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)

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Submitter Contact Information

Submitter Contact Information

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

Physician Information

 
Hospital Privilege Information

Practitioners are required to have staff privileges with a UPMC Insurance Services Division participating hospital at the time of credentialing.

The following practitioner types may be exempted from having hospital privileges, if they have a written admitting arrangement with a like participating practitioner or hospitalist and acknowledged by all parties, who will admit members to a UPMC Insurance Services Division participating hospital. The hospitalist must be contracted with a participating hospital

  • Allergy & Immunology
  • Dermatology
  • Dental Anesthesiology
  • Pain Management
  • Physician Medicine & Rehabilitation
  • Primary Care Providers including Family Medicine, General Practice, Internal Medicine, Pediatrics specialties
  • Ophthalmologists who only participate in the UPMC Vision Advantage Plan
  • Specialist Providers who have downsized the scope of their practice to only see patients in the office.
  • Physician Extenders must have admitting privileges to a UPMC Insurance Services Division hospital, or an agreement with either a collaborating physician or a hospitalist organization who has admitting privileges to a UPMC Insurance Services Division participating hospital and is a participating physician with UPMC Insurance Services Division, recognizing that these two roles may not necessarily be performed by the same person.
 

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.

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.

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