INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35339, 1019, 27367, NULL, '2021-05-11 00:00:00.000', 'Approved', 'Welcome Letter attached. Eff 11/27/2019', NULL, NULL, '2021-05-04 10:30:36', '2021-05-04 10:30:36'),
(35340, 1019, 27368, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35341, 1019, 27368, NULL, '2021-05-11 00:00:00.000', 'Approved', 'Welcome Letter Attached. Eff 11/06/2020', NULL, NULL, '2021-05-04 11:12:19', '2021-05-04 11:12:19'),
(35342, 1019, 27369, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35343, 1019, 27369, NULL, '2021-05-11 00:00:00.000', 'Approved', 'Welcome Letter attached. Eff 03/17/2020', NULL, NULL, '2021-05-04 10:52:45', '2021-05-04 10:52:45'),
(35344, 1019, 27370, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35345, 1019, 27370, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-05-04 08:42:54', '2021-05-04 08:42:54'),
(35346, 1019, 27370, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to : provider.relations@beaconhealthoptions.com SUB: Enrollment Status || Providers || SNBCARE || Beacon   Hello, Can you please let me know about the enrollment status for following providers under our group.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-04 08:43:08', '2021-05-04 08:43:08'),
(35347, 1019, 27370, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Received the following email from Sarah: provider.relations@beaconhealthoptions.com Good Morning, I have reviewed each provider file and have left notes below in red.  Rodesia Edmundson – Application received 4/6/21 and still processing – Event 9091975 NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Barbara Hignite – Application received 4/6/21 and still processing – Event 9091459 NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell – Application received 4/7/21 and still processing – Event 9093081 NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich – Application received 4/5/21 and still processing – Event 9091316 NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere – Application received 4/7/21 and still processing – Event 1098601 NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman – CAQH Application needed – please complete attached application and return for processing NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva – Application received 4/7/21 and still processing – Event 9093128 NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile – Application received 4/7/21 and still processing – Event 9093091 NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Thank You!     Sarah Oakes  Network Management Rep I, Northeast  –––––––––––––––––––––––  Beacon Health Options  500 Unicorn Park Drive Suite 401  Woburn, MA 01801  Office: 800.397.1630  Direct: 781-496-4024  www.beaconhealthoptions.com', NULL, NULL, '2021-05-04 08:43:19', '2021-05-04 08:43:19'),
(35348, 1019, 27370, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Called Beacon @ (800) 397-1630 spoke with rep Sierra conversation is mentioned below:  All providers applications have been received and are under review and group is added under all three locations under both plans (BHO/BHS) we have request the copy of group contract. we\'ll receive the contract in 3-2 business days.  Ref# 04/22/2021 - 1371173 Sierra Y', NULL, NULL, '2021-05-04 08:43:34', '2021-05-04 08:43:34'),
(35349, 1019, 27370, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: RE: Enrollment Status || Providers || SNBCARE || Beacon attn Shashi  Hello Shashi, Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.   Individual Provider   L\'Etoile, Melody NPI: 1942687108 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Edmundson, Rodesia NPI: 1124622667 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hefti, Prisca NPI: 1508133182 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Khan, Fauzia Wali NPI: 1699761965 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Pionke, Peggy NPI: 1699307322 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rashid, Mahreen NPI: 1396393146 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Schubert, Jonathan NPI: 1235755505 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Smith, Kerry NPI: 1275083230 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Tawakol, Katie NPI:1609222116 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-04 08:43:49', '2021-05-04 08:43:49'),
(35350, 1019, 27370, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:31:11', '2021-05-20 08:31:11'),
(35351, 1019, 27370, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:54', '2021-06-05 11:20:54'),
(35352, 1019, 27370, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:04:10', '2021-06-24 08:04:10'),
(35353, 1019, 27370, NULL, '2021-09-03 00:00:00.000', 'Not Eligible', 'Provider is no longer working with SNBCARE ', NULL, NULL, '2021-08-27 08:34:36', '2021-08-27 08:34:36'),
(35354, 1019, 27371, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35355, 1019, 27371, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-05-04 08:38:41', '2021-05-04 08:38:41'),
(35356, 1019, 27371, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to : provider.relations@beaconhealthoptions.com SUB: Enrollment Status || Providers || SNBCARE || Beacon   Hello, Can you please let me know about the enrollment status for following providers under our group.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-04 08:38:57', '2021-05-04 08:38:57'),
(35357, 1019, 27371, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Received the following email from Sarah: provider.relations@beaconhealthoptions.com Good Morning, I have reviewed each provider file and have left notes below in red.  Rodesia Edmundson – Application received 4/6/21 and still processing – Event 9091975 NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Barbara Hignite – Application received 4/6/21 and still processing – Event 9091459 NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell – Application received 4/7/21 and still processing – Event 9093081 NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich – Application received 4/5/21 and still processing – Event 9091316 NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere – Application received 4/7/21 and still processing – Event 1098601 NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman – CAQH Application needed – please complete attached application and return for processing NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva – Application received 4/7/21 and still processing – Event 9093128 NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile – Application received 4/7/21 and still processing – Event 9093091 NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Thank You!     Sarah Oakes  Network Management Rep I, Northeast  –––––––––––––––––––––––  Beacon Health Options  500 Unicorn Park Drive Suite 401  Woburn, MA 01801  Office: 800.397.1630  Direct: 781-496-4024  www.beaconhealthoptions.com ', NULL, NULL, '2021-05-04 08:39:15', '2021-05-04 08:39:15'),
(35358, 1019, 27371, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Called Beacon @ (800) 397-1630 spoke with rep Sierra conversation is mentioned below:  All providers applications have been received and are under review and group is added under all three locations under both plans (BHO/BHS) we have request the copy of group contract. we\'ll receive the contract in 3-2 business days.  Ref# 04/22/2021 - 1371173 Sierra Y', NULL, NULL, '2021-05-04 08:39:26', '2021-05-04 08:39:26'),
(35359, 1019, 27371, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: RE: Enrollment Status || Providers || SNBCARE || Beacon attn Shashi  Hello Shashi, Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.   Individual Provider   L\'Etoile, Melody NPI: 1942687108 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Edmundson, Rodesia NPI: 1124622667 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hefti, Prisca NPI: 1508133182 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Khan, Fauzia Wali NPI: 1699761965 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Pionke, Peggy NPI: 1699307322 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rashid, Mahreen NPI: 1396393146 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Schubert, Jonathan NPI: 1235755505 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Smith, Kerry NPI: 1275083230 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Tawakol, Katie NPI:1609222116 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-04 08:39:36', '2021-05-04 08:39:36'),
(35360, 1019, 27371, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:32:36', '2021-05-20 08:32:36'),
(35361, 1019, 27371, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:46', '2021-06-05 11:20:46'),
(35362, 1019, 27371, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:04:04', '2021-06-24 08:04:04'),
(35363, 1019, 27371, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  Hello, Can you please let me know about the enrollment status for the following providers under our group.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Rodesia Edmundson NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Mary Gibbons  NPI: 1942388483  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702.  Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Prisca Hefti NPI: 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Fauzia Wali Khan  NPI: 1699761965  Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Lynetta Loveland NPI: 1598163602  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Cemetrice Muhammed NPI: 1548843410  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Regards,  Alex', NULL, NULL, '2021-08-24 11:23:46', '2021-08-24 11:23:46'),
(35364, 1019, 27371, NULL, '2021-09-20 00:00:00.000', 'Approved', 'Eff 08/13/2021, attached is the Welcome Letter for ref', NULL, NULL, '2021-09-13 09:48:51', '2021-09-13 09:48:51'),
(35365, 1019, 27372, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35366, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-05-04 08:35:52', '2021-05-04 08:35:52'),
(35367, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Resent the CAQH application by fax at (866) 612-7790 ', NULL, NULL, '2021-05-04 08:36:07', '2021-05-04 08:36:07'),
(35368, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to : provider.relations@beaconhealthoptions.com SUB: Enrollment Status || Providers || SNBCARE || Beacon   Hello, Can you please let me know about the enrollment status for following providers under our group.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-04 08:36:20', '2021-05-04 08:36:20'),
(35369, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Received the following email from Sarah: provider.relations@beaconhealthoptions.com Good Morning, I have reviewed each provider file and have left notes below in red.  Rodesia Edmundson – Application received 4/6/21 and still processing – Event 9091975 NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Barbara Hignite – Application received 4/6/21 and still processing – Event 9091459 NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell – Application received 4/7/21 and still processing – Event 9093081 NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich – Application received 4/5/21 and still processing – Event 9091316 NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere – Application received 4/7/21 and still processing – Event 1098601 NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman – CAQH Application needed – please complete attached application and return for processing NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva – Application received 4/7/21 and still processing – Event 9093128 NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile – Application received 4/7/21 and still processing – Event 9093091 NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Thank You!     Sarah Oakes  Network Management Rep I, Northeast  –––––––––––––––––––––––  Beacon Health Options  500 Unicorn Park Drive Suite 401  Woburn, MA 01801  Office: 800.397.1630  Direct: 781-496-4024  www.beaconhealthoptions.com', NULL, NULL, '2021-05-04 08:36:31', '2021-05-04 08:36:31'),
(35370, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Called Beacon @ (800) 397-1630 spoke with rep Sierra conversation is mentioned below:  All providers applications have been received and are under review and group is added under all three locations under both plans (BHO/BHS) we have request the copy of group contract. we\'ll receive the contract in 3-2 business days.  Ref# 04/22/2021 - 1371173 Sierra Y', NULL, NULL, '2021-05-04 08:36:41', '2021-05-04 08:36:41'),
(35371, 1019, 27372, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: RE: Enrollment Status || Providers || SNBCARE || Beacon attn Shashi  Hello Shashi, Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.   Individual Provider   L\'Etoile, Melody NPI: 1942687108 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Edmundson, Rodesia NPI: 1124622667 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hefti, Prisca NPI: 1508133182 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Khan, Fauzia Wali NPI: 1699761965 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Pionke, Peggy NPI: 1699307322 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rashid, Mahreen NPI: 1396393146 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Schubert, Jonathan NPI: 1235755505 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Smith, Kerry NPI: 1275083230 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Tawakol, Katie NPI:1609222116 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-04 08:36:54', '2021-05-04 08:36:54'),
(35372, 1019, 27372, NULL, '2021-05-27 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:24:42', '2021-05-20 08:24:42'),
(35373, 1019, 27372, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:40', '2021-06-05 11:20:40'),
(35374, 1019, 27372, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:03:59', '2021-06-24 08:03:59'),
(35375, 1019, 27372, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com   Hello, Can you please let me know about the enrollment status for the following providers under our group. Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Individual NPI: Rodesia Edmundson NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767. Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767. Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Prisca Hefti NPI: 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767. Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767. Fauzia Wali Khan NPI: 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767. Lynetta Loveland NPI: 1598163602 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767. Cemetrice Muhammed NPI: 1548843410 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Regards, Alex', NULL, NULL, '2021-08-24 11:16:44', '2021-08-24 11:16:44'),
(35376, 11056, 27372, NULL, '2021-12-09 00:00:00.000', 'In Process', 'Email received from:  provider.relations@beaconhealthoptions.com  Sub:  JESSICA HARTMAN Beacon  Good afternoon,     We have looked into the providers listed below in table and have a few updates:     Jessica Hartman – Missing ANCC certification and the application has been denied. You will need to reapply for this provider on the online portal including the ANCC certification.     The other 3 providers listed below are currently in process.     Please let me know if you have any other questions.     Thank you        Dan Haller  Provider Network Consultant  Northeast Provider Relations  Beacon Health Options', NULL, NULL, '2021-12-02 16:49:35', '2021-12-02 16:49:35'),
(35377, 11056, 27372, NULL, '2021-12-10 00:00:00.000', 'Not Eligible', 'Due to ANCC certification.  Jessica Hartman – Missing ANCC certification and the application has been denied. ', NULL, NULL, '2021-12-03 13:03:37', '2021-12-03 13:03:37'),
(35378, 1019, 27373, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35379, 1019, 27373, NULL, '2021-05-11 00:00:00.000', 'On Hold', 'The enrollment request is pending on the provider\'s RI PMHNP license to be issued. ', NULL, NULL, '2021-05-04 08:51:01', '2021-05-04 08:51:01'),
(35380, 1019, 27373, NULL, '2021-11-01 00:00:00.000', 'Not Eligible', 'Provider will no longer be working with SNBCare.', NULL, NULL, '2021-10-25 10:42:32', '2021-10-25 10:42:32'),
(35381, 1019, 27374, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-03 15:24:23', '2021-05-03 15:24:23'),
(35382, 1019, 27374, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-05-04 08:32:59', '2021-05-04 08:32:59');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35383, 1019, 27374, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to : provider.relations@beaconhealthoptions.com SUB: Enrollment Status || Providers || SNBCARE || Beacon   Hello, Can you please let me know about the enrollment status for following providers under our group.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-04 08:33:11', '2021-05-04 08:33:11'),
(35384, 1019, 27374, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Received the following email from Sarah: provider.relations@beaconhealthoptions.com Good Morning, I have reviewed each provider file and have left notes below in red.  Rodesia Edmundson – Application received 4/6/21 and still processing – Event 9091975 NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Barbara Hignite – Application received 4/6/21 and still processing – Event 9091459 NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell – Application received 4/7/21 and still processing – Event 9093081 NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich – Application received 4/5/21 and still processing – Event 9091316 NPI: 1710489760 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Justin Souliere – Application received 4/7/21 and still processing – Event 1098601 NPI: 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Jessica Hartman – CAQH Application needed – please complete attached application and return for processing NPI: 1326665472 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva – Application received 4/7/21 and still processing – Event 9093128 NPI: 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile – Application received 4/7/21 and still processing – Event 9093091 NPI: 1942687108  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Thank You!     Sarah Oakes  Network Management Rep I, Northeast  –––––––––––––––––––––––  Beacon Health Options  500 Unicorn Park Drive Suite 401  Woburn, MA 01801  Office: 800.397.1630  Direct: 781-496-4024  www.beaconhealthoptions.com', NULL, NULL, '2021-05-04 08:33:19', '2021-05-04 08:33:19'),
(35385, 1019, 27374, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Called Beacon @ (800) 397-1630 spoke with rep Sierra conversation is mentioned below:  All providers applications have been received and are under review and group is added under all three locations under both plans (BHO/BHS) we have request the copy of group contract. we\'ll receive the contract in 3-2 business days.  Ref# 04/22/2021 - 1371173 Sierra Y', NULL, NULL, '2021-05-04 08:33:28', '2021-05-04 08:33:28'),
(35386, 1019, 27374, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: RE: Enrollment Status || Providers || SNBCARE || Beacon attn Shashi  Hello Shashi, Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.   Individual Provider   L\'Etoile, Melody NPI: 1942687108 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. Edmundson, Rodesia NPI: 1124622667 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hefti, Prisca NPI: 1508133182 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Khan, Fauzia Wali NPI: 1699761965 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Pionke, Peggy NPI: 1699307322 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rashid, Mahreen NPI: 1396393146 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Schubert, Jonathan NPI: 1235755505 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Smith, Kerry NPI: 1275083230 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Tawakol, Katie NPI:1609222116 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.  Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-04 08:33:44', '2021-05-04 08:33:44'),
(35387, 1019, 27374, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:36:54', '2021-05-20 08:36:54'),
(35388, 1019, 27374, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:33', '2021-06-05 11:20:33'),
(35389, 1019, 27374, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:03:53', '2021-06-24 08:03:53'),
(35390, 1019, 27374, NULL, '2021-08-17 00:00:00.000', 'Approved', 'Received the welcome letter from dataentry@beaconhealthoptions.com, Eff 07/27/2021.  See attached for reference.', NULL, NULL, '2021-08-10 22:40:06', '2021-08-10 22:40:06'),
(35391, 1019, 28267, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-04 10:09:35', '2021-05-04 10:09:35'),
(35392, 1019, 28267, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'Called Beacon @ (800) 397-1630 spoke with rep Sierra conversation is mentioned below:  All providers applications have been received and are under review and group is added under all three locations under both plans (BHO/BHS) we have request the copy of group contract. we\'ll receive the contract in 3-2 business days.  Ref# 04/22/2021 - 1371173 Sierra Y', NULL, NULL, '2021-05-04 11:23:01', '2021-05-04 11:23:01'),
(35393, 1019, 28267, NULL, '2021-05-11 00:00:00.000', 'In Process', 'Contract request form faxed at (866) 612-7795. Attached is the copy of request contract form see attachment. ', NULL, NULL, '2021-05-04 11:23:12', '2021-05-04 11:23:12'),
(35394, 1019, 28267, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:40:37', '2021-05-20 08:40:37'),
(35395, 1019, 28267, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:26', '2021-06-05 11:20:26'),
(35396, 1019, 28267, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:03:46', '2021-06-24 08:03:46'),
(35397, 1019, 28267, NULL, '2021-09-06 00:00:00.000', 'Approved', 'Group enrolled effective date 11/27/2019, attached is the Welcome Letter', NULL, NULL, '2021-08-30 10:21:50', '2021-08-30 10:21:50'),
(35398, 1019, 28268, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-04 10:12:20', '2021-05-04 10:12:20'),
(35399, 1019, 28268, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:40:52', '2021-05-20 08:40:52'),
(35400, 1019, 28268, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:20:01', '2021-06-05 11:20:01'),
(35401, 1019, 28268, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:03:40', '2021-06-24 08:03:40'),
(35402, 1019, 28268, NULL, '2021-09-06 00:00:00.000', 'Approved', 'Group enrolled effective date 11/27/2019, attached is the Welcome Letter', NULL, NULL, '2021-08-30 10:21:41', '2021-08-30 10:21:41'),
(35403, 1019, 28269, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-04 10:13:56', '2021-05-04 10:13:56'),
(35404, 1019, 28269, NULL, '2021-05-11 00:00:00.000', 'Initiated', 'Contract request form faxed at (866) 612-7795. Attached is the copy of request contract form see attachment. ', NULL, NULL, '2021-05-04 11:16:21', '2021-05-04 11:16:21'),
(35405, 1019, 28269, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-05-20 08:41:05', '2021-05-20 08:41:05'),
(35406, 1019, 28269, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BHS/BHO ATTN Shashi 2nd Attempt  Hello Shashi,  Hope you are doing good, I need the enrollment status for the following providers, under our group and the following locations under our group.     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Individual Provider     Mary Gibbons NPI: 1942388483 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    L\'Etoile, Melody  NPI: 1942687108  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Edmundson, Rodesia NPI: 1124622667 Location: 100 New State Highway, Raynham, MA, 02767.     Hefti, Prisca NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.     Hignite, Barbara NPI: 1982617262 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Loveland, Lynnetta NPI: 1598163602 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767. Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.   Rozell, Carlee NPI: 1225645393 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Schubert, Jonathan NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.     Smith, Kerry NPI: 1275083230 Location: 100 New State Highway, Raynham, MA, 02767.     Tawakol, Katie NPI:1609222116 Location: 100 New State Highway, Raynham, MA, 02767.     Ullrich, Jennifer NPI: 1710489760 Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.     Souliere, Justin NPI: 1710576004 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Hartman, Jessica NPI: 1326665472 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Location: 100 New State Highway, Raynham, MA, 02767.    Oliva, Erin NPI: 1407349632 Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.    Regards, Alex', NULL, NULL, '2021-06-05 11:19:53', '2021-06-05 11:19:53'),
(35407, 1019, 28269, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com  Good afternoon Alex,  I am looking into. Need some time. Thank you for your patience.   Thank you! Shashi Seth Network Management Rep I, Northeast Provider Relations', NULL, NULL, '2021-06-24 08:03:33', '2021-06-24 08:03:33'),
(35408, 1019, 28269, NULL, '2021-09-06 00:00:00.000', 'Approved', 'Group enrolled effective date 11/27/2019, attached is the Welcome Letter', NULL, NULL, '2021-08-30 10:21:57', '2021-08-30 10:21:57'),
(35409, 1006, 28270, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 08:24:18', '2021-05-05 08:24:18'),
(35410, 1006, 28270, NULL, '2021-06-11 00:00:00.000', 'In Process', 'Sent a f/u email @ \"Widow, Shuntell M\" shuntell.widow@aetna.com and also called Aetna:  Sub: [SEND SECURE] Aetna General Business #NAF413559  \"Hello Shuntell M,   Could you please send us the contract again as there is no message or attachment listed on the email?  Thank you. \"', NULL, NULL, '2021-06-04 14:47:39', '2021-06-04 14:47:39'),
