Join Our Provider Network


This submission is a request for participation only and not the formal credential application.
Please allow up to 10 business days for a response.


Submitter Contact Information

Ancillary Providers
Physicians and Extenders (CRNP, CNM, CRNA)
Ancillary Providers Physicians and Extenders (CRNP, CNM, CRNA, PA)
* Indicates required field

Providers that utilize CAQH may enter their CAQH Provider ID in the space below.After review of the participation request submitted, UPMC Health Plan will retrieve the provider's CAQH application for credentialing. Please ensure CAQH has recently been attested, all documentation is current, and UPMC has authorization to view the application.

CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

Submitter Contact Information

Submitter Contact Information

 
 
Physician Information – All providers fill out this section – All providers fill out this section

Physician Information

 

Please be aware that you may not qualify to be contracted for all the products you have selected.

PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products.

Practice Information

Practice Information


Primary Practice:
 
 
Secondary Practice:
 
 

Providers that utilize CAQH may enter their CAQH provider ID in the space below. After review of the participation request submitted, UPMC Health Plan will retrieve the provider’s CAQH application for credentialing.

CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

Please note, PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products

By submitting this request for participation, I hereby attest that all of the information I am about to submit is true and accurate to the best of my knowledge. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from UPMC Health Plan should I be approved.