Welcome toParticipating Provider Agreement • June 29th, 2015
the primary diagnosis code; (e) an indication as to whether or not dilation was performed; (f) a description of services provided (i.e. examination, materials, etc.); and (g) all necessary prescription eyewear order information (if applicable). Further, all electronically submitted claims must include PROVIDER’s National Provider Identifier (NPI) number in order to be deemed a “Clean Claim”. Any claim that does not have all of the information herein set forth may be pended or denied until all information is received from the PROVIDER and/or Member. Claims from Participating Providers under investigation for fraud or abuse and claims submitted with a tax identification number not documented on a properly W-9 form are not Clean Claims. Further, submission of a properly completed CMS Form 1500 or any applicable Uniform Claim Form and any attachments approved or adopted for use in the applicable jurisdiction for payment of Covered Services and as promulgated by the rules and regulations of
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • April 26th, 2023
This Participating Provider Agreement (“Agreement”) is made and entered into this day of , (“Effective Date”), by and between (“Dentist”) and Dominion Dental Services, Inc., on behalf of itself and its applicable affiliates (“Plan”). Whenever mentioned herein, the term “Dentist” shall include all employees and agents of Dentist, including all partners, dentists, dental associates, and all staff personnel under Dentist’s direct supervision and/or control. Dentist and Plan may hereinafter be referred to individually as a “Party” and collectively as the “Parties.” The Regulatory Compliance Addendum attached to this Agreement as Exhibit A is expressly incorporated into this Agreement and is binding upon the Parties to this Agreement. In the event of any inconsistent or contrary language between the Regulatory Compliance Addendum and any other part of this Agreement, including but not limited to exhibits, attachments or amendments, the Parties agree that the provisions of the Regulatory Com
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • January 7th, 2019 • Georgia
THIS PARTICIPATING PROVIDER AGREEMENT (the “Agreement”), effective as of , 2019 (the “Effective Date”), is made and entered into by and among Zelis Network Solutions, LLC on behalf of itself and its subsidiaries and affiliates, including any and all entities under common ownership or control, with principal offices located at Two Concourse Parkway, Suite 300, Atlanta, GA 30328, (hereinafter referred to as “Network”) and “Network Provider” as defined below:
HEALTHYCT, INC. PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • April 25th, 2016 • Connecticut
and among , a Provider organized under the laws of the state of Connecticut (hereinafter “Provider”) and HealthyCT, Inc., a Connecticut nonprofit corporation (“HCT”). Hereinafter, Provider and HCT may be referred to as a “Party” or collectively, “Parties”).
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • June 25th, 2019 • North Carolina
THIS PARTICIPATING PROVIDER AGREEMENT (“Agreement”) is made and entered into by and between WellCare Health Plans, Inc. (“WellCare”), on behalf of itself and Health Plan (as such term is defined below) and (“Contracted Provider”). WellCare, Health Plan, and Contracted Provider are sometimes referred to together as the “Parties” and individually as a “Party”.