(35411, 1006, 28270, NULL, '2021-06-16 00:00:00.000', 'Approved', 'The copy of the executed urgentcare contract has been received and is attached for reference in the main group tasks. Both the locations are added under the group. Ref# 6023635857', NULL, NULL, '2021-06-09 09:30:46', '2021-06-09 09:30:46'),
(35412, 1006, 28271, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35413, 3040, 28271, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: axhartma@texaschildrens.org   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TCHP ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TCHP for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:40:35', '2021-06-07 12:40:35'),
(35414, 1006, 28271, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Hello,   I hope you\'re doing well, we want to enroll the following group and providers with TCHP, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 17:01:53', '2021-06-24 17:01:53'),
(35415, 1006, 28271, NULL, '2021-07-21 00:00:00.000', 'In Process', 'We received the following email from TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Please submit a letter of interest questionnaire with a w9. The application is on our website www.texaschildrenshealthplan.org *for providers\"  Replied with:  \"Hello,   Please find the attached LOI for our urgent care, do let me know if anything else is required to proceed.   Thank you. \"  The form is attached in group task for reference. ', NULL, NULL, '2021-07-14 12:48:18', '2021-07-14 12:48:18'),
(35416, 1006, 28271, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the following update from jointchp@texaschildrens.org:  Sub: Letter of Interest Questionnaire - CBUC - TCHP  \"Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.\"', NULL, NULL, '2021-08-03 16:00:59', '2021-08-03 16:00:59'),
(35417, 11056, 28271, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : jointchp@texaschildrens.org  &  tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Good evening!  Hope all is well. I want to inquire about the enrollment status of the below mentioned practice and providers. Have my applications of the below mentioned providers been reviewed or not yet?  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 15:25:56', '2021-08-18 15:25:56'),
(35418, 11056, 28271, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,     I was able to find a submission of an LOI (attached) for provider Mercedita Flynn and a denial letter that was sent.  Please see attachments.     Let me know if you have any more questions  -Liz        Self Note  20210802037174969  Mercedita N Flynn', NULL, NULL, '2021-08-24 17:01:47', '2021-08-24 17:01:47'),
(35419, 11056, 28271, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Email sent to : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP   Good morning Liz!  Hope this email finds you well. We have confirmed the NPI of the provider Mercedita Flynn from TMHP & is also attested. Therefore, please consider this application. Please see the attachment below.  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-17 12:50:16', '2021-09-17 12:50:16'),
(35420, 11056, 28271, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,  Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.   Thank you  Liz Ramirez Contract Specialist Texas Children’s Health Plan', NULL, NULL, '2021-09-28 09:45:59', '2021-09-28 09:45:59'),
(35421, 11056, 28271, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : tchpnetworkmanagement@texaschildrens.org & bxgupta@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Group- Coastal Bend Urgent Care, LLC   Katherine Paterson         1164776548 Please see attached denial letter  20211001038052743     Mercedita Flynn               1619166188 Please see attached denial letter  20210930038036249     Monica Gonzalez             1871132811 Please see attached denial letter  20210930038036263   No TCHP does not work with BEE county. Our apologies.  You can also check yourself on website at texaschildrens.org yourself which county TCHP serves.', NULL, NULL, '2021-10-07 10:36:52', '2021-10-07 10:36:52'),
(35422, 1006, 28272, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35423, 3040, 28272, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: TXCredentialing@amerigroup.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Amerigroup for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 09:56:32', '2021-06-07 09:56:32'),
(35424, 1006, 28272, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Good Day to you.  Is this a PCP clinic or a true Urgent Care?  The latter option means that the entity bills globally.\"  Sent reply:  \"Hello,   This is a true Urgent care, please let me know how we can proceed with the request.  Thank you!\"', NULL, NULL, '2021-06-24 14:38:34', '2021-06-24 14:38:34'),
(35425, 11056, 28272, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email received from : txcredentialing@amerigroup.com  Sub : Enrollment Query || Coastal Bend Urgent Care & George West Medical Clinic - Amerigroup   Please send us a letterhead with the following and include a w9:   **Legal name / DBA  **NPI#  **Taxonomy Code  **Service locations  **Billing location  **phone / Fax / office hours / age limits  **TPI / Medicare #  **CLIA #', NULL, NULL, '2021-07-06 17:04:34', '2021-07-06 17:04:34'),
(35426, 11056, 28272, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group  Greetings,  Hope you are doing well. Here is the information you requested for and kindly see the attachments.  Practice Details: Practice  Legal name / DBA  : Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349 Taxonomy Code :  261QU0200X - Clinic/Center Urgent Care  Main practice & billing location : 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address : 504A Houston Street George West , TX 78022-3663  Practice phone : 361-226-1126 Practice  Fax :  361 542-4076 TPI / Medicare # : 588832 CLIA # : 45D2132336 Practice age limits : 0 till 100  Practice  office hours :   Monday 9AM–5PM Tuesday 9AM–5PM Wednesday 9AM–5PM Thursday 9AM–5PM Friday 9AM–5PM Saturday Closed Sunday Closed  If you have any questions or concerns feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-07-07 09:10:42', '2021-07-07 09:10:42'),
(35427, 1006, 28272, NULL, '2021-08-13 00:00:00.000', 'In Process', 'Sent f/u email @ txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I wanted to get an update regarding the enrollment status for the following group and providers:  Group Name: Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349  Main practice & billing location: 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Name: Katherine Moten Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-08-06 13:52:39', '2021-08-06 13:52:39'),
(35428, 1006, 28272, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I hope you\'re doing well, I am still waiting on the status of my application. Please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-08-16 16:00:51', '2021-08-16 16:00:51'),
(35429, 11056, 28272, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com, latoyna.henry@amerigroup.com, Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good afternoon!  Hope you are doing well. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead! ', NULL, NULL, '2021-08-23 16:34:15', '2021-08-23 16:34:15');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35430, 11056, 28272, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : mpsweb@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope you are doing well. It has been so long since you haven\'t responded to our emails. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice. Please provide me with the latest updates soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead!   Called but not received by anyone. Left out a voice mail regarding the enrollment status.', NULL, NULL, '2021-09-03 14:06:14', '2021-09-03 14:06:14'),
(35431, 11056, 28272, NULL, '2021-09-27 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope all is well with you. It had been a long since our email got responded back. We are still waiting to get the latest updates related our enrollment applications for the following providers under the Practice Tax I.D mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# : 1164776548  Provider Name: Mercedita N Flynn Provider NPI# : 1619166188  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!  I had words with Kim U at 800-454-3730. She said that there is no contact no. of Amerigroup Credentialing dept. they only contact through emails.  Ref code : i-140308714', NULL, NULL, '2021-09-20 12:23:04', '2021-09-20 12:23:04'),
(35432, 11056, 28272, NULL, '2021-10-07 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com & Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||   Good evening!  Hope this email finds you well. Please see the location again. Please note that our facilities are located in BEEVILLE , TX & George West , TX, not in Corpus Christi.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!', NULL, NULL, '2021-09-30 15:36:30', '2021-09-30 15:36:30'),
(35433, 11056, 28272, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good Morning,  Your request has been received for provider enrollment.  Please note that Amerigroup currently does not service the Hidalgo or the Corpus Christi Service Delivery Areas.   Hi There, those locations are within the Corpus Christi service delivery area, Amerigroup currently does not have membership down in that region.   Those areas are managed by other Medicaid Managed Care Organizations.   Thank you again for your interest.  Sincerely,', NULL, NULL, '2021-10-07 15:35:52', '2021-10-07 15:35:52'),
(35434, 1006, 28273, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35435, 1006, 28273, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'Sent an email @ pdsdallas@aetna.com to verify enrollment status of provider and group:   Sub: Enrollment Status Query - CBUC - First Health  \"Hello,   I hope you\'re doing well, I wanted to get an update on the enrollment status for the following providers and group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264  Provider Name: Katherine Paterson NPI# 1164776548 Provider Name: Jennifer Tudor NPI# 1720455835 Provider Name: Mercedita Flynn NPI# 1619166188  Please get back to me as soon as possible. Also, if any of the providers or the group isn\'t enrolled, please let me know what the process is to start the enrollment.  Thank you.\"', NULL, NULL, '2021-05-05 13:42:14', '2021-05-05 13:42:14'),
(35436, 1006, 28273, NULL, '2021-06-16 00:00:00.000', 'Approved', 'We received the following reply from Bharath, Bollu BharathB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Provider Name                NPI             Cpd Id         TIN           Effective Date          Status  Flynn, Mercedita N   1619166188   2570154   811890349   12/01/2019   Active Approved\"', NULL, NULL, '2021-06-09 10:24:41', '2021-06-09 10:24:41'),
(35437, 1006, 28274, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35438, 3040, 28274, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: info@usamco.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || MCO ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in MCO for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:10:38', '2021-06-07 12:10:38'),
(35439, 1006, 28274, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ info@usamco.com:  Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hello,  I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled under MCO and if not what the procedure would be to enroll them, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663 Provider Name: Katherine PatersonProvider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.   Thank you!\"', NULL, NULL, '2021-06-24 16:40:38', '2021-06-24 16:40:38'),
(35440, 1006, 28274, NULL, '2021-07-20 00:00:00.000', 'Approved', 'We received the following approval confirmation email from ProviderMarketingInfo ProviderMarketingInfo@usamco.com:   Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hi Brad,  I show that there is an active agreement with TIN 81-1890349 since 2/22/17 under the name Beeville Medical Clinic and the two DBA’s Coastal Bend Urgent Care LLC and Coastal Bend Long Term Care.  I show two addresses under this agreement, 600 S Hillside Dr and 301 S Hillside Dr Ste 4.  I have CC’ed our Provider Relations department on this email and they will be able to add the 504 A Houston St address below.  With regards to the providers, as the agreement is as an Ancillary group, you do not need to add/credential new providers. Any provider billing under the TIN and one of the addresses on file will be counted as in-network.  Please let me know if you have any further questions.  Sarah Cozzetto Lead Network Development Coordinator\"', NULL, NULL, '2021-07-13 17:14:30', '2021-07-13 17:14:30'),
(35441, 1006, 28275, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35442, 3040, 28275, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@memorialhermann.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Memorial Hermann for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:13:29', '2021-06-07 12:13:29'),
(35443, 1006, 28275, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  \"Good Morning,  You will need to complete the Request for Application form online. You can do that by going here https://healthplan.memorialhermann.org/-/media/memorial-hermann/healthplan/files/providers/health-plan-request-to-participate.ashx?la=en&hash=27F819BE45E95E2EA8789FB1902B4D2F and completing the request to participate form online and forwarding to the email on the form.  Regards, Jo\"  The form is filled out and sent out to them and attached to the main group task for reference.   Sent to MHHP Contracting MHHPContracting@memorialhermann.org:  \"Hello,   Please find the attached network participation form for our group, please let me know if anything else is needed for this request.  Thank you!\"', NULL, NULL, '2021-06-24 16:50:21', '2021-06-24 16:50:21'),
(35444, 1006, 28275, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ MHHP Contracting MHHPContracting@memorialhermann.org  MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub; Network Participation Form - CBUC/GWMC - Memorial Hermann  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for our group and providers. Their information is as follows:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\'', NULL, NULL, '2021-07-13 17:22:53', '2021-07-13 17:22:53'),
(35445, 1006, 28275, NULL, '2021-08-02 00:00:00.000', 'In Process', 'We received the following response from MHHP Contracting MHHPContracting@memorialhermann.org:  Sub: Memorial Hermann Health Plan Request to Participate  \"We are in receipt of Coastal Bend Urgent Care’s request to become a participating provider with Memorial Hermann Health Plans and need additional information to proceed with your request.  Please provide the following information:  List of services provided ·         Do you provide Virtual Health Services?  Current service area and/or list of locations List of all employed/contracted providers (if applicable) including NPs and PAs (please include individual NPIs) What age population is served? Please list 0-2 years of age; 2-18 years of age; 18+ years Where do you have privileges? Please list all Hospitals, Ambulatory Surgery Centers, etc. Link to website Current W-9 Current quality and outcomes data Any additional information you would like presented to the Network Access and Adequacy Committee   Your participation request will be presented at the next NAAC meeting following receipt of the additional information.\"  Responded to the queries.', NULL, NULL, '2021-07-26 13:20:07', '2021-07-26 13:20:07'),
(35446, 1006, 28275, NULL, '2021-08-05 00:00:00.000', 'Not Eligible', 'We received  the following denial notification from MHHPContracting@memorialhermann.org:  Sub: Memorial Hermann Health Plan Request to Participate  \"At this time, the cities listed below are out of our network area, and we do not contract out of network at this time. I am withdrawing your application for participation. If something changes in the near future, we will let you know. Please let me know if you have any questions.  Thank you. Camilla Paige\"', NULL, NULL, '2021-07-29 13:34:34', '2021-07-29 13:34:34'),
(35447, 1006, 28277, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35448, 3040, 28277, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: david.balli@molinahealthcare.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Molina Health||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Molina Health for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:31:21', '2021-06-07 12:31:21'),
(35449, 1006, 28277, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from MHTContractrequest mhtcontractrequest@molinahealthcare.com:  Sub: Attn: Contracting Team - CBUC/GWMC - Molina   \"Good Afternoon Mr. Adil Abbas  I am doing fine, how do are you doing?  I did research for Coastal Bend Urgent Care and it does not show up in our system.  I tried both the Tax id and Group NPI. Please complete this contract request form and return along with a current W-9 to fax number: 877-900-5655 Attn: Contracting Team or email form to: mhtcontractrequest@molinahealthcare.com  Please let me know if you need further information or assistances.  Thank you  David Balli Representative Provider Service  II Molina Healthcare of Texas, Inc. 4316 South McColl Road Edinburg, TX  78539 I Phone: (956) 532-5211 Righ tfax: (877) 900-8454 Email: david.balli@molinahealthcare.com\"  The form was filled out and sent to mhtcontractrequest@molinahealthcare.com, form is attached in the main group task for reference. ', NULL, NULL, '2021-06-25 12:43:29', '2021-06-25 12:43:29'),
(35450, 1006, 28277, NULL, '2021-07-08 00:00:00.000', 'In Process', 'We received the following update from MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Molina Provider Contract - Coastal Bend Urgent Care, LLC  \"Good Afternoon,  Happy Wednesday! Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for (Coastal Bend Urgent Care, LLC ) to contract under TAX ID number (81-1890349).  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below: EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com 888-562-5442 x200249   Have a wonderful day! Thank you, Tyhesha Price MHT| Provider Contracts Molina Healthcare of Texas, Inc. 1660 Westridge Circle N Irving, TX 75038 Mhtcontractrequest@Molinahealthcare.com\"', NULL, NULL, '2021-07-01 15:55:06', '2021-07-01 15:55:06'),
(35451, 1006, 28277, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the following update from Juliana.Mata@molinahealthcare.com:  Sub: Molina Contract Packet - Coastal Bend Urgent Care LLC DBA Beeville Medical Clinic  \"Good afternoon,  Happy Monday!!  Hope you are doing well.  I am following up to my previous email. Please be advised unless all forms are returned, we will not be able to continue contracting process.  any assistance will be greatly appreciated.  Thank you in advance  Juliana Mata | Associate Specialist Provider Contracts Molina Healthcare Of Texas Molina Healthcare Of Texas, Inc Juliana.Mata@Molinahealthcare.com 1660 Westridge Circle N. Irving, TX 75038 \'  (888) 562-5442 ext 200249\"  Replied with the requested information:  \"Hello Juliana,   I apologize for the delay, here\'s the requested information hopefully it suffices. We also have a secondary location and the address is as follows: 504A Houston Street, George West, TX 78022-3663  Do let me know if anything else is required to proceed.\"', NULL, NULL, '2021-08-03 14:06:01', '2021-08-03 14:06:01'),
(35452, 11056, 28277, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good evening!  Hope all is well. Please provide me with the latest updates of the enrollment status of following providers & practice and the secondary location too. Kindly also update me about the applications and forms submitted to you regarding enrollment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Furthermore,if documents and information is needed please let me know. Please don\'t hesitate to contact me directly.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-18 15:51:27', '2021-08-18 15:51:27'),
(35453, 11056, 28277, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning,  Happy Thursday!!  Hope you are doing well.  Per information on our system, service location  301 S. Hillside Drive is in process  of credentialing.  Service location 504  A  Houston Street, we are missing a contract request form, could you please fill out form and submit back to me at your earliest convenience?  Individual providers are not contracted under Urgent Care Facility.  Molina contracts facility directly.     Hope this information helps.  Thank you        Juliana Mata | Associate Specialist Provider Contracts  Molina Healthcare Of Texas  Molina Healthcare Of Texas, Inc  Juliana.Mata@Molinahealthcare.com  1660 Westridge Circle N.  Irving, TX 75038  \'  (888) 562-5442 ext 200249', NULL, NULL, '2021-08-24 14:06:00', '2021-08-24 14:06:00'),
(35454, 11056, 28277, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope all is well. Here is the filled contract request form for the secondary service location 504-A, Houston Street. Please see the attachment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Furthermore, if any additional information is required please let me know. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-03 15:03:05', '2021-09-03 15:03:05'),
(35455, 11056, 28277, NULL, '2021-10-01 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for Coastal Bend Urgent Care LLC to contract under TAX ID number 81-1890349.  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below:  EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com   888-562-5442 x200249', NULL, NULL, '2021-09-24 11:45:33', '2021-09-24 11:45:33'),
(35456, 11056, 28277, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well. Please provide me with the updates on the credentialing of  the facility mentioned below with Molina Health under the Tax ID with both locations listed below.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location 504A Houston Street, George West, TX 78022-3663  If you need any information or documents related to this please let me know. Waiting for your reply.  Thank you! Have a great weekend!', NULL, NULL, '2021-10-06 12:38:10', '2021-10-06 12:38:10'),
(35457, 11056, 28277, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub  : Enrollment Status Query - CBUC/GWMC - Molina Health  Good  afternoon,  Happy Wednesday!!  Hope you are doing well.  per information on   our system,  both facilities are in process for credentialing.  Once credentialing process is complete, we will go ahead and forward contract to be loaded  into network billing system.  thank you  for your patience', NULL, NULL, '2021-10-14 15:48:02', '2021-10-14 15:48:02'),
(35458, 11056, 28277, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Tuesday!!  Hope you are doing well.  Per information on our system, both facilities are credential complete, we are waiting on execution from plan\'s president.  Once PSA is executed,  we will go ahead and forward contract to be loaded into network billing system,  this process might take 30-45 days.', NULL, NULL, '2021-10-22 10:22:41', '2021-10-22 10:22:41'),
(35459, 11056, 28277, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning Juliana!  Hope you had a great week yet. Please let us know about the execution of the Plan\'s President. Has the PSA been executed yet or not? Is that loaded into your billing system?  Eagerly, waiting to hear back from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-11-09 14:11:56', '2021-11-09 14:11:56'),
(35460, 11056, 28277, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Friday!!  Hope you are doing well.  Per information on our system, both locations are in process of being loaded into the network billing system, this process might take 30-45 days.  Thank you for your patience', NULL, NULL, '2021-11-24 12:14:04', '2021-11-24 12:14:04'),
(35461, 11056, 28277, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well.  Thank you for the update and prompt response. Try to escalate the loading process and let it be completed before the time period.  Have a wonderful day!', NULL, NULL, '2021-12-06 17:02:15', '2021-12-06 17:02:15'),
(35462, 11056, 28277, NULL, '2021-12-28 00:00:00.000', 'Approved', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health   Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, service location 301 S. Hillside Drive is loaded into network billing system with effective date 12/15/2021.  Please see attached for welcome letter.  2nd service location is in process of being loaded into network billing system.  thank you for your patience.     Thank you     Juliana Mata | Associate Specialist Provider Contracts  Please see the attachment', NULL, NULL, '2021-12-21 17:39:41', '2021-12-21 17:39:41'),
(35463, 1006, 28278, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35464, 1006, 28278, NULL, '2021-06-15 00:00:00.000', 'Initiated', 'We submitted a group enrollment request via the Wellcare website:  \"Your form was submitted successfully. Thank you for contacting us. A representative will be in contact to discuss your interest in becoming a participating Provider.\"  Enrollment form is attached in the group task for reference. ', NULL, NULL, '2021-06-08 16:31:03', '2021-06-08 16:31:03'),
(35465, 1006, 28278, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from ProspectiveProviderTX ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Dear Provider:  Thank you for your interest in joining our network, please allow 30 Calendar days for us to review your request.  Sincerely, Network Management – Texas | www.wellcare.com\"  Sent f/u email:   \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of my application. Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 10:19:24', '2021-06-25 10:19:24'),
