SCAN Online Provider Portal Account Request Form

SCAN Online Provider Portal Account Request Form

For Contracted IPA and Downstream Providers

PLEASE READ: SCAN Health Plan® only grants access to SCAN contracted providers, IPA, and hospital and ancillary downstream providers affiliated with SCAN contracted affiliated providers or directly contracted with SCAN.
All non-contracted providers requiring eligibility and/or claims assistance, please contact:
·  Eligibility (SCAN’s Voice Response System): 877-270-7226; press option 8 to speak with a live representative.
·  SCAN Claims department: 800-307-8003
We are gathering this information to protect the confidentiality of member information. Information will be matched with the data stored in our system. Note that for Billing Services, additional documentation is required.
SCAN Contracted Affiliated Provider Information (Medical Group/IPA/Hospital/Ancillary) (Required)
IPA Hospital Ancillary / Eligibility verification Claims (only for SCAN direct contracted ancillary /hospital providers)
Provider Name: / Individual Organization
Provider NPI: / Provider tax ID:
Requestor Information
First and last name
Email address (required)
Organization name
Organization type / Physician Hospital Ancillary services Billing service
Other:
Physical/office address / Address:
City: State: ZIP:
Telephone/fax / Phone: Extension: Fax:
Billing address
(for our records only) / Physical address:
City: State: ZIP:
PO Box:
Tax ID: / NPI (required) Organization NPI: Individual NPI:
Physician’s State License No.
(if applicable)
Provider Administrator or Physician Signature
Title: / Signature:
Return completed form via secure email to .
(user account & temporary password will be send within 7 to 10 business days)

Network Management - Updated: 2/10/17