Become a Participating Provider

Providers requesting enrollment due to the COVID-19 Pandemic will not be credentialed with the plan. Upon the expiration of the applicable Executive Orders (EO), on which your temporary participation was approved, you will be required to meet all our network requirements, including our contracting, credentialing and enrollment criteria, for continued participation in our network.

See credentialing requirements for all specialties

To enroll a new practitioner with the Health Plan, complete the Application for Practitioner Enrollment Open a PDF for the following practitioner types.

To add an additional Tax ID number, complete the Practitioner Demographic Changes form.

  • Acupuncturist [LAC]
  • Anesthesiologist
  • Audiologist [AuD]
  • Certified Diabetic Educator (affiliated with Physician Group or Hospital)
  • Certified Diabetic Educator [CDE] (Independent)
  • Certified Nurse Midwife – Home Birth [CNM]
  • Certified Nurse Midwife [CNM]
  • Certified Registered Nurse Anesthetists [CRNA]
  • Clinical Psychologist [PhD; PsyD]
  • Doctor of Chiropractic [DC]
  • Doctor of Optometry [OD]
  • Doctor of Podiatry [DPM]
  • Doula
  • Emergency Medicine
  • Enterostomal Therapy
  • Genetic Counselor 
  • Hospitalist
  • Licensed Behavioral Analyst [ABA]
  • Licensed Clinical Social Worker [LCSW]
  • Licensed Marriage & Family Therapist [LMFT]
  • Licensed Mental Health Counselor [LMHC]
  • Locum Tenens
  • MD/DO - Psychiatry only (all other MD/DO specialties, see below)
  • Medical Doctor [MD/MBBS/BMED]
  • Nurse Practitioner, Primary Care [NP]
  • Nurse Practitioner, Psychiatry [PMHNP]
  • Occupational Therapist [OT]
  • Oral Maxillofacial Surgery [DMD] 
  • Osteopathic Doctor [DO]
  • Pathologist
  • Physical Therapist [PT]
  • Radiologist including Tele-Radiologist
  • Registered Dietician (affiliated with Physician Group or Hospital)
  • Registered Dietician [RD] (Independent)
  • Speech Pathologist [SLP]

See credentialing requirements for all specialties

For the following practitioner types, complete the Application for Non-Physician Health Care Practitioner Open a PDF to:

  • Enroll a new Non-Physician Health Care Practitioner with the Health Plan under the supervision of physician
  • Update the demographic information (Tax ID, address, etc.) for a currently enrolled non-physician health care practitioner
  • Update collaborating/supervising physician for a currently enrolled non-physician health care practitioner

Non-Physician Health Care Practitioners

  • Certified Behavior Analyst Assistant
  • Nurse Practitioner
  • Physician Assistant
  • Registered Nurse First Assistant

See credentialing requirements for all specialties

Complete the Application for Health CoachOpen a PDF to:

  • Add a Health Coach for Medicare and Medicaid Diabetes Prevention Program (MDPP)
  • Update a Health Coach for an existing MDPP supplier

See credentialing requirements for all specialties

To enroll a new dental provider with the Health Plan, complete the Application for Dental Enrollment Open a PDF

To add an additional Tax ID number, complete the Practitioner Demographic Changes form.

  • Endodontist
  • General
  • Oral Maxillofacial Surgery (Credentialing may be required)
  • Orthodontist
  • Pediatric Dentist
  • Periodontist
  • Prosthodontist

Complete the Practitioner Demographic Changes form if you are already enrolled and need to make changes to your practice.

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