(35466, 1006, 28278, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Sent another f/u email @ ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Hello,   I hope you\'re doing well, I\'m still waiting on the status of this enrollment request.  Please get back to me as soon as you\'re able.  Thank you.\"', NULL, NULL, '2021-07-14 17:15:53', '2021-07-14 17:15:53'),
(35467, 1006, 28278, NULL, '2021-08-02 00:00:00.000', 'In Process', 'Received response from Superior, requesting the form. The form is filled and sent out @ SHP-Network Development shp.networkdevelopment@superiorhealthplan.com:  Sub:  Add Provider- Mercedita Flynn - CBUC  \"Hello,   I hope you\'re doing well, please find the attached contract form for our provider to add them to our group. Do let me know if anything else is required.   Thank you.\" ', NULL, NULL, '2021-07-26 10:06:54', '2021-07-26 10:06:54'),
(35468, 11056, 28278, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com  Sub : Add Provider- Mercedita Flynn - CBUC  Good evening!  Hope all is well. Please provide me with the latest updates regarding the enrollment status of the following provider under the Tax ID mentioned below.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 16:57:39', '2021-08-18 16:57:39'),
(35469, 11056, 28278, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com  Sub : Add Provider- Mercedita Flynn - CBUC  Good evening!  Hope all is well. Please provide me with the latest updates regarding the enrollment status of the following provider under the Tax ID mentioned below.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-24 13:49:28', '2021-08-24 13:49:28'),
(35470, 11056, 28278, NULL, '2021-09-09 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com  Sub : Add Provider- Mercedita Flynn - CBUC  Good evening!  Hope all is well. Please provide me with the latest updates regarding the enrollment status of the following provider under the Tax ID mentioned below.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!  Also left out a voice mail related to get the credentialing status.', NULL, NULL, '2021-09-01 14:38:27', '2021-09-01 14:38:27'),
(35471, 11056, 28278, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Rep : Rose S  Katherine Paterson in network 07/01/2021 participating with wellcare  Mercedita Flynn in network 07/01/2021 participating with wellcare  interaction code : 1296311845  application needed for the group.', NULL, NULL, '2021-09-17 17:12:23', '2021-09-17 17:12:23'),
(35472, 11056, 28278, NULL, '2021-10-06 00:00:00.000', 'In Process', 'Email sent to : TERESA.Argueta@wellcare.com & ProspectiveProviderTX@wellcare.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC   Good afternoon!  Hope all is well with you. I want to get the latest update regarding the enrollment status of the below mentioned providers under the facility TIN with Wellcare.   Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811  If you have any questions or concerns feel free to reach out to me soon. Waiting for your response.  Thank you! Have a great day!', NULL, NULL, '2021-09-29 13:25:08', '2021-09-29 13:25:08'),
(35473, 11056, 28278, NULL, '2021-10-07 00:00:00.000', 'Approved', 'Approval Email received from : ProspectiveProviderTX@wellcare.com & cynthia.barnett@wellcare.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC   New Providers for Costal Bend Urgent Care  Hello,   The providers below are PAR effective 7/1/2021.   Hi Ahmed,  Here is the spreadsheet on your providers for Coastal Bend Urgent Care.  Take care.  Cyn  Please see the attachment.', NULL, NULL, '2021-09-30 14:00:16', '2021-09-30 14:00:16'),
(35474, 1006, 28279, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35475, 1006, 28279, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'The provider enrollment request is already in process under our group, which is already enrolled with Ambetter and the provider will automatically be assigned the plan once enrollment is finished. ', NULL, NULL, '2021-05-05 12:30:04', '2021-05-05 12:30:04'),
(35476, 1006, 28279, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent following enrollment query @ AM.Austin@SuperiorHealthPlan.com & SHP.NetworkDevelopment@superiorhealthplan.com:  Sub: Enrollment Query - CBUC/GWMC -  Superior Health/Ambetter  \"Hello,  I wanted to verify if the following group and providers were enrolled with Superior Healthplan & Ambetter under the mentioned addresses:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548  Provider Name: Mercedita Flynn NPI# 1619166188  Provider Name: Jennifer Tudor NPI# 1720455835  Please get back to me as soon as you\'re able. Thank you. \"', NULL, NULL, '2021-06-09 09:49:10', '2021-06-09 09:49:10'),
(35477, 1006, 28279, NULL, '2021-07-06 00:00:00.000', 'Approved', 'Approval confirmation:  Mercedita Flynn: Eff: 02/01/2021  Ref# I57969070', NULL, NULL, '2021-06-29 16:52:31', '2021-06-29 16:52:31'),
(35478, 1006, 28280, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35479, 3040, 28280, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: trpndataentry@trpnppo.com, providerrelations@trpnppo.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TRPN ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TRPN for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:43:43', '2021-06-07 12:43:43'),
(35480, 1006, 28280, NULL, '2021-07-02 00:00:00.000', 'In Process', 'Sent f/u email @ trpndataentry@trpnppo.com & TRPN Provider Relations providerrelations@trpnppo.com:  Sub: Enrollment Status/Request - CBUC/GWMC - TRPN  \"Hello, I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled.   The information is as follows: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 09:23:15', '2021-06-25 09:23:15'),
(35481, 11056, 28280, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : trpndataentry@trpnppo.com  Sub : Enrollment Requisition Query - Coastal Bend Urgent Care & George West Medical Clinic - TRPN  Greetings,  Hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled. The information is as follows:  Practices: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Providers: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Kindly get back to me as soon as possible.  Thank you!', NULL, NULL, '2021-07-06 16:50:34', '2021-07-06 16:50:34'),
(35482, 1006, 28280, NULL, '2021-08-17 00:00:00.000', 'In Process', 'As per my discussion with TRPN we need to send a provider update form to them, requested a copy, and sent it to trpndataentry@trpnppo.com:  Sub: Provider Update Form - CBUC/GWMC - TRPN  \"Hello,   Please find the attached provider update forms for our providers. Please let me know if anything else is required to continue.   Thank you!\"  Attached for reference in provider tasks. ', NULL, NULL, '2021-08-10 12:44:08', '2021-08-10 12:44:08'),
(35483, 11056, 28280, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : 	trpndataentry@trpnppo.com  Sub : Enrollment Status Updates - CBUC/GWMC - TRPN  Good morning!  Hope all is well. I want to inquire about the enrollment status of the below mentioned practice and providers. Please respond to me soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you need any documents or information regarding this feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 14:08:45', '2021-08-18 14:08:45'),
(35484, 11056, 28280, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to :  trpndataentry@trpnppo.com, providerrelations@trpnppo.com   & AVasquez@trpnppo.com  Sub : Provider Update Form - CBUC/GWMC - TRPN   Good afternoon!  Hope this email finds you well. Please inform me with the latest updates regarding enrollment status of the following providers under the practice in TRPN. Please also inform me about the provider\'s update forms.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Monica Gonzalez Provider NPI# 1871132811  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you have any questions or queries or need any information or documents feel free to reach out to me. Waiting to hear from you soon.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-24 13:32:48', '2021-08-24 13:32:48'),
(35485, 11056, 28280, NULL, '2021-09-09 00:00:00.000', 'Approved', 'Approval Email received from : trpndataentry@trpnppo.com  Sub : RE: Enrollment Status Updates - CBUC/GWMC - TRPN  Hi,     This request is completed,     Provider Mercedita Flynn is Active, effective date 01/01/2017,  Provider Katherine Paterson is Active, effective date 01/01/2017,  Provider Monica Gonzalez is Active, effective date 01/01/2021.', NULL, NULL, '2021-09-01 16:02:47', '2021-09-01 16:02:47'),
(35486, 1006, 28281, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35487, 3040, 28281, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: dhpcontracting@dchstx.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Driscoll  for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you    ', NULL, NULL, '2021-06-07 10:37:38', '2021-06-07 10:37:38'),
(35488, 1006, 28281, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following email from dhpcontracting@dchstx.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  \"Good afternoon,  Please complete the attached documents for each provider and email them to dhpcontracting@dchstx.org.  We will also need a current PAA or Collaborative agreement for each of the mid-level practitioners.  Thank you Karla Claunch\"  Requested Ryan to send us copies of the PAA/Collaborative agreement to avoid any delays.   \"Hello Ryan,  We need updated copies of the following documents for the mentioned providers: Mercedita Flynn An updated copy of AANP CertificationFrank Dehnisch An updated copy of Malpractice Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to. Thank you!\"', NULL, NULL, '2021-06-25 13:48:56', '2021-06-25 13:48:56'),
(35489, 1006, 28281, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Still waiting on Ryan to send us PAA/Collab agreement for all providers to proceed with this request, sent another reminder via hangouts/google chat:  \"Hello Ryan,  I just wanted to ask if it would be possible for you to get us the following information: We need updated copies of the following documents for the mentioned providers:  Mercedita Flynn An updated copy of AANP Certification Frank Dehnisch An updated copy of Malpractice  Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to.  Thank you!  Also, if you could send us the update CLIA of both CBUC & GWMC\"', NULL, NULL, '2021-07-14 16:27:36', '2021-07-14 16:27:36'),
(35490, 11056, 28281, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Still waiting for the  Updated MALPRACTICE : Frank Dehnisch  Updated  AANP Certification : Mercedita Flynn  by Ryan.', NULL, NULL, '2021-08-18 15:04:00', '2021-08-18 15:04:00'),
(35491, 11056, 28281, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Ryan hasn\'t responded to our emails and calls too.  Still waiting for the  Updated MALPRACTICE : Frank Dehnisch  Updated  AANP Certification : Mercedita Flynn  by Ryan.', NULL, NULL, '2021-08-25 08:21:30', '2021-08-25 08:21:30'),
(35492, 11056, 28281, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Email sent to : Karla.Claunch@dchstx.org  Sub  : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good evening Karla!  Hope this email finds you well. Here are the forms with attached documents in the Pdf too with W9s, which you requested for in the previous email for enrollment process. Please find the attachments.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Primary Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# 1164776548  Provider Name: Flynn, Mercedita  Provider NPI# 1619166188  Provider Name: Gonzalez, Monica Provider NPI# 1427509264  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great day', NULL, NULL, '2021-09-17 12:19:16', '2021-09-17 12:19:16'),
(35493, 11056, 28281, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email received from : Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon,  Thank you for these requests but, the disclosure statements were not attached for Monica Gonzalez NP and Katherine Paterson NP.  Please email these directly to me when completed.  They are all now in the credentialing process.  Please allow 60-90 days to complete.  Once complete, you will receive a welcome letter with their effective date.  Thank you  Karla Claunch   ', NULL, NULL, '2021-09-28 16:58:25', '2021-09-28 16:58:25'),
(35494, 11056, 28281, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  My apologies,  I am just noticing that this practice is currently not participating with us.  All providers requested are mid-level who will need a supervising physician.  The physician will also need to be a Driscoll Health Plan participating physician.  If their supervising physician is not already credentialed with us, we will also need to credential them.  We will also need the current PAA or Collaborative agreement between the NP’s and supervising physician.  They should have one on file within the practice.  We are withdrawing these providers  due to not currently having a supervising physician on file for this practice.  We can re-activate them once the remaining, required information is received and they have an established, participating, supervising physician.  We look forward to working with you and eager to hear from you again soon.  Please let me know if you need any further assistance.  Karla Claunch  ', NULL, NULL, '2021-10-06 16:31:08', '2021-10-06 16:31:08'),
(35495, 11056, 28281, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email sent to : Karla.Claunch@dchstx.org  Sub : Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Hey Karla!  Hope you had a great weekend. You don\'t need to apologise. We do have a supervising physician for this practice and want to let him participate with Driscoll Health Plan. Please suggest to me the procedure to credential the supervising physician as soon as possible.  Supervising Physician Details: Name : Frank Dehnisch NPi # : 1952376345 CAQH I.D # : 10577534  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Thank you! Have a wonderful day!', NULL, NULL, '2021-10-14 15:44:38', '2021-10-14 15:44:38'),
(35496, 11056, 28281, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from: Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon,  I wish the weekend was much longer but, here we are.  We will need the same documents for the supervising physician and he must carry them on his license.  Please send a Request for Contact as well as the DHP addendum and disclosure as below.', NULL, NULL, '2021-10-22 08:49:36', '2021-10-22 08:49:36');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35497, 11056, 28281, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope this email finds you well. Please find the attached forms for the Supervising physician enrollment with Driscoll. Please accept my apology for the delay. If any corrections are required please let me know.  Supervising Physician Details: Name : Frank Dehnisch NPi # : 1952376345 CAQH I.D # : 10577534  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Thank you! Have a blessed day!', NULL, NULL, '2021-11-09 14:33:39', '2021-11-09 14:33:39'),
(35498, 11056, 28281, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email sent to:  Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Hello,  Thank you for this request.  Before I begin, the addendum needs to be completed with all information.  The disclosure is named and signed by Mercedita Flynn so, we will need his own, signed by him please.  This provider will not be processed until this information is received.  Your prompt attention will avoid delays and withdrawal.  I look forward to hearing from you soon.  Thank you  Karla Claunch   Provided them with their requirement.', NULL, NULL, '2021-11-24 10:03:23', '2021-11-24 10:03:23'),
(35499, 11056, 28281, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good morning!  Hope this email finds you well. Here you go. Please find the corrected one in the attachment.  If anything else is needed feel free to reach out to me.  Take Care!  Thank you!', NULL, NULL, '2021-12-06 16:40:14', '2021-12-06 16:40:14'),
(35500, 11056, 28281, NULL, '2021-12-24 00:00:00.000', 'In Process', 'Email received from:  Karla.Claunch@dchstx.org  Sub:  Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good afternoon,  You only sent one disclosure, it was for Mercedita which I already have.   I am needing one for both of these providers please-Monica Gonzalez NP and Katherine Paterson NP  They are now in process.  Please allow 60-90 days to complete the process.  I am looking forward to hearing back from you soon with these disclosures and all of their PAA/Collaborative Agreements  Thank you', NULL, NULL, '2021-12-17 14:47:39', '2021-12-17 14:47:39'),
(35501, 11056, 28281, NULL, '2021-12-29 00:00:00.000', 'In Process', '	 Email sent to: Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope you are having a blessed day. Please find the attached disclosure for Monica Gonzalez and Katherine Paterson. We will provide you with their PAA/Collaborative Agreements near in the future.  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Take Care!  Thank you! Have a wonderful day!', NULL, NULL, '2021-12-22 11:11:31', '2021-12-22 11:11:31'),
(35502, 19067, 28281, NULL, '2022-01-06 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope this email finds you well. Kindly do provide me with the recent accomplishments of the credentialing process of the below-mentioned providers under facility TIN.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location	504A Houston Street, George West, TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811   Please get back to me soon with the updates and if credentialing is completed do provide me with effective dates and welcome letters.  Thank you! Have a wonderful weekend!', NULL, NULL, '2021-12-30 11:01:13', '2021-12-30 11:01:13'),
(35503, 19067, 28281, NULL, '2022-01-10 00:00:00.000', 'In Process', 'Email received from: Diana.Flores@dchstx.org  Subject: CREDENTIALING- Mercedita N. Flynn FNP   Mercedita N. Flynn, FNP  NPI # 1619166188  Coastal Bend Urgent Care LLC  Tax ID # 81-1890349     Good morning Ahmed     In order to initiate the credentialing process for Mercedita with Driscoll Health Plan, please provide the following information to avoid delay in credentialing the provider.     ·         Attestation pages with current signature and date-Attached  ·         Addendum--Attached please fill in % of time supervised  ·         Copy of PAA/ Collaborating Agreement-attached or if you already have your own and it provides the information requested on our form you can send it in.  ·         Copy of current DEA-License- in CAQH its expired  Copy of current CLIA-per addendum* you have a CLIA in the office please provide a copy of certificate Texas Standardized Credentialing Application is missing required information in order to complete your application. See highlighted pages attached, review in its entirety for accuracy and fill in information. You can fill in attached pages or go online to CAQH. Once completed I can retrieve pages online. TSCA-page-5-call coverage normally  listed is the Supervising physician TSCA-page-6- Check Payable To-normally list the corporation name as it appears on W-9    I have attached forms needed, please provide the above required documents to process the application.     If you have any questions please contact me via email or by phone.     Thank you in advance for your cooperation.     Sincerely     Diana R. Flores  Credentialing Specialist  4525 Ayers St  Corpus Christi, TX 78415-1401  Office:  (361) 694-5563  Fax: (361) 808-2182  Email: diana.flores@dchstx.org  Website: www.driscollhealthplan.com', NULL, NULL, '2022-01-03 12:44:30', '2022-01-03 12:44:30'),
(35504, 19067, 28281, NULL, '2022-01-17 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Greetings!  Any updates on the previously mentioned request.  Thanks, Hammad Ahmed.', NULL, NULL, '2022-01-09 22:22:51', '2022-01-09 22:22:51'),
(35505, 19067, 28281, NULL, '2022-01-17 00:00:00.000', 'In Process', 'Email received from: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||    Good morning,  I sent the welcome packet and contract 12/28/2021 to the credentialing contact email we have on file.  I have attached everything to this email for you.    ', NULL, NULL, '2022-01-10 09:24:49', '2022-01-10 09:24:49'),
(35506, 19067, 28281, NULL, '2022-02-01 00:00:00.000', 'In Process', 'Email received from: Diana.Flores@dchstx.org  Subject: CREDENTIALING- Mercedita N. Flynn FNP    Mercedita N. Flynn, FNP  NPI # 1619166188  Coastal Bend Urgent Care LLC  Tax ID # 81-1890349     Good morning Ahmed     In order to initiate the credentialing process for Mercedita with Driscoll Health Plan, please provide the following information to avoid delay in credentialing the provider.     ·         Attestation pages with current signature and date-Attached  ·         Addendum--Attached please fill in % of time supervised  ·         Copy of PAA/ Collaborating Agreement-attached or if you already have your own and it provides the information requested on our form you can send it in.  ·         Copy of current DEA-License- in CAQH its expired  Copy of current CLIA-per addendum* you have a CLIA in the office please provide a copy of certificate Texas Standardized Credentialing Application is missing required information in order to complete your application. See highlighted pages attached, review in its entirety for accuracy and fill in information. You can fill in attached pages or go online to CAQH. Once completed I can retrieve pages online. TSCA-page-5-call coverage normally  listed is the Supervising physician TSCA-page-6- Check Payable To-normally list the corporation name as it appears on W-9    I have attached forms needed, please provide the above required documents to process the application.     If you have any questions please contact me via email or by phone.     Thank you in advance for your cooperation.     Sincerely     Diana R. Flores  Credentialing Specialist  4525 Ayers St  Corpus Christi, TX 78415-1401  Office:  (361) 694-5563  Fax: (361) 808-2182  Email: diana.flores@dchstx.org  Website: www.driscollhealthplan.com', NULL, NULL, '2022-01-25 10:18:51', '2022-01-25 10:18:51'),
(35507, 1019, 28281, NULL, '2022-02-09 00:00:00.000', 'Approved', 'Received the following email from Karla.Claunch@dchstx.org  Good morning,  I sent the welcome packet and contract 12/28/2021 to the credentialing contact email we have on file.  I have attached everything to this email for you.  Effective date: 01/01/2022 See Attachment B in the Attached is the Welcome Letter', NULL, NULL, '2022-02-02 13:11:48', '2022-02-02 13:11:48'),
(35508, 1006, 28282, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35509, 1006, 28282, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'Submitted enrollment request via Anci-Care\'s website:   \"Apply to ACS Network  Congratulations on taking your first step to becoming a Provider-Partner in the ACS Provider Network. Your account has been established. An email with instructions on how to log in and begin the application process has been sent to your email address. Please use the link provided along with the login (your email address) to begin the application process.  Thank you for your interest in Ancillary Care Services.\"', NULL, NULL, '2021-05-05 13:16:14', '2021-05-05 13:16:14'),
(35510, 1006, 28282, NULL, '2021-06-15 00:00:00.000', 'In Process', 'Sent following enrollment query @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,  We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to. Thank you. \"', NULL, NULL, '2021-06-08 16:16:01', '2021-06-08 16:16:01'),
(35511, 1006, 28282, NULL, '2021-07-02 00:00:00.000', 'In Process', 'The previous email was sent to an incorrect address, sent corrected email @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,    We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to.  Thank you.\"  ', NULL, NULL, '2021-06-25 17:06:06', '2021-06-25 17:06:06'),
(35512, 1006, 28282, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Received following notification from email:  \"Your message to providerdevelopment@anci-care.com couldn\'t be delivered. The group providerdevelopment only accepts messages from people in its organization or on its allowed senders list, and your email address isn\'t on the list.\"  Sent corrected email @ ACS VIP Providers vipproviders@anci-care.com.', NULL, NULL, '2021-07-14 14:56:03', '2021-07-14 14:56:03'),
(35513, 1006, 28282, NULL, '2021-07-23 00:00:00.000', 'In Process', 'Received the following update from Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hi Brad,  Our Medical Advisory Committee is meeting tomorrow. Please allow 7-10 business days after approvals for me to send you an official letter.  Best Regards,  Jennifer Maligaya | Sr. Provider Relations, ACS and MyDecision HealthSmart | Network Solutions Office: 405 241 4811 | Fax: 214 574 1121 Jennifer.maligaya@healthsmart.com | www.HealthSmart.com\"', NULL, NULL, '2021-07-16 16:56:23', '2021-07-16 16:56:23'),
(35514, 1006, 28282, NULL, '2021-08-04 00:00:00.000', 'In Process', 'Sent f/u email @ Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello Jennifer,   I wanted to get an update regarding this request, please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-07-28 12:29:45', '2021-07-28 12:29:45'),
