• Disclaimer

    This application is to facilitate your request to join the Group Health Cooperative of South Central Wisconsin (GHC-SCW) network. Completing this application does not guarantee that your organization will be approved as a contracted provider. Your request will be reviewed, and if approved, your organization will undergo contracting and credentialing. If denied, your organization will receive a written notification with the denial decision.

    GHC-SCW reserves the right to not consider incomplete applications and encourages applicants to provide as much information as possible. If GHC-SCW needs more information about your request to make a determination, we will contact you.

    If your organization is approved, it is important to note that GHC-SCW members cannot receive care from your organization until the effective date of the contract AND credentialing has been completed. If a GHC-SCW member receives care from your organization prior to the effective date of the contract and completion of credentialing, claims will be denied for HMO members or paid as out-of-network for POS and PPO members. Credentialing dates cannot be backdated due to NCQA requirements. The credentialing process for the GHC-SCW network can take anywhere from 45 to 90 days.

    If your application is denied, your organization will need to wait one (1) year to reapply. Subsequent requests received prior to one (1) year from the date of the initial denial will be responded to with a letter stating that your organization must wait one (1) year from the date of the initial denial to reapply.

  • Provider Information 

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  • Does your organization have a website?*
  • Is your organization affiliated with a larger group, parent company, or health care organization?*
  • Is your organization a national provider servicing a wide range of states across the country?*
  • Does your organization provide ONLY facility-based services? (Select any that apply.)*
  • Does your organization physically provide services EXCLUSIVELY in the patient’s home? (e.g. in-home health care, etc.)*

  • Behavioral Health

  • Is your organization a Behavioral Health provider?*

  • Medicaid Information

  • Is your organization certified and willing to accept Medicaid patients?*
  • Does your clinic/facility have a limit of Medicaid patients you accept? (NOTE: We do not promote limiting patient panel size according to their health insurance coverage, including Medicaid).*

  • Primary Office Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does this Practice Location have Extended Hours?*
  • Does this location provide any of the following?*

  • Primary Contact Information

    This is the individual who we can contact with request-related questions or who can connect us with others in your organization for more specific questions.

  • Format: (000) 000-0000.

  • Contracting Contact Information

    This is the individual who we can contact with contract-related questions and documents, receive contract correspondence, etc.

  • Is the Contracting contact also the Primary contact?*
  • Format: (000) 000-0000.

  • Official Notice Information

    This is the location where all legal information (e.g. rate increases or fee schedules) is sent.

  • Is the Official Notice contact also the Primary contact?*
  • Format: (000) 000-0000.

  • Health Information Manager (HIM) Information

    This is the individual who we can contact to request medical records.

  • Is the HIM contact also the Primary contact?*
  • Format: (000) 000-0000.

  • Outreach Contact Information

    This is the individual who we can contact for roster questions and/or validation requests.

  • Is the Outreach contact also the Primary contact?*
  • Format: (000) 000-0000.

  • Signatory Contact Information

    This is the individual who will sign contracts and other official documentation on behalf of your organization.

  • Is the Signatory contact also the Primary contact?*
  • Format: (000) 000-0000.

  • Submitter Contact Information

    This is the person completing this form. Their e-mail address will be used to receive the formal decision from our internal review committee.

  • Is the Submitter also the Primary contact?*
  • Format: (000) 000-0000.

  • Billing Information

  • Format: (000) 000-0000.

  • Claims Submission Information

  • Claims will be submitted on:*
  • Claims will be submitted via:*

  • Provider Self-Service Information

  • How does your organization check member eligibility and claims status?*
  • Is your organization interested in Electronic Fund Transfer (EFT) payment?*

  • Credentialing Information

  • Are you willing to enter into a delegated credentialing agreement?*
  • Does your organization currently delegate provider credentialing to an NCQA-compliant delegate/vendor?*
  • Format: (000) 000-0000.

  • Additional Information

  • Is the provider in good standing with state and federal regulatory bodies?*
  • Is the provider approved by an accrediting body?*
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