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:   
				

					

						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.  
					

						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.    
					

						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?
				

					

					Locate the Provider Action Request (PAR) Form below and click the provided link. 
					

					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.)  
					

					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.