(35515, 1006, 28282, NULL, '2021-08-13 00:00:00.000', 'In Process', 'We received the following update from jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Good Morning,  I show that Coastal Bend Urgent Care, LLC And ACS are currently contracted since 7/20/2017. Records indicate that you are due for credentialing.  Please see the attached Re-credentialing Profile.  Best Regards,  Jennifer Maligaya | Sr. Provider Relations, ACS and MyDecision HealthSmart | Network Solutions Office: 405 241 4811 | Fax: 214 574 1121 Jennifer.maligaya@healthsmart.com | www.HealthSmart.com\"  Replied with:  \"Hello Jennifer,  Please find the attached information, do let me know if you need anything else.  Thank you. \"', NULL, NULL, '2021-08-06 15:12:02', '2021-08-06 15:12:02'),
(35516, 1006, 28282, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello Jennifer,  I hope you\'re doing well, I just wanted to check in on the status of enrollment for our group. Can you please get back to me on this?  Thank you.\"', NULL, NULL, '2021-08-16 16:07:49', '2021-08-16 16:07:49'),
(35517, 11056, 28282, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Coastal Bend Urgent Care is already contracted with ACS.     Recredentialing is complete just waiting on the approval meeting on 9/16.     No further action is necessary.  Claims are still being processing for this provider.     Jennifer Maligaya is no longer with ACS/HealthSmart.     Please continue to use VIPproviders@anci-care.com for updates.     New provider agreements please email me:  patti.davidson@healthsmart.com     Thank you,     Patti Davidson | Manager, Network Development  HealthSmart | Network Solutions  Office: 972 388 3091 | Fax: 214 574 1121  patti.davidson@healthsmart.com | www.HealthSmart.com', NULL, NULL, '2021-08-23 17:10:11', '2021-08-23 17:10:11'),
(35518, 11056, 28282, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Good morning!  Hope all is well. Could you please provide me the enrollment updates,effective dates and welcome or approval letter for the following providers and practice soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Monica Gonzalez Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-03 14:32:31', '2021-09-03 14:32:31'),
(35519, 11056, 28282, NULL, '2021-09-21 00:00:00.000', 'In Process', 'Email sent to : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Good morning!  Hope all is well. Could you please provide me the enrollment updates, effective dates and welcome or approval letter for the following providers and practice soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Monica Gonzalez Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-14 14:30:28', '2021-09-14 14:30:28'),
(35520, 11056, 28282, NULL, '2021-10-04 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Coastal Bend Urgent Care is already contracted with ACS.  Recredentialing is complete just waiting on the approval meeting on 9/16.  No further action is necessary.  Claims are still being processing for this provider.    Thank you, Patti Davidson | Manager, Network Development HealthSmart | Network Solutions Office: 972 388 3091 | Fax: 214 574 1121 patti.davidson@healthsmart.com | www.HealthSmart.com', NULL, NULL, '2021-09-27 10:33:17', '2021-09-27 10:33:17'),
(35521, 11056, 28282, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Hi.   The provider below is already contracted.  We are only recredentialing the site.     You will receive the recredentialing approval letter from our credentialing department after 2 weeks.', NULL, NULL, '2021-10-06 14:49:50', '2021-10-06 14:49:50'),
(35522, 11056, 28282, NULL, '2021-10-14 00:00:00.000', 'Approved', 'Ancillary contract has been completed.  There is no need of the providers to be credentialed.', NULL, NULL, '2021-10-07 10:56:34', '2021-10-07 10:56:34'),
(35523, 1006, 28283, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35524, 3040, 28283, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@triwest.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Triwest for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:59:55', '2021-06-07 12:59:55'),
(35525, 11056, 28283, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Email sent to : providerservices@triwest.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers with Triwest for our group under the below locations.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548    Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# : 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a blessed day!', NULL, NULL, '2021-06-24 13:12:34', '2021-06-24 13:12:34'),
(35526, 1006, 28283, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of enrollment for our group and providers mentioned in the previous email.   Please get back to me as soon as possible.  Thank you.', NULL, NULL, '2021-07-13 17:28:52', '2021-07-13 17:28:52'),
(35527, 1006, 28283, NULL, '2021-08-02 00:00:00.000', 'In Process', 'Spoke with the representative (Margo Rose, O: (916) 389-6334) ​and she said that the request is in-process and we should send an email to credentialing@triwest.com, sent f/u email.', NULL, NULL, '2021-07-26 16:06:11', '2021-07-26 16:06:11'),
(35528, 1006, 28283, NULL, '2021-08-10 00:00:00.000', 'In Process', 'Sent f/u email @ credentialing@triwest.com:  Sub: Enrollment Status - CBUC/GWMC - Triwest  \"Hello,   We\'re still waiting on an update on this request. Please get back to me as soon as you\'re able to.  Thank you. \"', NULL, NULL, '2021-08-03 16:13:20', '2021-08-03 16:13:20'),
(35529, 11056, 28283, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : 	credentialing@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening!  Hope this email finds you well. I wanted to get an update regarding the status of enrollment for our group and providers mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 16:16:33', '2021-08-18 16:16:33'),
(35530, 11056, 28283, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : 	credentialing@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening!  Hope this email finds you well. I wanted to get an update regarding the status of enrollment for our group and providers mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 16:20:25', '2021-08-18 16:20:25'),
(35531, 11056, 28283, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : credentialing@triwest.com, providerservices@triwest.com, jmonson@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening!  Hope this email finds you well. I am still waiting to get an update regarding the status of enrollment for our group and providers mentioned below. Please respond to me as soon as possible.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-24 10:42:05', '2021-08-24 10:42:05'),
(35532, 11056, 28283, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : jmonson@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening Jess!  Hope this email finds you well. Thank you so much for the prompt response. Please provide me with the welcome or approval letters for the below mentioned providers and practice as soon as possible.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great weekend!', NULL, NULL, '2021-09-03 14:43:54', '2021-09-03 14:43:54'),
(35533, 11056, 28283, NULL, '2021-10-01 00:00:00.000', 'In Process', 'mail received from : mlarsen@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Confidential  Good Morning,  The providers : Paterson, Katherine D  and Flynn, Mercedita N have been added for Aperture review as of 9/5/2021.  This credentialing process may take between 30-90 days and once approved you will receive an approval letter with contracted dates. If you have further questions please reach out to the email listed.   providerdataupdate@triwest.com  Thank you for caring for our nation’s veterans.  Michelle Larsen Provider Services mlarsen@Triwest.com 480-481-5549', NULL, NULL, '2021-09-24 14:52:56', '2021-09-24 14:52:56'),
(35534, 11056, 28283, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : Larsen, Michelle  Sub : RE: FW: Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Sensitive     Good Morning  Ahmed,  I normally do not work this area of credentialing, I work on a specific area and have been helping out with the emails.  In the future you will want to reach out to the email I have added below.  I was able to see that your providers are loaded into Aperture and are pending review.  I am told this can take from 30 to 90 days and sometimes as much as 120 days to complete depending on the documents required by Aperture.  The providers were enter on 9/5/2021 and it shows the provider files are in the initial process of review.  I can only give you the time estimated to complete the process. An approval letter will be sent to you once the process is complete and it will have the contract information on it.   I will not be helping with these emails any longer and will return to my regular tasks of entering the providers for review.  Thank you for your kind comments!    providerdataupdate@triwest.com    Thank you for caring for our nation’s veterans.     Michelle Larsen Provider Services mlarsen@Triwest.com 480-481-5549   ', NULL, NULL, '2021-10-06 12:52:15', '2021-10-06 12:52:15'),
(35535, 11056, 28283, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email sent to : providerdataupdate@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good afternoon!  Hope this email finds you well. Please provide me with the latest updates regarding the providers and facility credentialing applications mentioned below under Tax I.D and both locations. And still waiting for the welcome letters for the providers.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663  Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811   If you have any questions or concerns or require any information or documents please let me know. Eagerly, waiting for the response.  Thank you! Have a great weekend!', NULL, NULL, '2021-10-14 15:56:05', '2021-10-14 15:56:05'),
(35536, 11056, 28283, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from : ccarroll@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest   TriWest Classification: Confidential   Talha,  I removed Michelle from the email as she is no longer in the same department.   We have both urgent cares loaded at the facility level as of 6/1/20 for CCN.  The providers below have credentialed but are in the process of being loaded.  You will receive the credentialing letter once completed.  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Provider is still in the cred process, pending with Aperture as of 9/5/21.  The credentialing process takes 30-90 days to complete.  Katherine Paterson  1164776548        Cecilia Carroll Direct Contract Manager TriWest Healthcare Alliance  O:  (623) 435-3343 F:  (866) 549-4618 ccarroll@triwest.com www.triwest.com', NULL, NULL, '2021-10-22 12:03:39', '2021-10-22 12:03:39'),
(35537, 11056, 28283, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email received from: ccarroll@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest   TriWest Classification: Confidential     Talha,     Reminder, Michelle is no longer in this department.      See below status of your urgent care and providers in question.     We have both urgent cares loaded at the facility level as of 6/1/20 for CCN.     The providers below have credentialed but are in the process of being loaded.  You will receive the credentialing letter once completed.  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Provider is still in the cred process, pending with Aperture as of 9/5/21.  The credentialing process takes 30-90 days to complete.  Katherine Paterson  1164776548              Cecilia Carroll  Direct Contract Manager  TriWest Healthcare Alliance  O:  (623) 435-3343  F:  (866) 549-4618  ccarroll@triwest.com  www.triwest.com', NULL, NULL, '2021-11-09 11:13:43', '2021-11-09 11:13:43'),
(35538, 11056, 28283, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from:  sbachman@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Confidential     Julie,  Please process the provider in Pending status and provider the effective dates for all three providers.     Group Name  Coastal Bend Urgent Care, LLC  Tax ID  81-1890349  Group NPI  1427509264  Primary Location  301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324  Secondary Location  504A Houston Street, George West , TX 78022-3663  Provider Name  NPI  Katherine Paterson  1164776548  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Sincerely,  Sandra Bachman  Team Lead, Provider Data Ops / TriWest Healthcare Alliance  P: 1 (855) 722-2838  F: (866) 589-7693  www.triwest.com', NULL, NULL, '2021-11-24 13:02:52', '2021-11-24 13:02:52'),
(35539, 11056, 28283, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  	jmiller@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest   Good morning Julie!  Hope this email finds you well. Please respond to this query at your earliest convenience. Provide us with the effective dates and welcome letters for all three providers soon.  Eagerly, waiting for your reply.  Thank you! Have a great day!', NULL, NULL, '2021-12-06 18:03:30', '2021-12-06 18:03:30'),
(35540, 11056, 28283, NULL, '2021-12-21 00:00:00.000', 'Approved', 'Email received from: jmonson@triwest.com & Credentialing@triwest.com & sdevi@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest  Talha,  Coastal Bend Urgent Care LLC, 301 S Hillside Dr, Ste 4 Beeville TX – 78102 and NPI: 1427509264 credentialed as of date 09/27/2019.  The location has been added. Effective 7/26/2021.  Here is the provider information that you have requested  Providers - Effective dates   Patterson – 10.15.21  Flynn – 9.29.21  Gonzalez – 10.5.21  Thank you.  Sailaja Devi Provider Credentialing Specialist TriWest Healthcare Alliance  Ph: (480) 530 4403 Fax: (866) 549-4610 Sdevi@triwest.com www.triwest.com', NULL, NULL, '2021-12-14 15:42:00', '2021-12-14 15:42:00'),
(35541, 1006, 28284, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:14', '2021-05-05 09:34:14'),
(35542, 1005, 28284, NULL, '2021-06-09 00:00:00.000', 'Not Eligible', 'Paramount does not cover Texas as it is an Ohio only plan, please find attached link for reference: https://www.paramounthealthcare.com/news/paramount-advantage-service-area-changes', NULL, NULL, '2021-06-01 14:20:48', '2021-06-01 14:20:48'),
(35543, 1006, 28296, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35544, 3040, 28296, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@renaissancefamily.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Renaissance Physicians ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Renaissance Physicians for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:35:00', '2021-06-07 12:35:00'),
(35545, 1006, 28296, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email to correct email address @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,  I hope you\'re doing well, we want to enroll the following group and providers with Renaissance Physicians, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 16:55:48', '2021-06-24 16:55:48'),
(35546, 1006, 28296, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,   I wanted to get an update regarding the status of our request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-07-13 17:24:57', '2021-07-13 17:24:57'),
(35547, 11056, 28296, NULL, '2021-08-25 00:00:00.000', 'In Process', '	 Email sent to : 	txgqproviderrelations@healthspring.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  Good afternoon!  Hope you are doing well. I want to inquire about the enrollment status of the below mentioned practice and providers. Please respond to me soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you have any questions or concerns or need documents please let me know.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-18 13:01:31', '2021-08-18 13:01:31'),
(35548, 11056, 28296, NULL, '2021-09-01 00:00:00.000', 'In Process', 'email sent to :  txgqproviderrelations@healthspring.com, joann.alanis@careallies.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  Good afternoon!  Hope you are doing well. I am still waiting to get an update regarding the enrollment status of the below mentioned practice and providers since july.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you have any questions or concerns or need documents please let me know.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-25 08:38:29', '2021-08-25 08:38:29'),
(35549, 11056, 28296, NULL, '2021-09-02 00:00:00.000', 'Not Eligible', 'Email received from : cresta.smith@careallies.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  These providers are not in the renaissance service area. We are only in the greater Houston area.     Thanks  Cresta', NULL, NULL, '2021-08-25 14:23:41', '2021-08-25 14:23:41'),
(35550, 1006, 28297, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35551, 1005, 28297, NULL, '2021-06-14 00:00:00.000', 'On Hold', 'Awaiting Molina\'s enrollment.', NULL, NULL, '2021-06-07 10:16:41', '2021-06-07 10:16:41'),
(35552, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'Initiated', 'Email sent to: david.balli@molinahealthcare.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Molina Health||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Molina Health for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-12-21 17:43:14', '2021-12-21 17:43:14'),
(35553, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'We received the following update from MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Molina Provider Contract - Coastal Bend Urgent Care, LLC  \"Good Afternoon,  Happy Wednesday! Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for (Coastal Bend Urgent Care, LLC ) to contract under TAX ID number (81-1890349).  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below: EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com 888-562-5442 x200249   Have a wonderful day! Thank you, Tyhesha Price MHT| Provider Contracts Molina Healthcare of Texas, Inc. 1660 Westridge Circle N Irving, TX 75038 Mhtcontractrequest@Molinahealthcare.com\"', NULL, NULL, '2021-12-21 17:43:47', '2021-12-21 17:43:47'),
(35554, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'We received the following update from Juliana.Mata@molinahealthcare.com:  Sub: Molina Contract Packet - Coastal Bend Urgent Care LLC DBA Beeville Medical Clinic  \"Good afternoon,  Happy Monday!!  Hope you are doing well.  I am following up to my previous email. Please be advised unless all forms are returned, we will not be able to continue contracting process.  any assistance will be greatly appreciated.  Thank you in advance  Juliana Mata | Associate Specialist Provider Contracts Molina Healthcare Of Texas Molina Healthcare Of Texas, Inc Juliana.Mata@Molinahealthcare.com 1660 Westridge Circle N. Irving, TX 75038 \'  (888) 562-5442 ext 200249\"  Replied with the requested information:  \"Hello Juliana,   I apologize for the delay, here\'s the requested information hopefully it suffices. We also have a secondary location and the address is as follows: 504A Houston Street, George West, TX 78022-3663  Do let me know if anything else is required to proceed.\"', NULL, NULL, '2021-12-21 17:44:23', '2021-12-21 17:44:23'),
(35555, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good evening!  Hope all is well. Please provide me with the latest updates of the enrollment status of following providers & practice and the secondary location too. Kindly also update me about the applications and forms submitted to you regarding enrollment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Furthermore,if documents and information is needed please let me know. Please don\'t hesitate to contact me directly.  Thank you! Have a great week ahead!', NULL, NULL, '2021-12-21 17:44:48', '2021-12-21 17:44:48'),
(35556, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope all is well. Here is the filled contract request form for the secondary service location 504-A, Houston Street. Please see the attachment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Furthermore, if any additional information is required please let me know. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-12-21 17:45:23', '2021-12-21 17:45:23'),
(35557, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for Coastal Bend Urgent Care LLC to contract under TAX ID number 81-1890349.  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below:  EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com   888-562-5442 x200249', NULL, NULL, '2021-12-21 17:45:46', '2021-12-21 17:45:46'),
(35558, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well. Please provide me with the updates on the credentialing of  the facility mentioned below with Molina Health under the Tax ID with both locations listed below.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location 504A Houston Street, George West, TX 78022-3663  If you need any information or documents related to this please let me know. Waiting for your reply.  Thank you! Have a great weekend!', NULL, NULL, '2021-12-21 17:46:11', '2021-12-21 17:46:11'),
(35559, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub  : Enrollment Status Query - CBUC/GWMC - Molina Health  Good  afternoon,  Happy Wednesday!!  Hope you are doing well.  per information on   our system,  both facilities are in process for credentialing.  Once credentialing process is complete, we will go ahead and forward contract to be loaded  into network billing system.  thank you  for your patience', NULL, NULL, '2021-12-21 17:46:44', '2021-12-21 17:46:44'),
(35560, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Tuesday!!  Hope you are doing well.  Per information on our system, both facilities are credential complete, we are waiting on execution from plan\'s president.  Once PSA is executed,  we will go ahead and forward contract to be loaded into network billing system,  this process might take 30-45 days.', NULL, NULL, '2021-12-21 17:50:21', '2021-12-21 17:50:21'),
(35561, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning Juliana!  Hope you had a great week yet. Please let us know about the execution of the Plan\'s President. Has the PSA been executed yet or not? Is that loaded into your billing system?  Eagerly, waiting to hear back from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-12-21 17:50:29', '2021-12-21 17:50:29'),
(35562, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Friday!!  Hope you are doing well.  Per information on our system, both locations are in process of being loaded into the network billing system, this process might take 30-45 days.  Thank you for your patience', NULL, NULL, '2021-12-21 17:51:10', '2021-12-21 17:51:10'),
(35563, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to:  Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well.  Thank you for the update and prompt response. Try to escalate the loading process and let it be completed before the time period.  Have a wonderful day!', NULL, NULL, '2021-12-21 17:51:32', '2021-12-21 17:51:32'),
(35564, 11056, 28297, NULL, '2021-12-28 00:00:00.000', 'Approved', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health   Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, service location 301 S. Hillside Drive is loaded into network billing system with effective date 12/15/2021.  Please see attached for welcome letter.  2nd service location is in process of being loaded into network billing system.  thank you for your patience.     Thank you     Juliana Mata | Associate Specialist Provider Contracts  Please see the attachment', NULL, NULL, '2021-12-21 17:52:03', '2021-12-21 17:52:03'),
(35565, 1006, 28298, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35566, 3040, 28298, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: axhartma@texaschildrens.org   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TCHP ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TCHP for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:40:39', '2021-06-07 12:40:39'),
(35567, 1006, 28298, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Hello,   I hope you\'re doing well, we want to enroll the following group and providers with TCHP, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 17:01:49', '2021-06-24 17:01:49'),
(35568, 1006, 28298, NULL, '2021-07-21 00:00:00.000', 'In Process', 'We received the following email from TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Please submit a letter of interest questionnaire with a w9. The application is on our website www.texaschildrenshealthplan.org *for providers\"  Replied with:  \"Hello,   Please find the attached LOI for our urgent care, do let me know if anything else is required to proceed.   Thank you. \"  The form is attached in group task for reference. ', NULL, NULL, '2021-07-14 12:48:15', '2021-07-14 12:48:15'),
(35569, 1006, 28298, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:01:03', '2021-07-26 09:01:03'),
(35570, 1006, 28299, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35571, 3040, 28299, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: TXCredentialing@amerigroup.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Amerigroup for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 09:56:35', '2021-06-07 09:56:35'),
(35572, 1006, 28299, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Good Day to you.  Is this a PCP clinic or a true Urgent Care?  The latter option means that the entity bills globally.\"  Sent reply:  \"Hello,   This is a true Urgent care, please let me know how we can proceed with the request.  Thank you!\"', NULL, NULL, '2021-06-24 14:38:30', '2021-06-24 14:38:30'),
(35573, 11056, 28299, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email received from : txcredentialing@amerigroup.com  Sub : Enrollment Query || Coastal Bend Urgent Care & George West Medical Clinic - Amerigroup   Please send us a letterhead with the following and include a w9:   **Legal name / DBA  **NPI#  **Taxonomy Code  **Service locations  **Billing location  **phone / Fax / office hours / age limits  **TPI / Medicare #  **CLIA #', NULL, NULL, '2021-07-06 17:04:44', '2021-07-06 17:04:44'),
