If you wish to add a practitioner to a current contract please follow these steps:
Please use this form to add a provider to your contract.
All licensed practitioners must be credentialed prior to providing services to CCHP members. (MD-DO-DPM-DC-APNP-CRNA-CNM-PhD-PsyD-LPC-LCSW-LMFT-CSAC-BCBA-AuD)
To participate in our BadgerCare product, applicants must be certified with Wisconsin Medicaid. To begin the credentialing process, CCHP uses the CAQH (Council for Affordable Quality Healthcare's) ProView™ application, which is available online.
- Already registered? Email your completed Practitioner Request Form to firstname.lastname@example.org
- Not registered? Register with CAQH at https://proview.caqh.org/PR/Registration and complete the CAQH credentialing application. Notify CCHP when you have registered with CAQH by emailing practitioner name, CAQH number, group name and individual NPI number to email@example.com
While completing the CAQH application, the following required information must be included in order to begin the credentialing process with CCHP:
- All information must be current and CAQH must be attested with current date
- All dates (work/employment/education) must include month and year
- Employment history for the last five years – must include start and end dates MDs/DOs must include complete history starting from medical education
- Gaps in employment greater than 60 days must be explained
- Hospital privileges must include hospital name, affiliation status, start date (MM/YY)
If in process, must include covering physician’s name, hospital affiliation, status, start date (month and year)
If no hospital privileges, need to explain admitting arrangements, if through a covering physician, include hospital name, affiliation status and start date (MM/YY)
- APNP’s / CRNA's are required to include a copy of their Collaborative Agreement, Specialty and/or Scope of Practice
- A copy of professional liability insurance face sheet (must include dates and incident/aggregate dollar amounts, amounts must be minimum $1 million/$3 million)