Provider Forms


How to Join Sagamore Health Network or submit changes.

What provider types does Sagamore Health Network, Inc. credential for participation?

Sagamore Health Network, Inc. currently credentials the following providers:

APN, APRN, ARNP – Advanced Practice Nurse LCSW – Licensed Clinical Social Worker
CNM – Certified Nurse Midwife LMFT – Licensed Marriage & Family Therapist
CNS, RN CNS – Clinical Nurse Specialist LMHC – Licensed Mental Health Counselor
CRNA – Certified Registered Nurse Anesthetist MD – Medical Doctor
DC – Chiropractor NP, ACNP, RN RNP – Nurse Practitioner
DDS, DMD – Oral Surgeon only OD - Optometrist
DO – Doctor of Osteopathy PA – Physician Assistant
DPM – Podiatrist PhD, PsyD, EdD – HSPP certified - Psychologist


What do I need to do if I want to join Sagamore Health Network, Inc.?

*If you are located in one of the following Indiana counties: Marshall or St. Joseph, please contact Provider Services at Select Health South Bend at (574) 283-5926.

For New Physicians, Psychologists and Allied Health Professionals/Mid-level Providers Wishing to Participate with Sagamore Health Network:

Sagamore requires the CAQH (Council for Affordable Quality Healthcare) application as the uniform application to be used. Below are the instructions for submitting information for credentialing:

  1. Please locate the Provider Data Sheet below and click on the link provided to complete. After completion, please print out the form and fax along with a W-9 to Network Development at
    (317) 573-2799. Please note that if you are submitting a PPO Provider Agreement along with this form you must mail the data sheet along with W-9 and contract to Sagamore Health Network, ATTN: Network Development, 11595 N. Meridian St., Ste. 600, Carmel, IN 46032.
  2. If you are not currently registered with CAQH and would like to register you may contact Network Development at (317) 208-3347 or (800) 933-3466 ext. 2083347 to set up CAQH ID.
  3. Midlevel providers (APN, APRN, ARNP, CNM, CNS, RN CNS, CRNA, DC, LCSW, LMFT, LMHC, NP, ACNP, RN RNP, OD & PA) please note that a one-time non-refundable application fee of $50.00 must be submitted with your completed Provider Data Sheet and W-9. The application fee helps defray costs associated with credentialing, administration and directory printings.

DATA SHEET/APPLICATION FORMS

Provider Data Sheet – must have CAQH Provider ID View

Please Note: To avoid delays in the credentialing process, the data sheet, W-9 and contract (if needed) should all be sent in together. CAQH must also be complete and all documents current.

Providers are afforded the opportunity to obtain the status of their credentialing or recredentialing application upon request and to review information, correct incomplete, inaccurate, or conflicting credentialing information. Any communication with Sagamore or CIGNA regarding provider credentialing data is confidential peer review communication protected by the Indiana Peer Review Act (I.C. 34-30-15-1 et. seq.).

For New Ancillary Facilities:

This section is for Ancillary Facilities only:
(Non-hospital & non-physician such as: ambulatory surgery centers, dialysis centers, durable medical equipment, home infusion therapy, hospice, labs, mental health facilities, orthotics and prosthetics, radiology, rehabilitation centers, among others).

Please click here to complete the New Ancillary Facility Questionnaire, print out the form and fax or mail to the Ancillary Contracting Specialist. The form may be completed online and printed, or you may choose to print a blank form.

This form is not the Application, it is only the questionnaire to begin the Application process. For questions, please contact the Ancillary Contracting Specialist at: (317) 208-3345 or (800) 933-3466
ext. 2083345.

For Hospitals:

Please contact the Network Development Contracting Assistant at (317) 208-3347 or (800) 933-3466
ext. 2083347, and they will direct you to the Contracting Representative for your area.

For Demographic Changes:

What do I need to do if I am a current provider with Sagamore Health Network, Inc. and need to make changes to my demographic information?

  1. Locate the Provider Action Request (PAR) Form below and click the provided link.
  2. Complete form with provider’s current information and the information you need to add, change, or delete. (Current information is important as most providers have multiple records within our system, and it is important to know precisely which record needs to be changed.)
  3. Mail or fax the completed form and required documents to Sagamore Health Network, Inc. as instructed on the bottom of the form.

PAR FORM - for a Participating Provider wishing to make any changes to current demographic information:

Provider Action Request Form (doc) View

Questions?

  • For Physician or Allied Health Professionals, please contact Network Development Contracting Assistant at (317) 208-3347 or (800) 933-3466 ext. 2083347 and they will direct you to the Contracting Representative for your area.
  • For Ancillary demographic changes, please contact the Ancillary Coordinator at (317) 208-3345 or (800) 933-3466 ext. 2083345.
  • For Hospital demographic changes, please contact the Network Development Contracting Assistant at (317) 208-3347 or (800) 933-3466 ext. 2083347 and they will direct you to the Contracting Representative for your area.