ADDRESS Group NPI number: ADDRESS Dear Healthcare Provider: CONTRACT ENCLOSEDParticipating Provider Agreement • August 7th, 2020
Enclosed please find a copy of the Highmark Professional Provider Agreement (“Commercial Agreement”). Please execute and return the Commercial Agreement in order for Highmark to finalize execution of this document. Upon finalization of your Commercial Agreement, you will receive a fully executed copy of the Commercial Agreement with an acknowledgment for your files. In addition, a Welcome Letter announcing your Highmark Commercial Agreement effective date(s), Group Provider Number and Managed Care Vendor Number will be returned to you for your files. Please note that new applicants should not see members or submit claims until notified that they have been accepted in the network via a Welcome Letter.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • November 8th, 2021
I, the undersigned (hereinafter referred to as "Provider" or "Contractor"), duly certified and participating in both the state Medicaid Program and the Federal Medicare Program, and, as applicable, duly licensed under the laws of the Commonwealth of Pennsylvania, in consideration of being enrolled by the Pennsylvania Department of Health, Chronic Renal Disease Program (hereinafter referred to as "Department" or "CRDP"), as a participating provider, do hereby agree to be legally bound as follows: I offer to and shall provide special health services pursuant to this Agreement for the Department to CRDP-eligible individuals in accordance with the restrictions indicated on the individual's CRDP identification card, make reports to the Department concerning such services, and accept compensation therefore in accordance with the terms and conditions stated or incorporated in this Agreement. This Agreement is effective as of
PARTICIPATING PROVIDER AGREEMENT WITH HIGHMARK BLUE SHIELDParticipating Provider Agreement • May 5th, 2005
Under the applicable laws of the Commonwealth of Pennsylvania, I am duly authorized to engage in the practice of . In consideration of being registered by Highmark Inc. d/b/a Highmark Blue Shield, an independent licensee of the Blue Cross and Blue Shield Association (hereinafter termed "Blue Shield"), as a participating provider, I do hereby agree as follows:
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • May 5th, 2020
This Participating Provider Agreement (together with all Attachments and amendments, this “Agreement”) is made and entered by and between Mental Health Crisis Center Of Lancaster County (“Provider”) and Nebraska Total Care, Inc. (“Health Plan”) (each a “Party” and collectively the “Parties”). This Agreement is effective as of the date designated by Health Plan on the signature page of this Agreement (“Effective Date”).
PREAMBLE AND RECITALSParticipating Provider Agreement • May 23rd, 2013 • New York
to States for Medical Assistance Programs, Section 1396 et seq., as amended from time to time, or any successor program(s) thereto regardless of the name(s) thereof.
PARTICIPATING PROVIDER AGREEMENT for Purchase of Sublocade and Brixadi HCA Agreement Number: K Clinic Agreement Number:Participating Provider Agreement • October 31st, 2024
THIS PARTICIPATING PROVIDER AGREEMENT (Agreement) is made by and between the Washington State Health Care Authority (HCA) and the undersigned clinic (Provider), pursuant to Department of Enterprise Services Statewide Agreement #19022.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • August 23rd, 2011 • Kentucky
THIS PARTICIPATING PROVIDER AGREEMENT (“Agreement”) is made and entered into as of (“Effective Date”) by and between WellCare Health Insurance of Illinois, Inc. d/b/a WellCare of Kentucky (“Health Plan”) and
EX1A-3 HLDRS RTS 6 f1a2018ex3-1_carolinacom.htm FORM OF PARTICIPATING PROVIDER AGREEMENT PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • May 5th, 2020
This Participating Provider Agreement (together with all Attachments and amendments, this “Agreement”) is made and entered by and among _______________________________________________________________ (“Provider”), Carolina Complete Health, Inc., a North Carolina corporation (“Health Plan”) and Carolina Complete Health Network, Inc., a Delaware corporation (“CCHN”) and subsidiary of the North Carolina Medical Society. This Agreement is effective as of the date designated by Health Plan on the signature page of this Agreement (“Effective Date”). For purposes of this Agreement, each of Provider and Health Plan (and, solely for purposes of Article VIII, CCHN) may be referred to herein as a “Party” and collectively as the “Parties.”
Delta Dental of Washington Participating Provider Agreement Delta Dental MedicaidParticipating Provider Agreement • May 16th, 2018 • Washington
This Participating Provider Agreement (“Participating Provider Agreement”) is entered into by and between the undersigned provider of dental services (“Participating Provider”), and Delta Dental of Washington, a Washington nonprofit corporation (“DDWA”), and is effective when fully executed by both parties. This Agreement governs services to be delivered by Participating Providers to persons covered by the State of Washington Apple Health Dental Program (“Apple Health”) and enrolled in a managed dental care plan offered by a Contractor, as defined herein that has contracted with DDWA to obtain the services of DDWA’s Participating Providers.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • May 5th, 2020 • Nebraska
THIS PARTICIPATING PROVIDER AGREEMENT (“Agreement”) is made and entered into by and between WellCare of Nebraska, Inc. (“Health Plan”) and Lancaster County of Nebraska d/b/a Mental Health Crisis Center (“Contracted Provider”). Health Plan and Contracted Provider are sometimes referred to together as the “Parties” and individually as a “Party”.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • July 16th, 2019 • Carolina
This Participating Provider Agreement (together with all Attachments and amendments, this “Agreement”) is made and entered by and among (“Provider”), Carolina Complete Health, Inc., a North Carolina corporation (“Carolina Complete”) and Carolina Complete Health Network, Inc., a Delaware corporation (“CCHN”) and subsidiary of the North Carolina Medical Society. This Agreement is effective as of the date designated by Carolina Complete on the signature page of this Agreement (“Effective Date”). For purposes of this Agreement, each of Provider and Carolina Complete (and, solely for purposes of Article VIII, CCHN) may be referred to herein as a “Party” and collectively as the “Parties.”
