CareSource

Health Partner Contract Form

Thank you for your interest in joining the CareSource® team!

For complete instructions please reference the Join Our Network Guide.

1. All fields marked with an (*) must have a response.

2. Save Your Draft: Once the submitter information section is complete you may save this request at any time by selecting “Save Draft” located at the bottom of the form. After selecting “Save Draft” you will receive an email with a link to access your partial application. (The reference ID can be used to identify the saved form in case there are problems with the link sent in the email.)

3. Group Information: This section collects general information about your Group and contract information. Please add all of your Group Medicaid IDs and Groups NPIs to this section. For example, if you have a Medicaid ID for Supportive Living and Behavioral Health, please add both. Also, if you provide services in counties with no physical office address, please “Add” those counties.

4. Provider Section: This section allows you to enter any number of health partner records that will be associated with this submission. For your final submission, at least one provider will be required. You may enter as many providers as are needed. A Provider Roster can also be attached under “Attach Supporting Documents” after adding the first provider.

5. Attach Required Documentation: Required documents will be indicated with an (*). Links are included below to connect you to the forms required for the application. Please ensure all directions on the Debarment Form are followed. Once a form is submitted for final review, you will not be able to modify your application in any way. However, if your submitted application contained errors or incomplete information, you will receive a notification with the ability to correct and/or add materials to your application.

Tip: Once information is entered into the Remit Address fields, that information can be automatically populated into the Mailing Address and Contractual Updates Address sections by simply checking the boxes at the top of each section respectively.

Tip: The Common address will be used to complete provider’s information as a master address. However, if for any reason the address needs to be changed, uncheck the “Copy Common Address,” this will allow insertion of a different address.

Please NOTE: Using “AutoFill” on this form could cause previous information entered to be modified or erased and could create errors.

Support and general questions can be addressed by contacting Provider Services. Please follow this link to obtain the contact information.


THIS FORM IS FOR NEW CONTRACT REQUESTS, ADDING NEW PRODUCTS, REMOVING A PRODUCT, AND TAX ID OR IRS NAME CHANGES.

ALL OTHER REQUESTS SUCH AS ADDING A PROVIDER(s) OR LOCATION NEED TO BE SUBMITTED ONLINE USING THE MAINTENANCE FORM LOCATED IN THE PROVIDER PORTAL AT:

Https://ProviderPortal.CareSource.com/GL/SelectPlan.aspx (REGISTRATION REQUIRED).

Please Indicate Your Request Type:


If you wish to create a contract request for Georgia Medicaid only, or you are a current contracted Georgia Medicaid Health Partner; please visit the Georgia Medicaid New Health Partner Contract Form at http://www.caresource.com/gacontract to complete your request. Georgia providers who wish to create a contract request for multiple Georgia products may continue using this form.

Product:

Submitter Information
Group Information

Please enter either Tax ID or Social Security Number.

Affiliated Tax ID Numbers

This application/contract request is for an entity billing as a group only. (Defined: The services/items that are provided by your organization are billed via the group and the individual providing them does not bill separately, i.e. DME, Lab, Ambulance etc. See the Step by Step User Guide for more information)

Please ensure that you are on PMF/OH Cred file before completing this form. To be added to the file click here: Log In (maximus.com)


Office Contact
 

Contract (or Signatory) Information

Remit Address

Mailing Address
 

Contractual Updates Address
 

Common Address for Re-Use

Add Providers/Locations

Provider Add Instructions

  1. Identify total number of providers to be added.
  2. Click 'ADD' to create data containers for total number of providers. These data containers can be removed one at a time using the 'REMOVE' button.

* You must add at least one Provider, unable to submit until added!


Disclosure of Ownership, Debarment and Criminal Convictions
  1. Before CareSource enters into or renews an agreement with your practice or corporate entity, you must disclose any debarment, proposed for debarment, suspension or declared ineligible status related to federal programs of yourself and your managing employees and anyone with an ownership or controlling interest in your practice or corporate entity.
  2. You must also notify CareSource of any federal or state government current or pending legal actions, criminal or civil, convictions, administrative actions, investigations or matters subject to arbitration.
  3. In addition, if the ownership or controlling interest of your practice or corporate entity changes, you have an obligation to notify us immediately. This also includes ownership and controlling interest by a spouse, parent, child or sibling.
  4. If you have ownership of a related medical entity where there are significant financial transactions, you may be required to provide information on your business dealings upon request.
  5. If you fail to provide this information, we are prohibited from doing business with you. Please refer to the Code of Federal Regulations 42 CFR 455.100-106 for more information and definitions of relevant terms.
  6. To obtain a copy of the Debarment Form, please download and fill out the form here, and attach it below.

You can download the roster template here https://www.caresource.com/arkansas/forms/. Please attach to Attach NOW - Roster.


Indiana Medicaid - ATTENTION! IN MEDICAID Organizational providers that operate under the provider types listed below, you are required to also attach a CareSource organizational application found here to the supporting documents button. FOR IN Medicaid Organizational Provider Types

Ambulatory Surgery Center
Birthing Center
Community Mental Health Center CMHC/SUD
Dialysis/ End State Renal
Health Departments
Home Health Providers
Home Infusion
Hospice Hospital
Opioid Treatment Program OTP
Orthotic Suppliers
Pathology Laboratories
Rehabilitation Facility
Skilled Nursing Facility
Urgent Care

Additional Information
Attach Required Documentation (Please DO NOT attach Zip files)

OH Medicaid Forms Please download the Provider Specialty Attestation form here: https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Resources/Publications/Forms/ODM10234Fillx.pdf. This form is required for submission.

AR MD & DO Forms

To obtain a copy of the Provider Attestation Form, please download and fill out the form here, and attach it below. (Link:https://www.caresource.com/documents/ar-provider-attestation-form/)

To obtain a copy of the CCVS Provider Authorization and Release Form, please download and fill out the form here?, and attach it below. (Link: https://www.caresource.com/documents/ar-ccvs-provider-auth-release-form/)

 

To save and come back later:

Support and general questions can be addressed by contacting Provider Services. Please follow this link to obtain the contact information.