for Health program too.

Who does not qualify for this Program?

  • While most Medicaid beneficiaries are qualified to participate in Health Choice, some are not owing to certain situations or restrictions of Medicaid eligibility. Among the awardees are:
  • People who receive Medicare,
  • Persons 65 years of age or older
  • Individuals who qualify for this under the spend down program
  • Medicaid recipients who have been or are likely to be continuously institutionalized for more than 30 consecutive days in a long-term care facility or a mental health institution (IMD).
  • Individuals institutionalized in a mentally retarded intermediate care facility (ICF-MR),
  • Recipients who have signed up for the Model Waiver, and
  • Individuals enrolled in limited coverage categories, such as women who get Family Planning Program services

How Would I Simply Register For The Health Choice Program?

If you qualify as a consequence of receiving Supplemental Security Income (SSI) or Temporary Cash Assistance (TCA), or as a result of this application procedure, you are likely eligible for Health program. You must enroll in if you applied for this through our services.

Enrollment with us is handled by a DHMH-approved enrollment broker. The enrollment broker is in charge of outreach, education, and enrolling most Medicaid-eligible beneficiaries in Health Choice. The enrollment broker offers you information about Managed Care Organizations (MCOs) in your county of residence, allowing you to select your own health plan and provider. You will receive the following information packet:

The names and addresses of the providers who are taking part.

A list of the benefits provided, including any benefits provided in addition to the basic needed package.

A narrative description of the MCO’s network’s clinical knowledge and experience with special needs populations.

Any paperwork required to select an MCO (including a Health Service Needs Information form)

The enrollment unit’s toll-free phone number.

How to Apply

Providers who use CAQH ProView to self-report credentialing information avoid having to fill out multiple, lengthy paper forms. As a general guideline, the following procedures can be taken:

  • Sign up for CAQH ProView
  • Get a CAQH ID
  • Complete and sign your profile
  • Please upload the necessary documentation

If any of your documents are missing or expired, the credentialing team will send you a letter with instructions on how to correct and submit the new information.

Initial Credentialing

A Practitioner is eligible for credentialing if they meet the following criteria:

  • They must have a current, unrestricted license to practise their profession.
  • Maintain a current Federal Drug Enforcement Agency (DEA) or Controlled Dangerous Substance (CDS).
  • Maintain the current malpractice insurance limits for their particular field.
  • Accept to provide information on any other health institution, professional health care organisation, licensing authority, and/or regulatory body’s sanctions and/or disciplinary action, including voluntary or involuntary limitation, reduction, or loss of clinical and/or technical skills, and current competence.
  • Show a level of professional competency similar to other network Practitioners in their field, as well as the capacity to provide cost-effective health care while meeting CareFirst’s geographic, specialized, and business needs.
  • Accept to take part in all quality management actions.
  • Provide a professional work history for each position listed, including the beginning and ending months. A gap in employment history of more than 6 months must be explained in writing.
  • Provide information on all education, training, and board certification requirements.

When a Practitioner submits a completed, signed, and dated credentialing application and Consent and Release Form, along with copies of their state license, DEA or CDS, malpractice face sheet, and curriculum vitae, the credentialing process begins. After that, the credentialing staff will do Primary Source Verification (PSV). In addition, all Practitioners will have their sites reviewed using the Office Site Review Tool, which is available upon request. The application, PSV, and site review findings are sent to the Credentialing Committee for consideration. The Credentialing Committee is made up of Practitioners that are part of the network. Initial credentialing/re-credentialing decisions are communicated in writing to all Practitioners.

Re-credentialing

Within three years following their last credentialing date, all Practitioners must be re-credentialed. CareFirst CHPDC re-verifies information that may change over time. Education, for example, is a static historical aspect that has not been re-verified. The purpose of the re-credentialing procedure is to identify any changes in the practitioner’s licensure, sanctions, certification, clinical privileges, competence, or health status that may influence the Practitioner’s ability to execute the services for which they have been hired. CareFirst CHPDC collects and verifies all re-credentialing information and documentation through primary sources. Furthermore, the re-credentialing process includes an evaluation of the practitioner’s performance with CareFirst CHPDC, which includes a review of medical records, access and site reviews, enrollee complaints, enrollee satisfaction, and information from quality improvement and Medical Management activities.

Perks of Credentialing

Quality relationships between health plans and providers are encouraged by CAQH. When a practitioner completes the online application with CAQH, that practitioner gains access to a single application that may be used for a variety of health plans. This cuts down on the time, money, and difficulties associated with healthcare management. One application takes about 1.5 hours to complete. It may take many hours to complete paper applications for multiple different health plans.

Three Benefits of Using CAQH ProView

Comply with reporting obligations – You can quickly self-report data required by health plans, hospitals, and other organizations when you use CAQH’s proView service. Only enter your information once if you want to be credentialed with different insurers.

  • Duplicate paperwork should be eliminated or reduced
  • Update your data – If your data changes, you may easily update it online
  • Attestation takes only a few minutes and should be done every 120 days

Choose Us over Others Will Get You Numerous Benefits

  • Over thousands of doctors to choose from
  • Doctor visits and wellness check-ups
  • Urgent and emergency care
  • A team of people who can help you get the care you need
  • Meals post hospital discharge
  • Benefit coordination
  • Acupuncture for substance abuse

Our Enrollment Is Always Open!

There is no deadline for applying for Medicaid, and if you are currently registered, you can switch to CareFirst whenever you choose.

CareFirst Phone No

Call the state’s toll-free number at1-800-977-7388. Monday through Friday | 7:00 a.m.–7:00 p.m.

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