(35574, 11056, 28299, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group  Greetings,  Hope you are doing well. Here is the information you requested for and kindly see the attachments.  Practice Details: Practice  Legal name / DBA  : Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349 Taxonomy Code :  261QU0200X - Clinic/Center Urgent Care  Main practice & billing location : 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address : 504A Houston Street George West , TX 78022-3663  Practice phone : 361-226-1126 Practice  Fax :  361 542-4076 TPI / Medicare # : 588832 CLIA # : 45D2132336 Practice age limits : 0 till 100  Practice  office hours :   Monday 9AM–5PM Tuesday 9AM–5PM Wednesday 9AM–5PM Thursday 9AM–5PM Friday 9AM–5PM Saturday Closed Sunday Closed  If you have any questions or concerns feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-07-07 09:10:48', '2021-07-07 09:10:48'),
(35575, 1006, 28299, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 08:57:56', '2021-07-26 08:57:56'),
(35576, 1006, 28300, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35577, 1006, 28300, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'Sent an email @ pdsdallas@aetna.com to verify enrollment status of provider and group:   Sub: Enrollment Status Query - CBUC - First Health  \"Hello,   I hope you\'re doing well, I wanted to get an update on the enrollment status for the following providers and group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264  Provider Name: Katherine Paterson NPI# 1164776548 Provider Name: Jennifer Tudor NPI# 1720455835 Provider Name: Mercedita Flynn NPI# 1619166188  Please get back to me as soon as possible. Also, if any of the providers or the group isn\'t enrolled, please let me know what the process is to start the enrollment.  Thank you.\"', NULL, NULL, '2021-05-05 13:42:09', '2021-05-05 13:42:09'),
(35578, 1006, 28300, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com cc \"Muchakurthi, Satish Kumar X\" MuchakurthiS@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello Bollu,   The requested information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264 TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548 License Number: 517795  Provider Name: Jennifer Tudor NPI# 1720455835 License Number: AP128673  Please let me know how long it will take to add these providers to our TIN with the mentioned addresses, also is Mercedita Flynn already added under both mentioned service locations?  Thank you.\"', NULL, NULL, '2021-06-09 10:21:01', '2021-06-09 10:21:01'),
(35579, 1006, 28300, NULL, '2021-07-06 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   I wanted to check in on the status of this request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-06-29 16:59:22', '2021-06-29 16:59:22'),
(35580, 1006, 28300, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 08:59:27', '2021-07-26 08:59:27'),
(35581, 1006, 28301, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35582, 3040, 28301, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: info@usamco.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || MCO ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in MCO for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:10:42', '2021-06-07 12:10:42'),
(35583, 1006, 28301, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ info@usamco.com:  Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hello,  I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled under MCO and if not what the procedure would be to enroll them, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663 Provider Name: Katherine PatersonProvider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.   Thank you!\"', NULL, NULL, '2021-06-24 16:40:35', '2021-06-24 16:40:35'),
(35584, 1006, 28301, NULL, '2021-07-20 00:00:00.000', 'Approved', 'We received the following approval confirmation email from ProviderMarketingInfo ProviderMarketingInfo@usamco.com:   Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hi Brad,  I show that there is an active agreement with TIN 81-1890349 since 2/22/17 under the name Beeville Medical Clinic and the two DBA’s Coastal Bend Urgent Care LLC and Coastal Bend Long Term Care.  I show two addresses under this agreement, 600 S Hillside Dr and 301 S Hillside Dr Ste 4.  I have CC’ed our Provider Relations department on this email and they will be able to add the 504 A Houston St address below.  With regards to the providers, as the agreement is as an Ancillary group, you do not need to add/credential new providers. Any provider billing under the TIN and one of the addresses on file will be counted as in-network.  Please let me know if you have any further questions.  Sarah Cozzetto Lead Network Development Coordinator\"', NULL, NULL, '2021-07-13 17:14:23', '2021-07-13 17:14:23'),
(35585, 1006, 28302, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35586, 3040, 28302, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@memorialhermann.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Memorial Hermann for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:13:32', '2021-06-07 12:13:32'),
(35587, 1006, 28302, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  \"Good Morning,  You will need to complete the Request for Application form online. You can do that by going here https://healthplan.memorialhermann.org/-/media/memorial-hermann/healthplan/files/providers/health-plan-request-to-participate.ashx?la=en&hash=27F819BE45E95E2EA8789FB1902B4D2F and completing the request to participate form online and forwarding to the email on the form.  Regards, Jo\"  The form is filled out and sent out to them and attached to the main group task for reference.   Sent to MHHP Contracting MHHPContracting@memorialhermann.org:  \"Hello,   Please find the attached network participation form for our group, please let me know if anything else is needed for this request.  Thank you!\"', NULL, NULL, '2021-06-24 16:50:18', '2021-06-24 16:50:18'),
(35588, 1006, 28302, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ MHHP Contracting MHHPContracting@memorialhermann.org  MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub; Network Participation Form - CBUC/GWMC - Memorial Hermann  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for our group and providers. Their information is as follows:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\'', NULL, NULL, '2021-07-13 17:22:49', '2021-07-13 17:22:49'),
(35589, 1006, 28302, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:00:26', '2021-07-26 09:00:26'),
(35590, 1006, 28304, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35591, 3040, 28304, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: david.balli@molinahealthcare.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Molina Health||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Molina Health for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:31:25', '2021-06-07 12:31:25'),
(35592, 1006, 28304, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from MHTContractrequest mhtcontractrequest@molinahealthcare.com:  Sub: Attn: Contracting Team - CBUC/GWMC - Molina   \"Good Afternoon Mr. Adil Abbas  I am doing fine, how do are you doing?  I did research for Coastal Bend Urgent Care and it does not show up in our system.  I tried both the Tax id and Group NPI. Please complete this contract request form and return along with a current W-9 to fax number: 877-900-5655 Attn: Contracting Team or email form to: mhtcontractrequest@molinahealthcare.com  Please let me know if you need further information or assistances.  Thank you  David Balli Representative Provider Service  II Molina Healthcare of Texas, Inc. 4316 South McColl Road Edinburg, TX  78539 I Phone: (956) 532-5211 Righ tfax: (877) 900-8454 Email: david.balli@molinahealthcare.com\"  The form was filled out and sent to mhtcontractrequest@molinahealthcare.com, form is attached in the main group task for reference. ', NULL, NULL, '2021-06-25 12:43:26', '2021-06-25 12:43:26'),
(35593, 1006, 28304, NULL, '2021-07-08 00:00:00.000', 'In Process', 'We received the following update from MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Molina Provider Contract - Coastal Bend Urgent Care, LLC  \"Good Afternoon,  Happy Wednesday! Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for (Coastal Bend Urgent Care, LLC ) to contract under TAX ID number (81-1890349).  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below: EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com 888-562-5442 x200249   Have a wonderful day! Thank you, Tyhesha Price MHT| Provider Contracts Molina Healthcare of Texas, Inc. 1660 Westridge Circle N Irving, TX 75038 Mhtcontractrequest@Molinahealthcare.com\"', NULL, NULL, '2021-07-01 15:55:03', '2021-07-01 15:55:03'),
(35594, 1006, 28304, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:00:39', '2021-07-26 09:00:39'),
(35595, 1006, 28305, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35596, 1006, 28305, NULL, '2021-06-15 00:00:00.000', 'Initiated', 'We submitted a group enrollment request via the Wellcare website:  \"Your form was submitted successfully. Thank you for contacting us. A representative will be in contact to discuss your interest in becoming a participating Provider.\"  Enrollment form is attached in the group task for reference. ', NULL, NULL, '2021-06-08 16:31:24', '2021-06-08 16:31:24'),
(35597, 1006, 28305, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from ProspectiveProviderTX ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Dear Provider:  Thank you for your interest in joining our network, please allow 30 Calendar days for us to review your request.  Sincerely, Network Management – Texas | www.wellcare.com\"  Sent f/u email:   \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of my application. Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 10:19:21', '2021-06-25 10:19:21'),
(35598, 1006, 28305, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Sent another f/u email @ ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Hello,   I hope you\'re doing well, I\'m still waiting on the status of this enrollment request.  Please get back to me as soon as you\'re able.  Thank you.\"', NULL, NULL, '2021-07-14 17:15:50', '2021-07-14 17:15:50'),
(35599, 1006, 28305, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:01:44', '2021-07-26 09:01:44'),
(35600, 1006, 28306, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35601, 1006, 28306, NULL, '2021-05-12 00:00:00.000', 'Initiated', 'The provider enrollment request is already in process under our group, which is already enrolled with Ambetter and the provider will automatically be assigned the plan once enrollment is finished. ', NULL, NULL, '2021-05-05 12:29:59', '2021-05-05 12:29:59'),
(35602, 1006, 28306, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent following enrollment query @ AM.Austin@SuperiorHealthPlan.com & SHP.NetworkDevelopment@superiorhealthplan.com:  Sub: Enrollment Query - CBUC/GWMC -  Superior Health/Ambetter  \"Hello,  I wanted to verify if the following group and providers were enrolled with Superior Healthplan & Ambetter under the mentioned addresses:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548  Provider Name: Mercedita Flynn NPI# 1619166188  Provider Name: Jennifer Tudor NPI# 1720455835  Please get back to me as soon as you\'re able. Thank you. \"', NULL, NULL, '2021-06-09 09:49:01', '2021-06-09 09:49:01'),
(35603, 1006, 28306, NULL, '2021-07-06 00:00:00.000', 'Approved', 'Approval confirmation:  Jennifer Tudor: Eff: 02/01/2021  Ref# I57969070 ', NULL, NULL, '2021-06-29 16:50:50', '2021-06-29 16:50:50'),
(35604, 1006, 28307, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35605, 3040, 28307, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: trpndataentry@trpnppo.com, providerrelations@trpnppo.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TRPN ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TRPN for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:43:47', '2021-06-07 12:43:47'),
(35606, 1006, 28307, NULL, '2021-07-02 00:00:00.000', 'In Process', 'Sent f/u email @ trpndataentry@trpnppo.com & TRPN Provider Relations providerrelations@trpnppo.com:  Sub: Enrollment Status/Request - CBUC/GWMC - TRPN  \"Hello, I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled.   The information is as follows: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 09:23:13', '2021-06-25 09:23:13'),
(35607, 11056, 28307, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : trpndataentry@trpnppo.com  Sub : Enrollment Requisition Query - Coastal Bend Urgent Care & George West Medical Clinic - TRPN  Greetings,  Hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled. The information is as follows:  Practices: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Providers: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Kindly get back to me as soon as possible.  Thank you!', NULL, NULL, '2021-07-06 16:50:27', '2021-07-06 16:50:27'),
(35608, 1006, 28307, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:01:09', '2021-07-26 09:01:09'),
(35609, 1006, 28308, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35610, 3040, 28308, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: dhpcontracting@dchstx.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Driscoll  for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you    ', NULL, NULL, '2021-06-07 10:37:44', '2021-06-07 10:37:44'),
(35611, 1006, 28308, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following email from dhpcontracting@dchstx.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  \"Good afternoon,  Please complete the attached documents for each provider and email them to dhpcontracting@dchstx.org.  We will also need a current PAA or Collaborative agreement for each of the mid-level practitioners.  Thank you Karla Claunch\"  Requested Ryan to send us copies of the PAA/Collaborative agreement to avoid any delays.   \"Hello Ryan,  We need updated copies of the following documents for the mentioned providers: Mercedita Flynn An updated copy of AANP CertificationFrank Dehnisch An updated copy of Malpractice Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to. Thank you!\"', NULL, NULL, '2021-06-25 13:48:51', '2021-06-25 13:48:51'),
(35612, 1006, 28308, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Still waiting on Ryan to send us PAA/Collab agreement for all providers to proceed with this request, sent another reminder via hangouts/google chat:  \"Hello Ryan,  I just wanted to ask if it would be possible for you to get us the following information: We need updated copies of the following documents for the mentioned providers:  Mercedita Flynn An updated copy of AANP Certification Frank Dehnisch An updated copy of Malpractice  Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to.  Thank you!  Also, if you could send us the update CLIA of both CBUC & GWMC\"', NULL, NULL, '2021-07-14 16:27:32', '2021-07-14 16:27:32'),
(35613, 1006, 28308, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 08:59:08', '2021-07-26 08:59:08'),
(35614, 1019, 28308, NULL, '2022-02-09 00:00:00.000', 'Approved', 'Received the following email from Karla.Claunch@dchstx.org  Good morning,  I sent the welcome packet and contract 12/28/2021 to the credentialing contact email we have on file.  I have attached everything to this email for you.  Effective date: 01/01/2022 Attached is the Welcome Letter', NULL, NULL, '2022-02-02 13:15:49', '2022-02-02 13:15:49'),
(35615, 1006, 28309, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35616, 1006, 28309, NULL, '2021-05-12 00:00:00.000', 'Initiated', 'Submitted enrollment request via Anci-Care\'s website:   \"Apply to ACS Network  Congratulations on taking your first step to becoming a Provider-Partner in the ACS Provider Network. Your account has been established. An email with instructions on how to log in and begin the application process has been sent to your email address. Please use the link provided along with the login (your email address) to begin the application process.  Thank you for your interest in Ancillary Care Services.\"', NULL, NULL, '2021-05-05 13:16:09', '2021-05-05 13:16:09'),
(35617, 1006, 28309, NULL, '2021-06-15 00:00:00.000', 'In Process', 'Sent following enrollment query @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,  We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to. Thank you. \"', NULL, NULL, '2021-06-08 16:15:56', '2021-06-08 16:15:56'),
(35618, 1006, 28309, NULL, '2021-07-02 00:00:00.000', 'In Process', 'The previous email was sent to an incorrect address, sent corrected email @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,    We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to.  Thank you.\"  ', NULL, NULL, '2021-06-25 17:06:02', '2021-06-25 17:06:02'),
(35619, 1006, 28309, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Received following notification from email:  \"Your message to providerdevelopment@anci-care.com couldn\'t be delivered. The group providerdevelopment only accepts messages from people in its organization or on its allowed senders list, and your email address isn\'t on the list.\"  Sent corrected email @ ACS VIP Providers vipproviders@anci-care.com.', NULL, NULL, '2021-07-14 14:56:00', '2021-07-14 14:56:00'),
(35620, 1006, 28309, NULL, '2021-07-23 00:00:00.000', 'In Process', 'Received the following update from Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hi Brad,  Our Medical Advisory Committee is meeting tomorrow. Please allow 7-10 business days after approvals for me to send you an official letter.  Best Regards,  Jennifer Maligaya | Sr. Provider Relations, ACS and MyDecision HealthSmart | Network Solutions Office: 405 241 4811 | Fax: 214 574 1121 Jennifer.maligaya@healthsmart.com | www.HealthSmart.com\"', NULL, NULL, '2021-07-16 16:56:20', '2021-07-16 16:56:20'),
(35621, 1006, 28309, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 08:58:32', '2021-07-26 08:58:32'),
(35622, 1006, 28310, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35623, 3040, 28310, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@triwest.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Triwest for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:59:59', '2021-06-07 12:59:59'),
(35624, 11056, 28310, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Email sent to : providerservices@triwest.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers with Triwest for our group under the below locations.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548    Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# : 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a blessed day!', NULL, NULL, '2021-06-24 13:12:47', '2021-06-24 13:12:47'),
(35625, 1006, 28310, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of enrollment for our group and providers mentioned in the previous email.   Please get back to me as soon as possible.  Thank you.', NULL, NULL, '2021-07-13 17:28:48', '2021-07-13 17:28:48'),
(35626, 1006, 28310, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:01:33', '2021-07-26 09:01:33'),
(35627, 1006, 28311, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:15', '2021-05-05 09:34:15'),
(35628, 1005, 28311, NULL, '2021-06-09 00:00:00.000', 'Not Eligible', 'Paramount does not cover Texas as it is an Ohio only plan, please find attached link for reference: https://www.paramounthealthcare.com/news/paramount-advantage-service-area-changes', NULL, NULL, '2021-06-01 14:20:59', '2021-06-01 14:20:59'),
(35629, 1006, 28323, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35630, 3040, 28323, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@renaissancefamily.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Renaissance Physicians ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Renaissance Physicians for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:35:05', '2021-06-07 12:35:05'),
(35631, 1006, 28323, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email to correct email address @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,  I hope you\'re doing well, we want to enroll the following group and providers with Renaissance Physicians, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 16:55:44', '2021-06-24 16:55:44'),
(35632, 1006, 28323, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,   I wanted to get an update regarding the status of our request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-07-13 17:24:53', '2021-07-13 17:24:53'),
(35633, 1006, 28323, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:00:52', '2021-07-26 09:00:52'),
(35634, 1006, 28324, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35635, 1005, 28324, NULL, '2021-06-14 00:00:00.000', 'On Hold', 'Awaiting Molina\'s enrollment.', NULL, NULL, '2021-06-07 10:16:26', '2021-06-07 10:16:26'),
(35636, 1006, 28324, NULL, '2021-08-02 00:00:00.000', 'Not Eligible', 'The provider is no longer a part of the group as per Ryan. ', NULL, NULL, '2021-07-26 09:02:15', '2021-07-26 09:02:15'),
(35637, 1006, 28325, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35638, 3040, 28325, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: axhartma@texaschildrens.org   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TCHP ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TCHP for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:40:42', '2021-06-07 12:40:42'),
(35639, 1006, 28325, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Hello,   I hope you\'re doing well, we want to enroll the following group and providers with TCHP, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 17:01:41', '2021-06-24 17:01:41'),
(35640, 1006, 28325, NULL, '2021-07-21 00:00:00.000', 'In Process', 'We received the following email from TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Please submit a letter of interest questionnaire with a w9. The application is on our website www.texaschildrenshealthplan.org *for providers\"  Replied with:  \"Hello,   Please find the attached LOI for our urgent care, do let me know if anything else is required to proceed.   Thank you. \"  The form is attached in group task for reference. ', NULL, NULL, '2021-07-14 12:48:11', '2021-07-14 12:48:11'),
(35641, 1006, 28325, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the following update from jointchp@texaschildrens.org:  Sub: Letter of Interest Questionnaire - CBUC - TCHP  \"Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.\"', NULL, NULL, '2021-08-03 16:00:56', '2021-08-03 16:00:56'),
(35642, 11056, 28325, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : jointchp@texaschildrens.org  &  tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Good evening!  Hope all is well. I want to inquire about the enrollment status of the below mentioned practice and providers. Have my applications of the below mentioned providers been reviewed or not yet?  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 15:25:45', '2021-08-18 15:25:45'),
(35643, 11056, 28325, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,     I was able to find a submission of an LOI (attached) for provider Mercedita Flynn and a denial letter that was sent.  Please see attachments.     Let me know if you have any more questions  -Liz        Self Note  20210802037174969  Mercedita N Flynn', NULL, NULL, '2021-08-24 17:01:40', '2021-08-24 17:01:40'),
(35644, 11056, 28325, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Email sent to : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP   Good morning Liz!  Hope this email finds you well. We have confirmed the NPI of the provider Mercedita Flynn from TMHP & is also attested. Therefore, please consider this application. Please see the attachment below.  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-17 12:50:10', '2021-09-17 12:50:10'),
(35645, 11056, 28325, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,  Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.   Thank you  Liz Ramirez Contract Specialist Texas Children’s Health Plan', NULL, NULL, '2021-09-28 09:45:52', '2021-09-28 09:45:52'),
(35646, 11056, 28325, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : tchpnetworkmanagement@texaschildrens.org & bxgupta@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Group- Coastal Bend Urgent Care, LLC   Katherine Paterson         1164776548 Please see attached denial letter  20211001038052743     Mercedita Flynn               1619166188 Please see attached denial letter  20210930038036249     Monica Gonzalez             1871132811 Please see attached denial letter  20210930038036263   No TCHP does not work with BEE county. Our apologies.  You can also check yourself on website at texaschildrens.org yourself which county TCHP serves.', NULL, NULL, '2021-10-07 10:36:43', '2021-10-07 10:36:43'),
(35647, 1006, 28326, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35648, 3040, 28326, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: TXCredentialing@amerigroup.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Amerigroup for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 09:56:38', '2021-06-07 09:56:38'),
(35649, 1006, 28326, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Good Day to you.  Is this a PCP clinic or a true Urgent Care?  The latter option means that the entity bills globally.\"  Sent reply:  \"Hello,   This is a true Urgent care, please let me know how we can proceed with the request.  Thank you!\"', NULL, NULL, '2021-06-24 14:38:20', '2021-06-24 14:38:20'),