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • February 14th, 2024
Effective April 1, 2024 the Participating Provider Agreement (the “Agreement”) between PacificSource Community Solutions (“Health Plan”) and Central Oregon Community Mental Health Programs (“CMHPs”) is amended to include the following:
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • June 21st, 2023
This Delegated Credentialing Attachment (“Delegation Attachment”) sets forth the terms and conditions under which Health Plan shall delegate to Provider specific credentialing and recredentialing activities. This Delegation Attachment will be coterminous with the provider agreement (the “Agreement”), unless sooner terminated as provided in Section 2.3 of this Attachment, and is contingent upon the successful completion and approval of the delegation audit as designated by the Health Plan; otherwise, if such delegation audit fails the Health Plan cannot proceed with the delegation to Provider and this Delegation Attachment is null and void.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • September 1st, 2011 • Kentucky
(“Contracted Provider”). Health Plan and Contracted Provider are sometimes referred to together as the “Parties” and individually as a “Party”.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • September 26th, 2017 • Kentucky
(“Contracted Provider”). Health Plan and Contracted Provider are sometimes referred to together as the “Parties” and individually as a “Party”.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • February 11th, 2020
WHEREAS, SELE-DENT, INC., has established a network of Dentists to render services to employees/members (“Eligible Participants”) of certain employers, unions and organizations (“Clients”);
AMENDMENT TO PARTICIPATING PROVIDER AGREEMENT WITH HEALTHLINK, INC.Participating Provider Agreement • December 30th, 2008
THIS AMENDMENT (this “Amendment”) is made and entered into between HealthLink, Inc., an Illinois corporation (“HealthLink”) and participating provider,(the “Other Party”).
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • April 12th, 2023
Effective January 1, 2023 the Participating Provider Agreement (the “Agreement”) between PacificSource Community Solutions (“Health Plan”) and Central Oregon Community Mental Health Programs (“CMHPs”) is amended to include the following:
PARTICIPATING PROVIDER AGREEMENT WITH HIGHMARK BLUE SHIELDParticipating Provider Agreement • May 14th, 2003
Under the applicable laws of the Commonwealth of Pennsylvania, I am duly authorized to engage in the practice of . In consideration of being registered by Highmark Inc. d/b/a Highmark Blue Shield, an independent licensee of the Blue Cross and Blue Shield Association (hereinafter termed "Blue Shield"), as a participating provider, I do hereby agree as follows:
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • June 14th, 2022
is made and entered by and between Mangum City Hospital Authority dba Mangum Regional Medical Center and Mangum Family Clinic (“Provider”) and Oklahoma Complete Health, Inc. (“Health Plan”) (each a “Party” and collectively the “Parties”). This Agreement is effective as of the date designated by Health Plan on the signature page of this Agreement (“Effective Date”).
