Request Participation within our Network
Thank you for your interest in participating with Health Net Health Plan of Oregon. We are excited that you have selected our provider network as your network of choice. Please select the Network Participation Request Form listed below based on your specialty and services you provide. Please return this completed form, along with your W9, to our email address: NewProviderRequestBox@TrilliumCHP.com (Please note: these forms do not replace the credentialing forms/ requirements for our contractual agreements and requirements)
Network Participation Request Forms:
All Medical Specialties except Behavioral Health/Substance use, and except requests managed by “External Contractors” Physician Network Participation Request Form (PDF)
- Solo Practitioners
- Allied health professionals such as:
- Dietitian, Nutritionist
- Physician Assistant
- Medical Groups
- Multi-Specialty Medical Groups
Ancillary Network Participation Request Forms:
- Ambulatory surgery centers (ASCs)
- Dialysis facilities
- Durable medical equipment (DME)
- Home health
- Home Infusion
- Long term acute care (LCTA)
- Orthotics and prosthetics (O&P)
- Ostomy and medical supplies
- Skilled nursing facilities (SNF)
- Sleep study centers
Network Requests Managed by External Contractors:
- Behavioral Health:
Unless an employer group utilizes another behavioral plan, MHN manages behavioral health and substance abuse benefits for Health Net members.
- Contact MHN directly or call 1-800-977-8216 to request participation in the MHN network.
- Physical Therapy, Speech Therapy and Occupational Therapy:
Contact Northwest Rehab Alliance (NWRA) at 1-800-219-8835 or email at firstname.lastname@example.org or visit the NWRA website
- Alternative Care Specialties such as Chiropractic, Naturopathic, Acupuncture- (Statewide)
Contact ASH Network (American Specialty Healthcare) at 1-800-678-9133 or visit the ASH Network website
- Retail Pharmacies:
Contact CVS Caremark® at 480-314-8457
- Vision Providers:
Contact EyeMed Vision Care online at the EyeMed website or 1-866-392-6058
- Dental Providers:
Contact Dental Benefit Providers (DBP) 1-877-410-0176
Network Participation Next Steps:
Once you have completed a Network Participation form, please email all of the documents to the email address listed above. Someone from our contracting department will review your request for network addition/participation. A representative will be in contact with you with regarding status of this review. (Please note: If you receive a contract, there will be additional credentialing documents required to finish the contracting process, see next sections.)
Credentialing Requirements/Forms for Contracted Practitioners:
- Data Form*
- Oregon Practitioner Credentialing Application (PDF) (Required only if not registered in CAQH)*
- Oregon Licensure*
- DEA (if applicable)*
- Certificate of Professional Liability Insurance*
- DOO 3974 for the group name, TIN and group NPI
*Action Required: If your practitioners are registered with CAQH, documents noted above are required to be uploaded in CAQH and current. Please authorize Centene Corp to access applications in CAQH.
Credentialing Requirements/Forms for Contracted Facilities
In order to complete enrollment, the following is required for facility credentialing:
- Facility Checklist (PDF)
- Facility Credentialing Application OPCA (PDF)
- Organizational Attestation (PDF)
- Policy for Seclusion and Restraint, OAR 410-141-3590 (2) (cc)
How Health Net Can Help you
Let us help you keep your practice in tip-top shape. Use the provider portal for the following:
- Create multiple user accounts for your staff members.
- Control permission settings for each staff member's account.
- Keep track of payments.
- Convenient 24/7 access to the forms you need most.