(35650, 11056, 28326, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email received from : txcredentialing@amerigroup.com  Sub : Enrollment Query || Coastal Bend Urgent Care & George West Medical Clinic - Amerigroup   Please send us a letterhead with the following and include a w9:   **Legal name / DBA  **NPI#  **Taxonomy Code  **Service locations  **Billing location  **phone / Fax / office hours / age limits  **TPI / Medicare #  **CLIA #', NULL, NULL, '2021-07-06 17:04:54', '2021-07-06 17:04:54');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35651, 11056, 28326, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group  Greetings,  Hope you are doing well. Here is the information you requested for and kindly see the attachments.  Practice Details: Practice  Legal name / DBA  : Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349 Taxonomy Code :  261QU0200X - Clinic/Center Urgent Care  Main practice & billing location : 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address : 504A Houston Street George West , TX 78022-3663  Practice phone : 361-226-1126 Practice  Fax :  361 542-4076 TPI / Medicare # : 588832 CLIA # : 45D2132336 Practice age limits : 0 till 100  Practice  office hours :   Monday 9AM–5PM Tuesday 9AM–5PM Wednesday 9AM–5PM Thursday 9AM–5PM Friday 9AM–5PM Saturday Closed Sunday Closed  If you have any questions or concerns feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-07-07 09:10:56', '2021-07-07 09:10:56'),
(35652, 1006, 28326, NULL, '2021-08-13 00:00:00.000', 'In Process', 'Sent f/u email @ txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I wanted to get an update regarding the enrollment status for the following group and providers:  Group Name: Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349  Main practice & billing location: 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Name: Katherine Moten Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-08-06 13:52:50', '2021-08-06 13:52:50'),
(35653, 1006, 28326, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I hope you\'re doing well, I am still waiting on the status of my application. Please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-08-16 16:00:47', '2021-08-16 16:00:47'),
(35654, 11056, 28326, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com, latoyna.henry@amerigroup.com, Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good afternoon!  Hope you are doing well. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead! ', NULL, NULL, '2021-08-23 16:34:10', '2021-08-23 16:34:10'),
(35655, 11056, 28326, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : mpsweb@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope you are doing well. It has been so long since you haven\'t responded to our emails. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice. Please provide me with the latest updates soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead!   Called but not received by anyone. Left out a voice mail regarding the enrollment status.', NULL, NULL, '2021-09-03 14:06:08', '2021-09-03 14:06:08'),
(35656, 11056, 28326, NULL, '2021-09-27 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope all is well with you. It had been a long since our email got responded back. We are still waiting to get the latest updates related our enrollment applications for the following providers under the Practice Tax I.D mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# : 1164776548  Provider Name: Mercedita N Flynn Provider NPI# : 1619166188  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!  I had words with Kim U at 800-454-3730. She said that there is no contact no. of Amerigroup Credentialing dept. they only contact through emails.  Ref code : i-140308714', NULL, NULL, '2021-09-20 12:22:57', '2021-09-20 12:22:57'),
(35657, 11056, 28326, NULL, '2021-10-07 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com & Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||   Good evening!  Hope this email finds you well. Please see the location again. Please note that our facilities are located in BEEVILLE , TX & George West , TX, not in Corpus Christi.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!', NULL, NULL, '2021-09-30 15:36:25', '2021-09-30 15:36:25'),
(35658, 11056, 28326, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good Morning,  Your request has been received for provider enrollment.  Please note that Amerigroup currently does not service the Hidalgo or the Corpus Christi Service Delivery Areas.   Hi There, those locations are within the Corpus Christi service delivery area, Amerigroup currently does not have membership down in that region.   Those areas are managed by other Medicaid Managed Care Organizations.   Thank you again for your interest.  Sincerely,', NULL, NULL, '2021-10-07 15:35:45', '2021-10-07 15:35:45'),
(35659, 1006, 28327, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35660, 1006, 28327, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'Sent an email @ pdsdallas@aetna.com to verify enrollment status of provider and group:   Sub: Enrollment Status Query - CBUC - First Health  \"Hello,   I hope you\'re doing well, I wanted to get an update on the enrollment status for the following providers and group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264  Provider Name: Katherine Paterson NPI# 1164776548 Provider Name: Jennifer Tudor NPI# 1720455835 Provider Name: Mercedita Flynn NPI# 1619166188  Please get back to me as soon as possible. Also, if any of the providers or the group isn\'t enrolled, please let me know what the process is to start the enrollment.  Thank you.\"', NULL, NULL, '2021-05-05 13:42:05', '2021-05-05 13:42:05'),
(35661, 1006, 28327, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com cc \"Muchakurthi, Satish Kumar X\" MuchakurthiS@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello Bollu,   The requested information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264 TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548 License Number: 517795  Provider Name: Jennifer Tudor NPI# 1720455835 License Number: AP128673  Please let me know how long it will take to add these providers to our TIN with the mentioned addresses, also is Mercedita Flynn already added under both mentioned service locations?  Thank you.\"', NULL, NULL, '2021-06-09 10:20:55', '2021-06-09 10:20:55'),
(35662, 1006, 28327, NULL, '2021-07-06 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   I wanted to check in on the status of this request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-06-29 16:59:18', '2021-06-29 16:59:18'),
(35663, 1006, 28327, NULL, '2021-08-04 00:00:00.000', 'In Process', 'Sent initiation and f/u email @ \"Bharath, Bollu\" BharathB@aetna.com & \"Talasila, Bala M\" TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   We are still waiting on the status of our initial request and here is the information for an additional provider, please get back to me as soon as possible.   Provider Name: Monica Gonzalez NPI# 1871132811 License Number: AP144421  Thank you. \"', NULL, NULL, '2021-07-28 16:27:21', '2021-07-28 16:27:21'),
(35664, 1006, 28327, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com & TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   We still have not received any updates regarding the status of enrollment for the following providers under the mentioned group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264 TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Mercedita Flynn NPI# 1619166188 License Number: AP118292  Provider Name: Katherine Paterson NPI# 1164776548 License Number: 517795  Provider Name: Monica Gonzalez NPI# 1871132811 License Number: AP144421  Please get back to me as soon as possible.  Thank you. \" ', NULL, NULL, '2021-08-16 12:18:38', '2021-08-16 12:18:38'),
(35665, 11056, 28327, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : MadirajuP@aetna.com, \"Sidley, Jeanette\" SidleyJ1@firsthealth.com, PDS Dallas  pdsdallas@aetna.com  Sub : Re: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059   Good afternoon!  Hope you are doing well. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead! ', NULL, NULL, '2021-08-23 17:02:30', '2021-08-23 17:02:30'),
(35666, 11056, 28327, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : BharathB@aetna.com  Sub : Re: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  Good afternoon!  Hope you are doing well. It has been so long since you haven\'t responded to our emails. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice. Please provide me with the latest updates soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great weekend! ', NULL, NULL, '2021-09-03 14:15:17', '2021-09-03 14:15:17'),
(35667, 11056, 28327, NULL, '2021-09-21 00:00:00.000', 'In Process', 'Email received from : DillikarA@aetna.com  Sub : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hi,  Please find the status of below provider as per requested.   S.no  Provider Name  NPI  Cpd Id  TIN  Effective Date  Status  1  Paterson, Katherine D  1164776548  2815476  811890349  -  Tax Id not found  2  Monica Gonzalez  1871132811  811890349  -  Provider not found    Regards, Bharath', NULL, NULL, '2021-09-14 13:22:37', '2021-09-14 13:22:37'),
(35668, 11056, 28327, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email sent to : DillikarA@aetna.com  Sub  : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hey Bharath!  Hope this email finds you well. Please guide and assist me regarding how to solve the below highlighted issues.  In the meantime, please do not hesitate to reach out if you have any questions or concerns.  Thank you! Have a great day!', NULL, NULL, '2021-09-28 12:39:18', '2021-09-28 12:39:18'),
(35669, 11056, 28327, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : SidleyJ1@firsthealth.com  Sub : RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hello Ahmed,  I hope that this email finds you well! I apologize that I have not been able to respond sooner, my son has been ill so I have been in and out of the office.  This is the new group agreement that we established that will become effective 11/1/21. It is still in the implementation stages but will be complete before the effective date. All providers listed on the roster you provided to me will be linked to the new agreement once effective.   I hope that this helps clarify.  Take care!  Jeanette Sidley Network Relations Consultant', NULL, NULL, '2021-10-06 15:02:24', '2021-10-06 15:02:24'),
(35670, 11056, 28327, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email received from : SidleyJ1@firsthealth.com  Sub : RE: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Good morning Ahmed,  I hope that this email finds you well! Thank you for the well wishes, we are hoping he starts to feel better soon.  I have attached a copy of the signed agreement to this email. I apologize if the system did not automatically send it to you when it was signed on our side.  The contract is currently in implementation with our Data Team. I will send over the welcome letter once I have your group ID.  As always, please do not hesitate to reach out if you have any questions or concerns.  Take care! Jeanette', NULL, NULL, '2021-10-14 15:39:03', '2021-10-14 15:39:03'),
(35671, 11056, 28327, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email sent to : SidleyJ1@firsthealth.com  Sub : Re: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Good morning Jeanette!  Hope this email finds you well. He will feel better soon. He is in my prayers.  Bundle of thanks for your prompt responses. And I am grateful to you for that.  Whenever the implementation is completed, please provide the welcome letter soon.   Thank you! Have a wonderful & blessed weekend ahead!', NULL, NULL, '2021-10-22 12:10:45', '2021-10-22 12:10:45'),
(35672, 11056, 28327, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: sidleyj1@firsthealth.com  Sub : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135   Good morning Jeanette!  Hope you & your son both are doing great. Please provide me with the latest updates about the implementation as well as on the welcome letters too. Kindly do the needful soon.  Please get back to me soon.  Thank you! Take Care!', NULL, NULL, '2021-11-09 15:27:43', '2021-11-09 15:27:43'),
(35673, 11056, 28327, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from:  sidleyj1@firsthealth.com  Sub:  Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hello,  It is with great pleasure to welcome you to the First Health Network. I would like to personally thank you for all of your time and efforts during the contracting process. You should have already received your fully executed copy of the First Health Agreement.  I would like to take a moment to share what to expect next and share important resources with you in order to allow a smooth process as your contract is implemented and beyond.  Next steps:  * While your contract is completely executed, your contract is currently in the process of being implemented in our system and your practitioners may still need to undergo the credentialing process. Please ensure you have updated your CAQH applications and attestations to ensure there will be no delays.  * Please send your provider group additions or terminations to the following email address: pdsdallas@aetna.com. You may reference your CPD ID # 1073945 (which becomes effective 11/01/2021).  * To check on the status of your requests, please contact either our Provider Services department at 800-226-5116 or you can send an inquiry via email to firsthealthcustomerservicemailbox@aetna.com.     * The Provider Services 800-line can also be contacted for questions related to provider effective dates, fee schedules, claim issues, ect. If they are unable to resolve your issue, they will document your concern & Contact information and route it to the appropriate department.     * For credentialing inquiries please contact 800-353-1232. It has been a pleasure working with you and I look forward to a mutually beneficial relationship.     Please feel free to forward this information to anyone that you feel would benefit.     Thank you,  Jeanette Sidley Network Relations Consultant  750 Riverpoint Drive West Sacramento, CA 95605  Phone: 916-374-4876 SidleyJ1@firsthealth.com TX, CO, KS, OK and MI', NULL, NULL, '2021-11-24 10:39:02', '2021-11-24 10:39:02'),
(35674, 11056, 28327, NULL, '2021-12-16 00:00:00.000', 'Approved', 'Email received from:  sidleyj1@firsthealth.com  Sub:  RE: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Good morning Ahmed,   I hope that this email finds you well! I apologize  Paterson, Katherine – eff 11/1/21 – system ID #2815476  Please see the attachment', NULL, NULL, '2021-12-09 13:42:52', '2021-12-09 13:42:52'),
(35675, 1006, 28328, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35676, 3040, 28328, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: info@usamco.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || MCO ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in MCO for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:10:45', '2021-06-07 12:10:45'),
(35677, 1006, 28328, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ info@usamco.com:  Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hello,  I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled under MCO and if not what the procedure would be to enroll them, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663 Provider Name: Katherine PatersonProvider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.   Thank you!\"', NULL, NULL, '2021-06-24 16:40:31', '2021-06-24 16:40:31'),
(35678, 1006, 28328, NULL, '2021-07-20 00:00:00.000', 'Approved', 'We received the following approval confirmation email from ProviderMarketingInfo ProviderMarketingInfo@usamco.com:   Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hi Brad,  I show that there is an active agreement with TIN 81-1890349 since 2/22/17 under the name Beeville Medical Clinic and the two DBA’s Coastal Bend Urgent Care LLC and Coastal Bend Long Term Care.  I show two addresses under this agreement, 600 S Hillside Dr and 301 S Hillside Dr Ste 4.  I have CC’ed our Provider Relations department on this email and they will be able to add the 504 A Houston St address below.  With regards to the providers, as the agreement is as an Ancillary group, you do not need to add/credential new providers. Any provider billing under the TIN and one of the addresses on file will be counted as in-network.  Please let me know if you have any further questions.  Sarah Cozzetto Lead Network Development Coordinator\"', NULL, NULL, '2021-07-13 17:14:19', '2021-07-13 17:14:19'),
(35679, 1006, 28329, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35680, 3040, 28329, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@memorialhermann.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Memorial Hermann for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:13:20', '2021-06-07 12:13:20'),
(35681, 1006, 28329, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  \"Good Morning,  You will need to complete the Request for Application form online. You can do that by going here https://healthplan.memorialhermann.org/-/media/memorial-hermann/healthplan/files/providers/health-plan-request-to-participate.ashx?la=en&hash=27F819BE45E95E2EA8789FB1902B4D2F and completing the request to participate form online and forwarding to the email on the form.  Regards, Jo\"  The form is filled out and sent out to them and attached to the main group task for reference.   Sent to MHHP Contracting MHHPContracting@memorialhermann.org:  \"Hello,   Please find the attached network participation form for our group, please let me know if anything else is needed for this request.  Thank you!\"', NULL, NULL, '2021-06-24 16:50:14', '2021-06-24 16:50:14'),
(35682, 1006, 28329, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ MHHP Contracting MHHPContracting@memorialhermann.org  MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub; Network Participation Form - CBUC/GWMC - Memorial Hermann  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for our group and providers. Their information is as follows:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\'', NULL, NULL, '2021-07-13 17:22:46', '2021-07-13 17:22:46'),
(35683, 1006, 28329, NULL, '2021-08-02 00:00:00.000', 'In Process', 'We received the following response from MHHP Contracting MHHPContracting@memorialhermann.org:  Sub: Memorial Hermann Health Plan Request to Participate  \"We are in receipt of Coastal Bend Urgent Care’s request to become a participating provider with Memorial Hermann Health Plans and need additional information to proceed with your request.  Please provide the following information:  List of services provided ·         Do you provide Virtual Health Services?  Current service area and/or list of locations List of all employed/contracted providers (if applicable) including NPs and PAs (please include individual NPIs) What age population is served? Please list 0-2 years of age; 2-18 years of age; 18+ years Where do you have privileges? Please list all Hospitals, Ambulatory Surgery Centers, etc. Link to website Current W-9 Current quality and outcomes data Any additional information you would like presented to the Network Access and Adequacy Committee   Your participation request will be presented at the next NAAC meeting following receipt of the additional information.\"  Responded to the queries.', NULL, NULL, '2021-07-26 13:20:03', '2021-07-26 13:20:03'),
(35684, 1006, 28329, NULL, '2021-08-05 00:00:00.000', 'Not Eligible', 'We received  the following denial notification from MHHPContracting@memorialhermann.org:  Sub: Memorial Hermann Health Plan Request to Participate  \"At this time, the cities listed below are out of our network area, and we do not contract out of network at this time. I am withdrawing your application for participation. If something changes in the near future, we will let you know. Please let me know if you have any questions.  Thank you. Camilla Paige\"', NULL, NULL, '2021-07-29 13:34:30', '2021-07-29 13:34:30'),
(35685, 1006, 28331, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35686, 3040, 28331, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: david.balli@molinahealthcare.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Molina Health||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Molina Health for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:31:28', '2021-06-07 12:31:28'),
(35687, 1006, 28331, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from MHTContractrequest mhtcontractrequest@molinahealthcare.com:  Sub: Attn: Contracting Team - CBUC/GWMC - Molina   \"Good Afternoon Mr. Adil Abbas  I am doing fine, how do are you doing?  I did research for Coastal Bend Urgent Care and it does not show up in our system.  I tried both the Tax id and Group NPI. Please complete this contract request form and return along with a current W-9 to fax number: 877-900-5655 Attn: Contracting Team or email form to: mhtcontractrequest@molinahealthcare.com  Please let me know if you need further information or assistances.  Thank you  David Balli Representative Provider Service  II Molina Healthcare of Texas, Inc. 4316 South McColl Road Edinburg, TX  78539 I Phone: (956) 532-5211 Righ tfax: (877) 900-8454 Email: david.balli@molinahealthcare.com\"  The form was filled out and sent to mhtcontractrequest@molinahealthcare.com, form is attached in the main group task for reference. ', NULL, NULL, '2021-06-25 12:43:22', '2021-06-25 12:43:22'),
(35688, 1006, 28331, NULL, '2021-07-08 00:00:00.000', 'In Process', 'We received the following update from MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Molina Provider Contract - Coastal Bend Urgent Care, LLC  \"Good Afternoon,  Happy Wednesday! Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for (Coastal Bend Urgent Care, LLC ) to contract under TAX ID number (81-1890349).  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below: EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com 888-562-5442 x200249   Have a wonderful day! Thank you, Tyhesha Price MHT| Provider Contracts Molina Healthcare of Texas, Inc. 1660 Westridge Circle N Irving, TX 75038 Mhtcontractrequest@Molinahealthcare.com\"', NULL, NULL, '2021-07-01 15:55:00', '2021-07-01 15:55:00'),
(35689, 1006, 28331, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the following update from Juliana.Mata@molinahealthcare.com:  Sub: Molina Contract Packet - Coastal Bend Urgent Care LLC DBA Beeville Medical Clinic  \"Good afternoon,  Happy Monday!!  Hope you are doing well.  I am following up to my previous email. Please be advised unless all forms are returned, we will not be able to continue contracting process.  any assistance will be greatly appreciated.  Thank you in advance  Juliana Mata | Associate Specialist Provider Contracts Molina Healthcare Of Texas Molina Healthcare Of Texas, Inc Juliana.Mata@Molinahealthcare.com 1660 Westridge Circle N. Irving, TX 75038 \'  (888) 562-5442 ext 200249\"  Replied with the requested information:  \"Hello Juliana,   I apologize for the delay, here\'s the requested information hopefully it suffices. We also have a secondary location and the address is as follows: 504A Houston Street, George West, TX 78022-3663  Do let me know if anything else is required to proceed.\"', NULL, NULL, '2021-08-03 14:06:46', '2021-08-03 14:06:46'),
(35690, 11056, 28331, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good evening!  Hope all is well. Please provide me with the latest updates of the enrollment status of following providers & practice and the secondary location too. Kindly also update me about the applications and forms submitted to you regarding enrollment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Furthermore,if documents and information is needed please let me know. Please don\'t hesitate to contact me directly.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-18 15:51:34', '2021-08-18 15:51:34'),
(35691, 11056, 28331, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning,  Happy Thursday!!  Hope you are doing well.  Per information on our system, service location  301 S. Hillside Drive is in process  of credentialing.  Service location 504  A  Houston Street, we are missing a contract request form, could you please fill out form and submit back to me at your earliest convenience?  Individual providers are not contracted under Urgent Care Facility.  Molina contracts facility directly.     Hope this information helps.  Thank you        Juliana Mata | Associate Specialist Provider Contracts  Molina Healthcare Of Texas  Molina Healthcare Of Texas, Inc  Juliana.Mata@Molinahealthcare.com  1660 Westridge Circle N.  Irving, TX 75038  \'  (888) 562-5442 ext 200249', NULL, NULL, '2021-08-24 14:05:50', '2021-08-24 14:05:50'),
(35692, 11056, 28331, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope all is well. Here is the filled contract request form for the secondary service location 504-A, Houston Street. Please see the attachment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Furthermore, if any additional information is required please let me know. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-03 15:02:53', '2021-09-03 15:02:53'),
(35693, 11056, 28331, NULL, '2021-10-01 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for Coastal Bend Urgent Care LLC to contract under TAX ID number 81-1890349.  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below:  EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com   888-562-5442 x200249', NULL, NULL, '2021-09-24 11:45:26', '2021-09-24 11:45:26'),
(35694, 11056, 28331, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well. Please provide me with the updates on the credentialing of  the facility mentioned below with Molina Health under the Tax ID with both locations listed below.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location 504A Houston Street, George West, TX 78022-3663  If you need any information or documents related to this please let me know. Waiting for your reply.  Thank you! Have a great weekend!', NULL, NULL, '2021-10-06 12:37:58', '2021-10-06 12:37:58'),
