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Add a New Provider or Term an Existing Provider

Add a New Provider or Term an Existing Provider

If submitting for specific WellCare product(s), indicate applicable products in Comments section

If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required.
 

EHP Roster Template (Excel)
(Roster template revised 02/04/2022)

1. Providers must be IMPACT approved for any Medicaid, YouthCare, or Dual product, and Medicaid numbers must be supplied

2. Prior to Ambetter and Medicare submissions:

  • Validate CAQH is current and accessible to the health plan for all practitioners
  • NOTE: CMS does not allow more than 20 locations per practitioner
  • If submitting a new facility or clinic, a credentialing application (PDF) will be required, along with the documents referenced on the last page of the application.

Update Requested By

If submitting for specific WellCare product(s), indicate applicable products in Comments section

Provider Name

Practitioner will be termed from all locations associated with this TIN.

If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required.

EHP Roster Template (Excel)
(Roster template revised 02/04/2022)

Update Requested By

This form will send your message to EHP Contracting as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with EHP Contracting through email, you accept associated risks. EHP Contracting does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.