1701 River Run, Suite 1103
Fort Worth, TX 76107
Ph: (817)484-6274 Fax: (817)420-9656
Provider name:______Look up key (TIOPA use only):______
Managed Care Organization SelectionsPlease select opt in or opt out on all options listed below and return with your credentialing application and required documentation.
BEHAVIORAL HEALTH
Associated Administrators Group, Inc (AAGI) dba Nexcaliber PPO
Opt In
Opt Out
Averde Hi Deductible PPO
Opt In
Opt Out
Beechstreet/ Concentra – PPO and Accelerated Payment
Opt In - PPO
Opt In – Accelerated Payment
Opt Out
Coventry/First Health – Auto and PPO
Opt In – PPO
Opt In – Auto
Opt Out
Galaxy Health Network – PPO, Commercial Medical Savings Card and Medicare Supplement
Opt In - PPO
Opt In – Medical Savings Card
Opt In – Medicare Supplement
Opt Out
Healthsmart Preferred Care – EPO, GEPO, POS and PPO
Opt In – EPO
Opt In – GEPO
Opt In – POS
Opt In – PPO
Opt In – Advanced Provider Payor Partnership (AP3)
Opt Out
Independent Medical Systems (IMS) – PPO
Opt In
Opt Out
Integrated Health Plan – PPO
Opt In – PPO
Opt Out
Interplan Health Group – PPO
Opt In – Accountable PPO
Opt In – Direct Care PPO
Opt In – Health Payors PPO
Opt Out
Miers Group – PPO and HMO
Opt In – HMO
Opt In – PPO
Opt Out
Multiplan – PPO and Value Point Discount Card
Opt In – PPO
Opt In – Value Point Medical Savings Card
Opt Out
National Choice Care –Auto and Group Health PPO
Opt In – Auto
Opt In – PPO (Group Health)
Opt Out
National Preferred Provider Network (NPPN) – PPO
Opt In
Opt Out
Prime Health Services, Inc – Auto, EPO, Group Health, IME and PPO
Opt In – Auto
Opt In – Group Health
Opt In – PPO
Opt Out
Private Healthcare Systems, Inc. (PHCS) – PPO and Savility PPO
Opt In – PPO
Opt In – Savility PPO
Opt Out
Provider Select, Inc – PPO Fka Provider Strategies, Inc.
Opt In
Opt Out
Texas True Choice – Star Network – Commercial PPO
Opt In – Star Network PPO
Opt Out
Three Rivers Provider Network – PPO (Auto, General Liability & Health)
Opt In – PPO
Opt Out
Universal Health Care of Texas
Opt In – PPO
Opt Out
USA Managed Care Organization – PPO and CHIP
Opt In – PPO
Opt In – CHIP
Opt Out
Worker’s Compensation ProductsIf you do not accept WC patients, please do not opt in to these plans.
BEHAVIORAL HEALTH
Interplan Health Group dba Accountable Health Plan – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Aetna Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Beechstreet/Concentra – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Coastalcomp Health Networks – Work Injury
Opt In – Work Injury
Opt Out
Corvel Healthcare – Worker’s Compensation (Must fill out attached attestation if opting in)
Opt In – Worker’s Compensation
Opt Out
Coventry/First Health – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Galaxy Health Network – Non-subscriber Work-related Injury
Opt In
Opt Out
Health e Innovations by Claims Administrative Services, Inc. – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Healthsmart Preferred Care – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Integrated Health Plan – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
National Choice Care – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Prime Health Services, Inc – Worker’s Compensation
Opt In – Worker’s Compensation
Opt In – EPO – Imaging & Diagnostic Network (Carveout)
Opt In – IME – Independent Medical or Second Opinion Network (Carveout)
Opt Out
The Reny Company – Non-subscriber Work Injury
Opt In
Opt Out
Rockport Healthcare Group - Worker’s Compensation
Opt In
Opt Out
Texas Healthcare Foundation – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Three Rivers Provider Network – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
USA Managed Care Organization – Worker’s Compensation
Opt In – Worker’s Compensation
Opt Out
Medicaid AND cHIP PRODUCTSMust have TPI number that has been attested to NPI number to participate in these plans
BEHAVIORAL HEALTH
Amerigroup Texas, Inc.
Opt In – HMO Medicaid
Opt In – CHIP
Opt In – Star Plus
Opt Out
Bravo Health Texas
Opt In – Star Plus
Opt Out
Molina
Opt In – CHIP
Opt In – HMO Medicaid
Opt In – Star Plus
Opt Out
Superior Health Plan
Opt In – CHIP
Opt In – Foster Care
Opt In – Star Plus
Opt Out
Texas True Choice – CHIP and Foster Care
Opt In – CHIP
Opt In – Foster Care
Opt Out
Universal Health Care – CHIP and Medicaid HMO
Opt In – CHIP
Opt In – Medicaid HMO
Opt Out
MEDICARE ADVANTAGE PRODUCTSYou must have an active Medicare number to participate with these plans
BEHAVIORAL HEALTH
Amerigroup Medicare Advantage HMO
Opt In
Opt Out
Bravo – Medicare Advantage PPO and HMO – Please note: The PPO products is not available in Rockwall, Ellis, Wise, Parker, Hood or Johnson counties.
Opt In – Medicare Advantage PPO
Opt In – Medicare Advantage HMO
Opt Out
Coventry/First Health (Advantra Medicare) – Medicare Advantage PPO
Opt In
Opt Out
Molina
Opt In – Special Needs Medicare Advantage
Opt In – Medicare Advantage HMO
Opt Out
Prime Health Services, Inc
Opt In – Medicare Advantage PFFS
Opt In – Medicare Advantage PPO
Opt Out
Superior Health Plan
Opt In – Medicare Advantage HMO
Opt Out
Universal American dba Texas First Healthplans – Medicare Advantage PPO and HMO
Opt In – Medicare Advantage PPO (Today’s Options PPO)
Opt In – Medicare Advantage HMO (Texan Plus HMO)
Opt Out
Texas Health Spring – Medicare Advantage PPO
Opt In
Opt Out
Universal Healthcare Medicare Advantage
Opt In – Medicare Advantage HMO
Opt In – Medicare Advantage PPO
Opt Out
Wellcare – Medicare Advantage HMO
Opt In
Opt Out
XL Health – Care Improvement Plus – Medicare Advantage PPO (Special needs – Congestive Heart Failure, End Stage Renal Disease, Chronic Obstructive Pulmonary Disorder and Diabetes patients only)
Opt In
Opt Out
Provider NameProvider Signature
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Date
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Updated October 5, 2018