(35695, 11056, 28331, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub  : Enrollment Status Query - CBUC/GWMC - Molina Health  Good  afternoon,  Happy Wednesday!!  Hope you are doing well.  per information on   our system,  both facilities are in process for credentialing.  Once credentialing process is complete, we will go ahead and forward contract to be loaded  into network billing system.  thank you  for your patience', NULL, NULL, '2021-10-14 15:47:57', '2021-10-14 15:47:57'),
(35696, 11056, 28331, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Tuesday!!  Hope you are doing well.  Per information on our system, both facilities are credential complete, we are waiting on execution from plan\'s president.  Once PSA is executed,  we will go ahead and forward contract to be loaded into network billing system,  this process might take 30-45 days.', NULL, NULL, '2021-10-22 10:21:56', '2021-10-22 10:21:56'),
(35697, 11056, 28331, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning Juliana!  Hope you had a great week yet. Please let us know about the execution of the Plan\'s President. Has the PSA been executed yet or not? Is that loaded into your billing system?  Eagerly, waiting to hear back from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-11-09 14:11:48', '2021-11-09 14:11:48'),
(35698, 11056, 28331, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Friday!!  Hope you are doing well.  Per information on our system, both locations are in process of being loaded into the network billing system, this process might take 30-45 days.  Thank you for your patience', NULL, NULL, '2021-11-24 12:13:58', '2021-11-24 12:13:58'),
(35699, 11056, 28331, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well.  Thank you for the update and prompt response. Try to escalate the loading process and let it be completed before the time period.  Have a wonderful day!', NULL, NULL, '2021-12-06 17:02:08', '2021-12-06 17:02:08'),
(35700, 11056, 28331, NULL, '2021-12-28 00:00:00.000', 'Approved', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health   Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, service location 301 S. Hillside Drive is loaded into network billing system with effective date 12/15/2021.  Please see attached for welcome letter.  2nd service location is in process of being loaded into network billing system.  thank you for your patience.     Thank you     Juliana Mata | Associate Specialist Provider Contracts  Please see the attachment', NULL, NULL, '2021-12-21 17:39:34', '2021-12-21 17:39:34'),
(35701, 1006, 28332, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35702, 1006, 28332, NULL, '2021-06-15 00:00:00.000', 'Initiated', 'We submitted a group enrollment request via the Wellcare website:  \"Your form was submitted successfully. Thank you for contacting us. A representative will be in contact to discuss your interest in becoming a participating Provider.\"  Enrollment form is attached in the group task for reference. ', NULL, NULL, '2021-06-08 16:31:21', '2021-06-08 16:31:21'),
(35703, 1006, 28332, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following reply from ProspectiveProviderTX ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Dear Provider:  Thank you for your interest in joining our network, please allow 30 Calendar days for us to review your request.  Sincerely, Network Management – Texas | www.wellcare.com\"  Sent f/u email:   \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of my application. Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 10:19:18', '2021-06-25 10:19:18'),
(35704, 1006, 28332, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Sent another f/u email @ ProspectiveProviderTX@wellcare.com:  Sub: RE: Become A Provider - Unsecured - Not Applicable - Texas  \"Hello,   I hope you\'re doing well, I\'m still waiting on the status of this enrollment request.  Please get back to me as soon as you\'re able.  Thank you.\"', NULL, NULL, '2021-07-14 17:15:47', '2021-07-14 17:15:47'),
(35705, 1006, 28332, NULL, '2021-08-02 00:00:00.000', 'In Process', 'Received response from Superior, requesting the form. The form is filled and sent out @ SHP-Network Development shp.networkdevelopment@superiorhealthplan.com:  Sub:  Add Provider- Katherine Paterson - CBUC  \"Hello,   I hope you\'re doing well, please find the attached contract form for our provider to add them to our group. Do let me know if anything else is required.   Thank you.\"', NULL, NULL, '2021-07-26 10:03:27', '2021-07-26 10:03:27'),
(35706, 1006, 28332, NULL, '2021-08-02 00:00:00.000', 'In Process', 'Received response from Superior, requesting the form. The form is filled and sent out @ SHP-Network Development shp.networkdevelopment@superiorhealthplan.com:  Sub:  Add Provider- Katherine Paterson - CBUC  \"Hello,   I hope you\'re doing well, please find the attached contract form for our provider to add them to our group. Do let me know if anything else is required.   Thank you.\"', NULL, NULL, '2021-07-26 10:03:28', '2021-07-26 10:03:28'),
(35707, 1006, 28332, NULL, '2021-08-05 00:00:00.000', 'In Process', 'We received the following update from SHP-NETWORKDEVELOPMENT@superiorhealthplan.com:  Sub: Add Provider- Katherine Paterson - CBUC  \"Hello  We received your completed application on 3/3/21. Your effective date is 6/1/21 and will be receiving a welcome packet shortly.   Thank you, Leslie Gilchrist Intake Coordinator Contract Management\"', NULL, NULL, '2021-07-29 09:26:39', '2021-07-29 09:26:39'),
(35708, 11056, 28332, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com  Sub: Add Provider- Katherine Paterson - CBUC & GWMC  Good evening Leslie!  Hope all is well. Please provide us with the welcome packet soon for the below mentioned provider:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 16:38:37', '2021-08-18 16:38:37'),
(35709, 11056, 28332, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com, M.CorpusChristi@superiorhealthplan.com, SHPNetwork.DevelopmentNPRContracting@superiorhealthplan.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC  Good evening!  Hope all is well.I have been waiting for the welcome packet since July, but haven\'t received it yet. Please provide us with the welcome packet soon for the below mentioned provider:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-24 13:45:13', '2021-08-24 13:45:13'),
(35710, 11056, 28332, NULL, '2021-09-09 00:00:00.000', 'In Process', 'Email sent to : shp.networkdevelopment@superiorhealthplan.com, M.CorpusChristi@superiorhealthplan.com, SHPNetwork.DevelopmentNPRContracting@superiorhealthplan.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC  Good evening!  Hope all is well.I have been waiting for the welcome packet since July, but haven\'t received it yet. Please provide us with the welcome packet soon for the below mentioned provider:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!    I have words with a Rep.  She can\'t able to find out the welcome packet and said they gonna contact me within 15 business days.', NULL, NULL, '2021-09-01 14:19:05', '2021-09-01 14:19:05'),
(35711, 11056, 28332, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Rep : Rose S  Katherine Paterson in network 07/01/2021 participating with wellcare  Mercedita Flynn in network 07/01/2021 participating with wellcare  interaction code : 1296311845  application needed for the group.', NULL, NULL, '2021-09-17 17:12:18', '2021-09-17 17:12:18'),
(35712, 11056, 28332, NULL, '2021-10-06 00:00:00.000', 'In Process', 'Email sent to : TERESA.Argueta@wellcare.com & ProspectiveProviderTX@wellcare.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC   Good afternoon!  Hope all is well with you. I want to get the latest update regarding the enrollment status of the below mentioned providers under the facility TIN with Wellcare.   Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811  If you have any questions or concerns feel free to reach out to me soon. Waiting for your response.  Thank you! Have a great day!', NULL, NULL, '2021-09-29 13:24:59', '2021-09-29 13:24:59'),
(35713, 11056, 28332, NULL, '2021-10-07 00:00:00.000', 'Approved', 'Approval Email received from : ProspectiveProviderTX@wellcare.com & cynthia.barnett@wellcare.com  Sub : Add Provider- Katherine Paterson - CBUC & GWMC   New Providers for Costal Bend Urgent Care  Hello,   The providers below are PAR effective 7/1/2021.   Hi Ahmed,  Here is the spreadsheet on your providers for Coastal Bend Urgent Care.  Take care.  Cyn  Please see the attachment.', NULL, NULL, '2021-09-30 13:59:37', '2021-09-30 13:59:37'),
(35714, 1006, 28333, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35715, 1006, 28333, NULL, '2021-05-12 00:00:00.000', 'Initiated', 'The provider enrollment request is already in process under our group, which is already enrolled with Ambetter and the provider will automatically be assigned the plan once enrollment is finished. ', NULL, NULL, '2021-05-05 12:29:55', '2021-05-05 12:29:55'),
(35716, 1006, 28333, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent following enrollment query @ AM.Austin@SuperiorHealthPlan.com & SHP.NetworkDevelopment@superiorhealthplan.com:  Sub: Enrollment Query - CBUC/GWMC -  Superior Health/Ambetter  \"Hello,  I wanted to verify if the following group and providers were enrolled with Superior Healthplan & Ambetter under the mentioned addresses:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548  Provider Name: Mercedita Flynn NPI# 1619166188  Provider Name: Jennifer Tudor NPI# 1720455835  Please get back to me as soon as you\'re able. Thank you. \"', NULL, NULL, '2021-06-09 09:48:55', '2021-06-09 09:48:55'),
(35717, 1006, 28333, NULL, '2021-07-06 00:00:00.000', 'Approved', 'Approval confirmation:  Katherine Paterson: Eff: 06/01/2021  Ref# I57969070 ', NULL, NULL, '2021-06-29 16:47:44', '2021-06-29 16:47:44'),
(35718, 1006, 28334, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35719, 3040, 28334, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: trpndataentry@trpnppo.com, providerrelations@trpnppo.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TRPN ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TRPN for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:43:51', '2021-06-07 12:43:51'),
(35720, 1006, 28334, NULL, '2021-07-02 00:00:00.000', 'In Process', 'Sent f/u email @ trpndataentry@trpnppo.com & TRPN Provider Relations providerrelations@trpnppo.com:  Sub: Enrollment Status/Request - CBUC/GWMC - TRPN  \"Hello, I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled.   The information is as follows: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-25 09:23:09', '2021-06-25 09:23:09'),
(35721, 11056, 28334, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : trpndataentry@trpnppo.com  Sub : Enrollment Requisition Query - Coastal Bend Urgent Care & George West Medical Clinic - TRPN  Greetings,  Hope you\'re doing well, we wanted to verify if the following group and providers were enrolled with TRPN or not? If so, what is required to get them enrolled. The information is as follows:  Practices: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Providers: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Kindly get back to me as soon as possible.  Thank you!', NULL, NULL, '2021-07-06 16:50:17', '2021-07-06 16:50:17'),
(35722, 1006, 28334, NULL, '2021-08-17 00:00:00.000', 'In Process', 'As per my discussion with TRPN we need to send a provider update form to them, requested a copy, and sent it to trpndataentry@trpnppo.com:  Sub: Provider Update Form - CBUC/GWMC - TRPN  \"Hello,   Please find the attached provider update forms for our providers. Please let me know if anything else is required to continue.   Thank you!\"  Attached for reference in provider tasks. ', NULL, NULL, '2021-08-10 12:44:44', '2021-08-10 12:44:44'),
(35723, 11056, 28334, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : 	trpndataentry@trpnppo.com  Sub : Enrollment Status Updates - CBUC/GWMC - TRPN  Good morning!  Hope all is well. I want to inquire about the enrollment status of the below mentioned practice and providers. Please respond to me soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you need any documents or information regarding this feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 14:08:27', '2021-08-18 14:08:27'),
(35724, 11056, 28334, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to :  trpndataentry@trpnppo.com, providerrelations@trpnppo.com   & AVasquez@trpnppo.com  Sub : Provider Update Form - CBUC/GWMC - TRPN   Good afternoon!  Hope this email finds you well. Please inform me with the latest updates regarding enrollment status of the following providers under the practice in TRPN. Please also inform me about the provider\'s update forms.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Monica Gonzalez Provider NPI# 1871132811  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you have any questions or queries or need any information or documents feel free to reach out to me. Waiting to hear from you soon.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-24 13:32:37', '2021-08-24 13:32:37'),
(35725, 11056, 28334, NULL, '2021-09-09 00:00:00.000', 'Approved', 'Approval Email received from : trpndataentry@trpnppo.com  Sub : RE: Enrollment Status Updates - CBUC/GWMC - TRPN  Hi,     This request is completed,     Provider Mercedita Flynn is Active, effective date 01/01/2017,  Provider Katherine Paterson is Active, effective date 01/01/2017,  Provider Monica Gonzalez is Active, effective date 01/01/2021.    Please see the attachment', NULL, NULL, '2021-09-01 15:58:07', '2021-09-01 15:58:07'),
(35726, 1006, 28335, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35727, 3040, 28335, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: dhpcontracting@dchstx.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Driscoll  for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you    ', NULL, NULL, '2021-06-07 10:37:48', '2021-06-07 10:37:48'),
(35728, 1006, 28335, NULL, '2021-07-02 00:00:00.000', 'In Process', 'We received the following email from dhpcontracting@dchstx.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  \"Good afternoon,  Please complete the attached documents for each provider and email them to dhpcontracting@dchstx.org.  We will also need a current PAA or Collaborative agreement for each of the mid-level practitioners.  Thank you Karla Claunch\"  Requested Ryan to send us copies of the PAA/Collaborative agreement to avoid any delays.   \"Hello Ryan,  We need updated copies of the following documents for the mentioned providers: Mercedita Flynn An updated copy of AANP CertificationFrank Dehnisch An updated copy of Malpractice Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to. Thank you!\"', NULL, NULL, '2021-06-25 13:48:47', '2021-06-25 13:48:47'),
(35729, 1006, 28335, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Still waiting on Ryan to send us PAA/Collab agreement for all providers to proceed with this request, sent another reminder via hangouts/google chat:  \"Hello Ryan,  I just wanted to ask if it would be possible for you to get us the following information: We need updated copies of the following documents for the mentioned providers:  Mercedita Flynn An updated copy of AANP Certification Frank Dehnisch An updated copy of Malpractice  Also, we would like copies of current PAA or Collaborative agreements for all the mid-level providers, please send these over as soon as you\'re able to.  Thank you!  Also, if you could send us the update CLIA of both CBUC & GWMC\"', NULL, NULL, '2021-07-14 16:27:29', '2021-07-14 16:27:29'),
(35730, 11056, 28335, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Still waiting for the  Updated MALPRACTICE : Frank Dehnisch  Updated  AANP Certification : Mercedita Flynn  by Ryan.', NULL, NULL, '2021-08-18 15:03:51', '2021-08-18 15:03:51'),
(35731, 11056, 28335, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Ryan hasn\'t responded to our emails and calls too.  Still waiting for the  Updated MALPRACTICE : Frank Dehnisch  Updated  AANP Certification : Mercedita Flynn  by Ryan.', NULL, NULL, '2021-08-25 08:21:16', '2021-08-25 08:21:16'),
(35732, 11056, 28335, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Email sent to : Karla.Claunch@dchstx.org  Sub  : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good evening Karla!  Hope this email finds you well. Here are the forms with attached documents in the Pdf too with W9s, which you requested for in the previous email for enrollment process. Please find the attachments.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Primary Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# 1164776548  Provider Name: Flynn, Mercedita  Provider NPI# 1619166188  Provider Name: Gonzalez, Monica Provider NPI# 1427509264  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great day', NULL, NULL, '2021-09-17 12:18:17', '2021-09-17 12:18:17'),
(35733, 11056, 28335, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email received from : Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon,  Thank you for these requests but, the disclosure statements were not attached for Monica Gonzalez NP and Katherine Paterson NP.  Please email these directly to me when completed.  They are all now in the credentialing process.  Please allow 60-90 days to complete.  Once complete, you will receive a welcome letter with their effective date.  Thank you  Karla Claunch   ', NULL, NULL, '2021-09-28 16:58:20', '2021-09-28 16:58:20'),
(35734, 11056, 28335, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  My apologies,  I am just noticing that this practice is currently not participating with us.  All providers requested are mid-level who will need a supervising physician.  The physician will also need to be a Driscoll Health Plan participating physician.  If their supervising physician is not already credentialed with us, we will also need to credential them.  We will also need the current PAA or Collaborative agreement between the NP’s and supervising physician.  They should have one on file within the practice.  We are withdrawing these providers  due to not currently having a supervising physician on file for this practice.  We can re-activate them once the remaining, required information is received and they have an established, participating, supervising physician.  We look forward to working with you and eager to hear from you again soon.  Please let me know if you need any further assistance.  Karla Claunch  ', NULL, NULL, '2021-10-06 16:31:02', '2021-10-06 16:31:02'),
(35735, 11056, 28335, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email sent to : Karla.Claunch@dchstx.org  Sub : Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Hey Karla!  Hope you had a great weekend. You don\'t need to apologise. We do have a supervising physician for this practice and want to let him participate with Driscoll Health Plan. Please suggest to me the procedure to credential the supervising physician as soon as possible.  Supervising Physician Details: Name : Frank Dehnisch NPi # : 1952376345 CAQH I.D # : 10577534  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Thank you! Have a wonderful day!', NULL, NULL, '2021-10-14 15:44:30', '2021-10-14 15:44:30'),
(35736, 11056, 28335, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from: Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon,  I wish the weekend was much longer but, here we are.  We will need the same documents for the supervising physician and he must carry them on his license.  Please send a Request for Contact as well as the DHP addendum and disclosure as below.', NULL, NULL, '2021-10-22 08:49:28', '2021-10-22 08:49:28'),
(35737, 11056, 28335, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Sub : Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope this email finds you well. Please find the attached forms for the Supervising physician enrollment with Driscoll. Please accept my apology for the delay. If any corrections are required please let me know.  Supervising Physician Details: Name : Frank Dehnisch NPi # : 1952376345 CAQH I.D # : 10577534  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Thank you! Have a blessed day!', NULL, NULL, '2021-11-09 14:33:29', '2021-11-09 14:33:29'),
(35738, 11056, 28335, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email sent to:  Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Hello,  Thank you for this request.  Before I begin, the addendum needs to be completed with all information.  The disclosure is named and signed by Mercedita Flynn so, we will need his own, signed by him please.  This provider will not be processed until this information is received.  Your prompt attention will avoid delays and withdrawal.  I look forward to hearing from you soon.  Thank you  Karla Claunch   Provided them with their requirement.', NULL, NULL, '2021-11-24 10:02:58', '2021-11-24 10:02:58'),
(35739, 11056, 28335, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good morning!  Hope this email finds you well. Here you go. Please find the corrected one in the attachment.  If anything else is needed feel free to reach out to me.  Take Care!  Thank you!', NULL, NULL, '2021-12-06 16:40:09', '2021-12-06 16:40:09'),
(35740, 11056, 28335, NULL, '2021-12-24 00:00:00.000', 'In Process', 'Email received from:  Karla.Claunch@dchstx.org  Sub:  Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Good afternoon,  You only sent one disclosure, it was for Mercedita which I already have.   I am needing one for both of these providers please-Monica Gonzalez NP and Katherine Paterson NP  They are now in process.  Please allow 60-90 days to complete the process.  I am looking forward to hearing back from you soon with these disclosures and all of their PAA/Collaborative Agreements  Thank you', NULL, NULL, '2021-12-17 14:47:31', '2021-12-17 14:47:31'),
(35741, 11056, 28335, NULL, '2021-12-29 00:00:00.000', 'In Process', '	 Email sent to: Karla.Claunch@dchstx.org  Sub: Fwd: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope you are having a blessed day. Please find the attached disclosure for Monica Gonzalez and Katherine Paterson. We will provide you with their PAA/Collaborative Agreements near in the future.  Please do not hesitate to contact me directly, if you have any questions or concerns I am happy to help.  Take Care!  Thank you! Have a wonderful day!', NULL, NULL, '2021-12-22 11:11:19', '2021-12-22 11:11:19'),
(35742, 19067, 28335, NULL, '2022-01-06 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||   Good afternoon!  Hope this email finds you well. Kindly do provide me with the recent accomplishments of the credentialing process of the below-mentioned providers under facility TIN.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location	504A Houston Street, George West, TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811   Please get back to me soon with the updates and if credentialing is completed do provide me with effective dates and welcome letters.  Thank you! Have a wonderful weekend!', NULL, NULL, '2021-12-30 11:01:05', '2021-12-30 11:01:05'),
(35743, 19067, 28335, NULL, '2022-01-17 00:00:00.000', 'In Process', 'Email sent to: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||  Greetings!  Any updates on the previously mentioned request.  Thanks, Hammad Ahmed.', NULL, NULL, '2022-01-09 22:22:35', '2022-01-09 22:22:35'),
(35744, 19067, 28335, NULL, '2022-01-17 00:00:00.000', 'In Process', 'Email received from: Karla.Claunch@dchstx.org  Subject: Re: FW: FW: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Driscoll ||    Good morning,  I sent the welcome packet and contract 12/28/2021 to the credentialing contact email we have on file.  I have attached everything to this email for you.    ', NULL, NULL, '2022-01-10 09:24:44', '2022-01-10 09:24:44'),
(35745, 19067, 28335, NULL, '2022-03-08 00:00:00.000', 'In Process', 'Email received from: Christine.Rodriguez@dchstx.org  Subject: Katherine D Paterson, NP    RE:             Katherine D Paterson, NP  NPI #:        1164776548  Tax ID#:     81-1890349     Good Morning,  I am currently working on the INITIAL application for Katherine D Paterson, NP for the Driscoll  Health Plan; and I need some additional  documentation completed.  (see attached)  ·         PAA Agreement  ·         Current Liability Insurance  ·         Page 5 of TSCA needs “Call Coverage” has to match the Supervising Physician  ·         Page 6 of TSCA needs “ Box Check Payable To” completed – Match W-9 form  ·         NP License  ·         Current W-9 form  Please forward all requested information to my attention via email within 5 business days.  Feel free to contact me if you have any questions.     **NOTE**  I have looked on the CAQH portal and the information has not been updated..     Thank you,  Christine S Rodriguez  Credentialing Specialist  4525 Ayers St  Corpus Christi, TX 78415-1401  Office:  (361) 694-4322  Fax: (361) 808-2182  Email: Christine.Rodriguez@dchstx.org  Website: www.driscollhealthplan.com', NULL, NULL, '2022-03-01 17:37:07', '2022-03-01 17:37:07'),
(35746, 19067, 28335, NULL, '2022-03-08 00:00:00.000', 'In Process', 'Email received from: Christine.Rodriguez@dchstx.org  Subject: Katherine D Paterson, NP    Hello,     I also need current ATTESTATIONS pages 11-12 with date/signature', NULL, NULL, '2022-03-01 17:37:48', '2022-03-01 17:37:48'),
(35747, 19067, 28335, NULL, '2022-03-08 00:00:00.000', 'In Process', 'Email sent to: christine.rodriguez@dchstx.org  Subject: Re: FW: Katherine D Paterson, NP   Hi Christine!  Kindly see the attached as per you requested.  Don\'t hesitate to reach me directly if you need any document or information.   Regards, Hammad Ahmed', NULL, NULL, '2022-03-01 17:39:11', '2022-03-01 17:39:11'),
