NETWORK MANAGEMENT FUNCTIONS
Carelon recognizes and acknowledges that our provider network is not only crucial to the success of our program, but also serves as one of our major “clients.” Because of this philosophy, network management functions have been carefully designed to provide a full range of services to our participating providers. These services are described below.
The Member and Provider Service staff is available from 8:00am to 5:00pm, Eastern Standard Time, Monday through Friday via the toll-free provider line at 877-615-8503.
The Member and Provider Service Representatives are responsible for handling questions directly or referring providers to other staff responsible for particular areas. Their departmental functions, relating to provider services, include:
- General provider information;
- Claims billing instructions;
- Claims adjustment research; and
- Provider education and problem solving.
Provider Field Coordinators assigned to specific counties or projects provide the following functions:
- Inquiries on joining the network;
- Application status;
- Credentialing and recredentialing;
- Network design, including contracting;
- Network monitoring; and
- Provider education.
In addition to answering providers’ questions and providing technical assistance, the Network Operations Manager ensures the provider’s demographic and reimbursement information is accurately loaded in the CareConnect. The Network Representatives are tasked with the following duties:
- Entering/updating demographic information (e.g., name, address, tax ID);
- Tracking services provided;
- Maintaining reimbursement schedules; and
- Monitoring network status.