Provider Manual

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:

• Provider-facing and in the field
• Recruitment
• Focus on all providers achieving success and improving provider experience by implementing a high-touch relationship-driven service model
• Signatories for PROMISe enrollment attestation
• Assess network adequacy & availability
• We consider our providers partners!
  • Through partnership, we are looking to create a lasting impact and creating administrative simplicity so providers can continue being the experts in caring for their patients – our members.