Internal Athletico Payor Relations Request Form
Prior to submitting a form, please ensure applicable attachments are included and all required fields are completed. If these requirements are not met, the form will be rejected.
- Must provide all applicable attachments (if applicable, attachments will be uploaded on next page after form is submitted)
- Must have all required fields completed
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Credentialing
Use this form if you need to:
- Request verification of new-hire enrollment status with contracted payors that require individual credentialing
- Request verification of out-of-network status for credentialed/enrolled providers or centers
- Review NPI discrepancies
- Request a review of provider directory discrepancies, including missing or incorrect location
- Review claim denials for credentialed or enrolled providers or centers
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Contract Network Status
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New Contract Network Participation
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Direct to Employer Agreement
Use this form if you need to:
Submit a request for employer agreements specific to an employer that would like to directly reimburse Athletico for services.
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Single Case Agreement
Use this form if you need to:
Submit a request for agreements specific to a particular individual that Athletico does not currently have a contract in place.
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Sub-Contractor Agreement
Use this form if you need to:
Submit a request for agreements (generally for workers’ compensation clients) when the current provider can’t meet the access requirements.
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Request for Proposal
Use this form if you need to:
Submit a request for RFP completion from potential partners.