Manuel du fournisseur


Providers must immediately notify Carelon Health of Pennsylvania (Carelon) by calling their Provider Field Coordinator or through notification in writing by mail, email or facsimile to 1-855-541-5211 (attention Provider Relations Department) upon the occurrence of any of the following:

  1. Inability to provide emergent care within one hour, urgent care within 24 hours, or routine care within seven days;
  2. Usage of alternative provider coverage in any situation when unable to treat Carelon members in active treatment (e.g. vacation);
  3. When reaching full (100%) capacity. Full capacity is considered the point at which the provider is unable to meet the access standards noted above or is unable to accept referrals for a particular level of care. Notices for full (100%) capacity should contain the reason for reaching capacity, the effective date, and the steps the provider will take to resume functioning at normal capacity.
  4. The inability to provide any portion of a prescribed service.

Network providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service if the provider serves only Medicaid members.