Provider Engagement Inquiry Form

Is this the same individual submitting the inquiry? * Yes No

Have you previously submitted a request to Provider Engagement through this Inquiry Form? * Yes No

Please select the category that most closely matches your inquiry. Availability: Relating to providers' ability to schedule an appointment for a member, including after hours, panel size, etc. Accessibility: After Hours coverage, accepting new members, telemedicine options, patient-centered medical home (PCMH) access. Accommodation: Supporting member needs and preferences (e.g., wheelchair access , languages spoken, ages served, etc.) Acceptability: Members comfort and experience with provider characteristics (e.g., language, office hours) Member Moves – Out of Area only requests Panel Status

Please select the category that most closely matches your inquiry. Site Required Inspection scheduling with your Provider Engagement Account Manager (PEAM) Education on credentialing or recredentialing process Guidance on health plan Electronic Medical Record (EMR) partners Member roster questions (for providers with assigned members) Medical record requests for Risk Adjustment or Chart Chase General claims questions related to resources and billing Escalating unresolved concerns after appropriate channels have been followed

Please select the category that most closely matches your inquiry. Education on high‑cost drugs and alternative treatment options Education on Identifying members overdue for preventive care visits Reviewing trends related to hospital readmissions or frequent ER visits Incentive opportunities tied to outreach, care objectives, and chronic condition management Mitigating member costs (hospital, pharmacy, etc.) Risk Adjustment documentation and capture Specialist referral support and guidance

What PE can do for you

When Should I Use This Form?

Provider Resources

Provider News

Provider Tools & Self-Service Forms

Standards for Appointment Scheduling

Provider Engagement Inquiry Form