All providers interested in participation in the Carelon provider network are required to complete and sign a Carelon participating provider application. Applications will only be accepted for those counties and levels of care in which the network is active. The credentialing process should be completed within 180 days of the date the provider signs the attestation form of the application. Before the contract is executed, providers and their services must be approved by Carelon National Credentialing Committee (NCC). Carelon’s credentialing criteria are tailored not only to meet the Commonwealth’s licensing criteria, but also to ensure that providers who are expert in serving Medicaid recipients are included in the network.
Carelon identifies a full continuum of Behavioral Health providers and services as well as developing a range of Supplemental Services to meet the needs of members. Carelon continues to monitor provider capacity and appropriate resources to meet access standards for services required by the Commonwealth of Pennsylvania. As part of this review, we consider the number of network providers who are not accepting new members as well as member complaints and quality of care concerns. As appropriate, providers receiving three out-of-network authorizations will be recruited into the Carelon provider network.
Carelon may not employ or contract with providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act.
Carelon will not discriminate against providers that serve high risk populations or specialize in conditions that require costly treatment.
Carelon does not provide funding for demonstration projects.
Providers that are declined for inclusion in the network are given written notice of the reason for the decision.