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • February 19th, 2020 • Maryland
THIS PARTICIPATING PROVIDER AGREEMENT (this “Agreement”) is entered into effective as of , 20 (the “Effective Date”) by and between One Health Quality Alliance, LLC, a Maryland nonprofit limited liability company (“CIN”) and
PRESBYTERIAN NETWORK, INC. PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • February 12th, 2019 • New Mexico
This Participating Provider Agreement (this “Agreement”) is dated as of the date specified below and is by and between Presbyterian Network, Inc., a New Mexico corporation (“PNI”), acting as agent for and on behalf of Payors, specifically including but not limited to, Presbyterian Health Plan, Inc. (“PHP”), a duly licensed health maintenance organization, and Presbyterian Insurance Company, Inc. (“PIC”), a duly licensed health insurance company, (referred to collectively as “Health Plan”), and Provider (as defined below):
HELP AMENDMENT TO PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • November 18th, 2015
This Amendment is entered into by and between Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, (“BCBSMT”), and (“Participating Provider”) hereinafter referred to as the “Parties.” By executing this Amendment, Participating Provider agrees to participate in the BCBSMT HELP Program Network, under the terms and conditions of the BCBSMT Participating Provider Agreement (the “Agreement”) and this Amendment.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • January 18th, 2021 • New York
WHEREAS, SELE-DENT, INC., has established a network of Dentists to render services to employees/members (“Eligible Participants”) of certain employers, unions and organizations (“Clients”);
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • February 23rd, 2016 • New York
This agreement (the “Agreement”), effective , is entered into by and among Crystal Run Health Plan, LLC and Crystal Run Health Insurance Company, Inc., each with a corporate address of 109 Rykowski Lane, Middletown, NY 10941 (hereafter referred to collectively as “Crystal Run”) and (“Provider”), with an address of
PARTICIPATING PROVIDER AGREEMENT (1354)Participating Provider Agreement • November 12th, 2015
Provider agrees to render professional medical services, as defined in Provider Application and is incorporated into this Agreement between PPNI and the undersigned Provider, to PREMIER PROVIDER NETWORK, INC. (PPNI) Members (“Patients”) with the same level of care and services given to private patients and at the rates agreed to in the Provider Fee Schedule. Provider understands that neither PPNI nor its affiliates are claims paying agents (Payors) and that the Patient is responsible for payment of the rates as agreed to in the Provider Fee Schedule at time of service.
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • July 27th, 2018 • Georgia
and entered into by and among Zelis Network Solutions, LLC on behalf of itself and its subsidiaries and affiliates, including any and all entities under common ownership or control, with principal offices located at Two Concourse Parkway, Suite 300, Atlanta, GA 30328, (hereinafter referred to as “Network”) and “Network Provider” as defined below:
PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • March 3rd, 2018
This Participating Provider Agreement (together with all Attachments and amendments, this “Agreement”) is made and entered by and among (“Provider”), Carolina Complete Health, Inc., a North Carolina corporation (“Health Plan”) and Carolina Complete Health Network, Inc., a Delaware corporation (“CCHN”) and subsidiary of the North Carolina Medical Society. This Agreement is effective as of the date designated by Health Plan on the signature page of this Agreement (“Effective Date”). For purposes of this Agreement, each of Provider and Health Plan (and, solely for purposes of Article VIII, CCHN) may be referred to herein as a “Party” and collectively as the “Parties.”
MHA LONG TERM CARE NETWORK, INC. PARTICIPATING PROVIDER AGREEMENTParticipating Provider Agreement • November 1st, 2007 • Paramount Acquisition Corp • Blank checks • New Jersey
This Participating LTC Pharmacy Agreement (“Agreement”) is between MHA Long Term Care Network, Inc. (“Network”) a Delaware corporation located at 25A Vreeland Ave #203, Florham Park, New Jersey 07932 and the Long-Term Care Pharmacy (“LTC Pharmacy”) which has executed the signature page hereof.
PARTICIPATING PROVIDER AGREEMENT WITH HIGHMARK BLUE SHIELDParticipating Provider Agreement • January 18th, 2000
Under the applicable laws of the Commonwealth of Pennsylvania, I am duly authorized to engage in the practice of . In consideration of being registered by Highmark Inc. d/b/a Highmark Blue Shield, an independent licensee of the Blue Cross and Blue Shield Association (hereinafter termed "Blue Shield"), as a participating provider, I do hereby agree as follows:
