Provider Network Application

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.
By checking “yes” below, your organization agrees to comply with the requirements above.*

Yes, I agree

Behavioral Health
Is your organization a Behavioral Health provider?*

YesNo
Number of Clinicians on Staff*
Number of Prescribers on Staff*
What Age Ranges Do You See?*
What Evidence-Based Treatment Do You Use?*
What Specific Disorders Do You Treat?*

Medicaid Information
Is your organization certified and willing to accept Medicaid patients?*

YesNo
Certifications*
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).*

YesNo
Indicate how this limitation is administered:*

Primary Office Information
Location Name:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County:*
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Please Give a General Description of the Services You Provide:*
Does this Practice Location have Extended Hours?*

YesNo
Does this location provide any of the following?*

Bilingual StaffOnsite InterpretersRemote Video or Telephone InterpretersWritten Translation ServicesAccommodations for People with Physical DisabilitiesCultural Competency Training for StaffNo, Not Applicable
Please explain in greater detail any items selected above.*

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.
Primary Contact Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
Contracting Contact Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
Official Notice Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
HIM Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
Outreach Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
Signatory Name*
Title*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com

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?*

YesNo
Submitter Name*
Title*
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Billing Information
Billing/Pay to Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.

Claims Submission Information
Claims will be submitted on:*

CMS 1500UB04Both CMS 1500 and UB04
Claims will be submitted via:*

Paper OnlyElectronically OnlyBoth Paper and Electronically

Provider Self-Service Information
How does your organization check member eligibility and claims status?*

Member Services DepartmentEDI Transactions
Is your organization interested in Electronic Fund Transfer (EFT) payment?*

YesNo

Credentialing Information
Are you willing to enter into a delegated credentialing agreement?*

YesNo
Does your organization currently delegate provider credentialing to an NCQA-compliant delegate/vendor?*

YesNo
List Vendor Name*
List Vendor Contact Person's Name*
List Vendor Contact Person's Phone Number*
Please enter a valid phone number.

Additional Information
Is the provider in good standing with state and federal regulatory bodies?*

YesNoN/A
State and Federal Regulatory Information*
Is the provider approved by an accrediting body?*

YesNoN/A
Accreditations*
If you have any attachments that you would like to include, please use the file upload on this page.

Cancelof
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Disclaimer

Provider Information

Behavioral Health

Medicaid Information

Primary Office Information

Primary Contact Information

Contracting Contact Information

Official Notice Information

Health Information Manager (HIM) Information

Outreach Contact Information

Signatory Contact Information

Submitter Contact Information

Billing Information

Claims Submission Information

Provider Self-Service Information

Credentialing Information

Additional Information