(35748, 19067, 28335, NULL, '2022-03-17 00:00:00.000', 'In Process', 'Email received from: Christine.Rodriguez@dchstx.org  Subject: 2nd REQUEST - FW: Katherine D Paterson, NP    Good Morning.     I noticed you also handle the Credentialing for this provider also.  If you could please  get me the information listed on the email below ASAP.      These application are on a time limit, so if the information is NOT received by Tuesday  March 8, 2022; the application will be WITHDRAWN.         Thank you,  Christine S Rodriguez  Credentialing Specialist  4525 Ayers St  Corpus Christi, TX 78415-1401  Office:  (361) 694-4322  Fax: (361) 808-2182  Email: Christine.Rodriguez@dchstx.org  Website: www.driscollhealthplan.com', NULL, NULL, '2022-03-10 16:12:01', '2022-03-10 16:12:01'),
(35749, 19067, 28335, NULL, '2022-03-17 00:00:00.000', 'In Process', 'Email sent to: christine.rodriguez@dchstx.org  Subject: Re: 2nd REQUEST - FW: Katherine D Paterson, NP   Hi Christine,  Kindly see the attached as per requested  Thanks.', NULL, NULL, '2022-03-10 16:12:56', '2022-03-10 16:12:56'),
(35750, 22077, 28335, NULL, '2022-04-28 00:00:00.000', 'In Process', 'Email received from: Christine.Rodriguez@dchstx.org  Subject: Katherine Paterson, NP & Monica Del Bosque Gonzalez, NP  Good Afternoon Alex,     Sorry for the delay I have been in meetings all morning.  Here is a Request for Contract.  I need a new one for each provider.     I will review all the information you have sent me and let you know if I need anything else.  This will be done tomorrow, since I will be in meetings for the rest of the day.     Have a great day…     Thank you,  Christine S Rodriguez  Credentialing Specialist  4525 Ayers St  Corpus Christi, TX 78415-1401  Office:  (361) 694-4322  Fax: (361) 808-2182  Email: Christine.Rodriguez@dchstx.org  Website: www.driscollhealthplan.com', NULL, NULL, '2022-04-21 15:40:30', '2022-04-21 15:40:30'),
(35751, 22077, 28335, NULL, '2022-04-28 00:00:00.000', 'In Process', 'Email sent to: Christine.Rodriguez@dchstx.org  Subject: 	Re: Katherine Paterson, NP & Monica Del Bosque Gonzalez, NP  Good Afternoon Christine,  Kindly see the attached application for each provider.  Have a great day,  Thanks & Regards.', NULL, NULL, '2022-04-21 15:42:06', '2022-04-21 15:42:06'),
(35752, 1006, 28336, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:16', '2021-05-05 09:34:16'),
(35753, 1006, 28336, NULL, '2021-05-12 00:00:00.000', 'Initiated', 'Submitted enrollment request via Anci-Care\'s website:   \"Apply to ACS Network  Congratulations on taking your first step to becoming a Provider-Partner in the ACS Provider Network. Your account has been established. An email with instructions on how to log in and begin the application process has been sent to your email address. Please use the link provided along with the login (your email address) to begin the application process.  Thank you for your interest in Ancillary Care Services.\"', NULL, NULL, '2021-05-05 13:16:05', '2021-05-05 13:16:05'),
(35754, 1006, 28336, NULL, '2021-06-15 00:00:00.000', 'In Process', 'Sent following enrollment query @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,  We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to. Thank you. \"', NULL, NULL, '2021-06-08 16:15:52', '2021-06-08 16:15:52'),
(35755, 1006, 28336, NULL, '2021-07-02 00:00:00.000', 'In Process', 'The previous email was sent to an incorrect address, sent corrected email @ providerdevelopment@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello,    We submitted an enrollment request last month for our group and wanted to get a status update on it, the group information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Please get back to me as soon as you\'re able to.  Thank you.\"  ', NULL, NULL, '2021-06-25 17:05:59', '2021-06-25 17:05:59'),
(35756, 1006, 28336, NULL, '2021-07-21 00:00:00.000', 'In Process', 'Received following notification from email:  \"Your message to providerdevelopment@anci-care.com couldn\'t be delivered. The group providerdevelopment only accepts messages from people in its organization or on its allowed senders list, and your email address isn\'t on the list.\"  Sent corrected email @ ACS VIP Providers vipproviders@anci-care.com.', NULL, NULL, '2021-07-14 14:55:56', '2021-07-14 14:55:56'),
(35757, 1006, 28336, NULL, '2021-07-23 00:00:00.000', 'In Process', 'Received the following update from Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hi Brad,  Our Medical Advisory Committee is meeting tomorrow. Please allow 7-10 business days after approvals for me to send you an official letter.  Best Regards,  Jennifer Maligaya | Sr. Provider Relations, ACS and MyDecision HealthSmart | Network Solutions Office: 405 241 4811 | Fax: 214 574 1121 Jennifer.maligaya@healthsmart.com | www.HealthSmart.com\"', NULL, NULL, '2021-07-16 16:56:16', '2021-07-16 16:56:16'),
(35758, 1006, 28336, NULL, '2021-08-04 00:00:00.000', 'In Process', 'Sent f/u email @ Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello Jennifer,   I wanted to get an update regarding this request, please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-07-28 12:29:41', '2021-07-28 12:29:41'),
(35759, 1006, 28336, NULL, '2021-08-13 00:00:00.000', 'In Process', 'We received the following update from jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Good Morning,  I show that Coastal Bend Urgent Care, LLC And ACS are currently contracted since 7/20/2017. Records indicate that you are due for credentialing.  Please see the attached Re-credentialing Profile.  Best Regards,  Jennifer Maligaya | Sr. Provider Relations, ACS and MyDecision HealthSmart | Network Solutions Office: 405 241 4811 | Fax: 214 574 1121 Jennifer.maligaya@healthsmart.com | www.HealthSmart.com\"  Replied with:  \"Hello Jennifer,  Please find the attached information, do let me know if you need anything else.  Thank you. \"', NULL, NULL, '2021-08-06 15:12:24', '2021-08-06 15:12:24'),
(35760, 1006, 28336, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ Jennifer MaligayaACS jmaligaya@anci-care.com:  Sub: Enrollment Query - CBUC/GWMC - Anci-Care  \"Hello Jennifer,  I hope you\'re doing well, I just wanted to check in on the status of enrollment for our group. Can you please get back to me on this?  Thank you.\"', NULL, NULL, '2021-08-16 16:07:45', '2021-08-16 16:07:45'),
(35761, 11056, 28336, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Coastal Bend Urgent Care is already contracted with ACS.     Recredentialing is complete just waiting on the approval meeting on 9/16.     No further action is necessary.  Claims are still being processing for this provider.     Jennifer Maligaya is no longer with ACS/HealthSmart.     Please continue to use VIPproviders@anci-care.com for updates.     New provider agreements please email me:  patti.davidson@healthsmart.com     Thank you,     Patti Davidson | Manager, Network Development  HealthSmart | Network Solutions  Office: 972 388 3091 | Fax: 214 574 1121  patti.davidson@healthsmart.com | www.HealthSmart.com', NULL, NULL, '2021-08-23 17:10:29', '2021-08-23 17:10:29'),
(35762, 11056, 28336, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Good morning!  Hope all is well. Could you please provide me the enrollment updates,effective dates and welcome or approval letter for the following providers and practice soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Monica Gonzalez Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-03 14:32:25', '2021-09-03 14:32:25'),
(35763, 11056, 28336, NULL, '2021-09-21 00:00:00.000', 'In Process', 'Email sent to : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Good morning!  Hope all is well. Could you please provide me the enrollment updates, effective dates and welcome or approval letter for the following providers and practice soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Monica Gonzalez Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-14 14:30:20', '2021-09-14 14:30:20'),
(35764, 11056, 28336, NULL, '2021-10-04 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Coastal Bend Urgent Care is already contracted with ACS.  Recredentialing is complete just waiting on the approval meeting on 9/16.  No further action is necessary.  Claims are still being processing for this provider.    Thank you, Patti Davidson | Manager, Network Development HealthSmart | Network Solutions Office: 972 388 3091 | Fax: 214 574 1121 patti.davidson@healthsmart.com | www.HealthSmart.com', NULL, NULL, '2021-09-27 10:33:03', '2021-09-27 10:33:03'),
(35765, 11056, 28336, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : pdavidson@anci-care.com  Sub : Re: Enrollment Query - CBUC/GWMC - Anci-Care  Hi.   The provider below is already contracted.  We are only recredentialing the site.     You will receive the recredentialing approval letter from our credentialing department after 2 weeks.', NULL, NULL, '2021-10-06 14:49:58', '2021-10-06 14:49:58'),
(35766, 11056, 28336, NULL, '2021-10-14 00:00:00.000', 'Approved', 'Ancillary contract has been completed.  There is no need of the providers to be credentialed.', NULL, NULL, '2021-10-07 10:56:28', '2021-10-07 10:56:28'),
(35767, 1006, 28337, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:17', '2021-05-05 09:34:17'),
(35768, 3040, 28337, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@triwest.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Triwest for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 13:00:02', '2021-06-07 13:00:02'),
(35769, 11056, 28337, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Email sent to : providerservices@triwest.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Triwest ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers with Triwest for our group under the below locations.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548    Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# : 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a blessed day!', NULL, NULL, '2021-06-24 13:13:02', '2021-06-24 13:13:02'),
(35770, 1006, 28337, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Hello,   I hope you\'re doing well, I wanted to get an update regarding the status of enrollment for our group and providers mentioned in the previous email.   Please get back to me as soon as possible.  Thank you.', NULL, NULL, '2021-07-13 17:28:31', '2021-07-13 17:28:31'),
(35771, 1006, 28337, NULL, '2021-08-02 00:00:00.000', 'In Process', 'Spoke with the representative (Margo Rose, O: (916) 389-6334) ​and she said that the request is in-process and we should send an email to credentialing@triwest.com, sent f/u email.', NULL, NULL, '2021-07-26 16:06:21', '2021-07-26 16:06:21'),
(35772, 1006, 28337, NULL, '2021-08-10 00:00:00.000', 'In Process', 'Sent f/u email @ credentialing@triwest.com:  Sub: Enrollment Status - CBUC/GWMC - Triwest  \"Hello,   We\'re still waiting on an update on this request. Please get back to me as soon as you\'re able to.  Thank you. \"', NULL, NULL, '2021-08-03 16:13:35', '2021-08-03 16:13:35'),
(35773, 11056, 28337, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : 	credentialing@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening!  Hope this email finds you well. I wanted to get an update regarding the status of enrollment for our group and providers mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 16:20:31', '2021-08-18 16:20:31'),
(35774, 11056, 28337, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : credentialing@triwest.com, providerservices@triwest.com, jmonson@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening!  Hope this email finds you well. I am still waiting to get an update regarding the status of enrollment for our group and providers mentioned below. Please respond to me as soon as possible.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-24 10:41:58', '2021-08-24 10:41:58'),
(35775, 11056, 28337, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : jmonson@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good evening Jess!  Hope this email finds you well. Thank you so much for the prompt response. Please provide me with the welcome or approval letters for the below mentioned providers and practice as soon as possible.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Practice Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name : Paterson, Katherine D Provider NPI# : 1164776548   Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# :1619166188  Provider 3:   Provider Name: Gonzalez, Monica Provider NPI# 1871132811  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great weekend!', NULL, NULL, '2021-09-03 14:43:48', '2021-09-03 14:43:48'),
(35776, 11056, 28337, NULL, '2021-10-01 00:00:00.000', 'In Process', 'mail received from : mlarsen@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Confidential  Good Morning,  The providers : Paterson, Katherine D  and Flynn, Mercedita N have been added for Aperture review as of 9/5/2021.  This credentialing process may take between 30-90 days and once approved you will receive an approval letter with contracted dates. If you have further questions please reach out to the email listed.   providerdataupdate@triwest.com  Thank you for caring for our nation’s veterans.  Michelle Larsen Provider Services mlarsen@Triwest.com 480-481-5549', NULL, NULL, '2021-09-24 14:52:47', '2021-09-24 14:52:47'),
(35777, 11056, 28337, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : mlarsen@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Confidential  Good Morning,  The providers : Paterson, Katherine D  and Flynn, Mercedita N have been added for Aperture review as of 9/5/2021.  This credentialing process may take between 30-90 days and once approved you will receive an approval letter with contracted dates. If you have further questions please reach out to the email listed.   providerdataupdate@triwest.com  Thank you for caring for our nation’s veterans.  Michelle Larsen Provider Services mlarsen@Triwest.com 480-481-5549', NULL, NULL, '2021-10-06 12:57:31', '2021-10-06 12:57:31'),
(35778, 11056, 28337, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email sent to : providerdataupdate@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest  Good afternoon!  Hope this email finds you well. Please provide me with the latest updates regarding the providers and facility credentialing applications mentioned below under Tax I.D and both locations. And still waiting for the welcome letters for the providers.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663  Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811   If you have any questions or concerns or require any information or documents please let me know. Eagerly, waiting for the response.  Thank you! Have a great weekend!', NULL, NULL, '2021-10-14 15:56:00', '2021-10-14 15:56:00'),
(35779, 11056, 28337, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email received from : ccarroll@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest   TriWest Classification: Confidential   Talha,  I removed Michelle from the email as she is no longer in the same department.   We have both urgent cares loaded at the facility level as of 6/1/20 for CCN.  The providers below have credentialed but are in the process of being loaded.  You will receive the credentialing letter once completed.  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Provider is still in the cred process, pending with Aperture as of 9/5/21.  The credentialing process takes 30-90 days to complete.  Katherine Paterson  1164776548        Cecilia Carroll Direct Contract Manager TriWest Healthcare Alliance  O:  (623) 435-3343 F:  (866) 549-4618 ccarroll@triwest.com www.triwest.com', NULL, NULL, '2021-10-22 12:03:34', '2021-10-22 12:03:34'),
(35780, 11056, 28337, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email received from: ccarroll@triwest.com  Sub : Enrollment Status Query - CBUC & GWMC - Triwest   TriWest Classification: Confidential     Talha,     Reminder, Michelle is no longer in this department.      See below status of your urgent care and providers in question.     We have both urgent cares loaded at the facility level as of 6/1/20 for CCN.     The providers below have credentialed but are in the process of being loaded.  You will receive the credentialing letter once completed.  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Provider is still in the cred process, pending with Aperture as of 9/5/21.  The credentialing process takes 30-90 days to complete.  Katherine Paterson  1164776548              Cecilia Carroll  Direct Contract Manager  TriWest Healthcare Alliance  O:  (623) 435-3343  F:  (866) 549-4618  ccarroll@triwest.com  www.triwest.com', NULL, NULL, '2021-11-09 11:14:01', '2021-11-09 11:14:01'),
(35781, 11056, 28337, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from:  sbachman@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest  TriWest Classification: Confidential     Julie,  Please process the provider in Pending status and provider the effective dates for all three providers.     Group Name  Coastal Bend Urgent Care, LLC  Tax ID  81-1890349  Group NPI  1427509264  Primary Location  301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324  Secondary Location  504A Houston Street, George West , TX 78022-3663  Provider Name  NPI  Katherine Paterson  1164776548  Mercedita Flynn  1619166188  Monica Gonzalez  1871132811     Sincerely,  Sandra Bachman  Team Lead, Provider Data Ops / TriWest Healthcare Alliance  P: 1 (855) 722-2838  F: (866) 589-7693  www.triwest.com', NULL, NULL, '2021-11-24 13:02:46', '2021-11-24 13:02:46'),
(35782, 11056, 28337, NULL, '2021-12-13 00:00:00.000', 'In Process', 'Email sent to:  	jmiller@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest   Good morning Julie!  Hope this email finds you well. Please respond to this query at your earliest convenience. Provide us with the effective dates and welcome letters for all three providers soon.  Eagerly, waiting for your reply.  Thank you! Have a great day!', NULL, NULL, '2021-12-06 18:03:19', '2021-12-06 18:03:19'),
(35783, 11056, 28337, NULL, '2021-12-21 00:00:00.000', 'Approved', 'Email received from: jmonson@triwest.com & Credentialing@triwest.com & sdevi@triwest.com  Sub: Enrollment Status Query - CBUC & GWMC - Triwest  Talha,  Coastal Bend Urgent Care LLC, 301 S Hillside Dr, Ste 4 Beeville TX – 78102 and NPI: 1427509264 credentialed as of date 09/27/2019.  The location has been added. Effective 7/26/2021.  Here is the provider information that you have requested  Providers - Effective dates   Patterson – 10.15.21  Flynn – 9.29.21  Gonzalez – 10.5.21  Thank you.  Sailaja Devi Provider Credentialing Specialist TriWest Healthcare Alliance  Ph: (480) 530 4403 Fax: (866) 549-4610 Sdevi@triwest.com www.triwest.com', NULL, NULL, '2021-12-14 15:41:50', '2021-12-14 15:41:50'),
(35784, 1006, 28338, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:17', '2021-05-05 09:34:17'),
(35785, 1005, 28338, NULL, '2021-06-09 00:00:00.000', 'Not Eligible', 'Paramount does not cover Texas as it is an Ohio only plan, please find attached link for reference: https://www.paramounthealthcare.com/news/paramount-advantage-service-area-changes', NULL, NULL, '2021-06-01 14:20:09', '2021-06-01 14:20:09'),
(35786, 1006, 28350, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:17', '2021-05-05 09:34:17'),
(35787, 3040, 28350, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@renaissancefamily.com   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Renaissance Physicians ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Renaissance Physicians for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:35:09', '2021-06-07 12:35:09');
INSERT INTO `cm_credentialing_task_logs` (`id`, `user_id`, `credentialing_task_id`, `last_follow_up`, `next_follow_up`, `status`, `details`, `image`, `pdf`, `created_at`, `updated_at`) VALUES
(35788, 1006, 28350, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email to correct email address @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,  I hope you\'re doing well, we want to enroll the following group and providers with Renaissance Physicians, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 16:55:42', '2021-06-24 16:55:42'),
(35789, 1006, 28350, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Sent f/u email @ txgqproviderrelations@healthspring.com:  Sub: Enrollment Request - CBUC/GWMC - Renaissance Physician  \"Hello,   I wanted to get an update regarding the status of our request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-07-13 17:24:50', '2021-07-13 17:24:50'),
(35790, 11056, 28350, NULL, '2021-08-25 00:00:00.000', 'In Process', '	 Email sent to : 	txgqproviderrelations@healthspring.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  Good afternoon!  Hope you are doing well. I want to inquire about the enrollment status of the below mentioned practice and providers. Please respond to me soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you have any questions or concerns or need documents please let me know.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-18 13:01:23', '2021-08-18 13:01:23'),
(35791, 11056, 28350, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Email sent to :  txgqproviderrelations@healthspring.com, joann.alanis@careallies.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  Good afternoon!  Hope you are doing well. I am still waiting to get an update regarding the enrollment status of the below mentioned practice and providers since july.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  If you have any questions or concerns or need documents please let me know.  Thank you! Have a great week ahead!', NULL, NULL, '2021-08-24 14:44:52', '2021-08-24 14:44:52'),
(35792, 11056, 28350, NULL, '2021-09-02 00:00:00.000', 'Not Eligible', 'Email received from : cresta.smith@careallies.com  Sub : Enrollment Status Query - Renaissance Physicians - CBUC/GWMC  These providers are not in the renaissance service area. We are only in the greater Houston area.     Thanks  Cresta', NULL, NULL, '2021-08-25 14:23:35', '2021-08-25 14:23:35'),
(35793, 1006, 28351, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:17', '2021-05-05 09:34:17'),
(35794, 1005, 28351, NULL, '2021-06-14 00:00:00.000', 'On Hold', 'Awaiting Molina\'s enrollment.', NULL, NULL, '2021-06-07 10:16:21', '2021-06-07 10:16:21'),
(35795, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'Initiated', 'Email sent to: david.balli@molinahealthcare.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Molina Health||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers Molina Health for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-12-21 17:43:09', '2021-12-21 17:43:09'),
(35796, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'We received the following update from MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Molina Provider Contract - Coastal Bend Urgent Care, LLC  \"Good Afternoon,  Happy Wednesday! Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for (Coastal Bend Urgent Care, LLC ) to contract under TAX ID number (81-1890349).  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below: EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com 888-562-5442 x200249   Have a wonderful day! Thank you, Tyhesha Price MHT| Provider Contracts Molina Healthcare of Texas, Inc. 1660 Westridge Circle N Irving, TX 75038 Mhtcontractrequest@Molinahealthcare.com\"', NULL, NULL, '2021-12-21 17:43:43', '2021-12-21 17:43:43'),
(35797, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'We received the following update from Juliana.Mata@molinahealthcare.com:  Sub: Molina Contract Packet - Coastal Bend Urgent Care LLC DBA Beeville Medical Clinic  \"Good afternoon,  Happy Monday!!  Hope you are doing well.  I am following up to my previous email. Please be advised unless all forms are returned, we will not be able to continue contracting process.  any assistance will be greatly appreciated.  Thank you in advance  Juliana Mata | Associate Specialist Provider Contracts Molina Healthcare Of Texas Molina Healthcare Of Texas, Inc Juliana.Mata@Molinahealthcare.com 1660 Westridge Circle N. Irving, TX 75038 \'  (888) 562-5442 ext 200249\"  Replied with the requested information:  \"Hello Juliana,   I apologize for the delay, here\'s the requested information hopefully it suffices. We also have a secondary location and the address is as follows: 504A Houston Street, George West, TX 78022-3663  Do let me know if anything else is required to proceed.\"', NULL, NULL, '2021-12-21 17:44:19', '2021-12-21 17:44:19'),
(35798, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good evening!  Hope all is well. Please provide me with the latest updates of the enrollment status of following providers & practice and the secondary location too. Kindly also update me about the applications and forms submitted to you regarding enrollment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson Provider NPI# 1164776548  Furthermore,if documents and information is needed please let me know. Please don\'t hesitate to contact me directly.  Thank you! Have a great week ahead!', NULL, NULL, '2021-12-21 17:44:44', '2021-12-21 17:44:44'),
(35799, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope all is well. Here is the filled contract request form for the secondary service location 504-A, Houston Street. Please see the attachment.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Furthermore, if any additional information is required please let me know. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-12-21 17:45:18', '2021-12-21 17:45:18'),
(35800, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Thank you again for your patience. Thank you for taking the first step to becoming a part of the Molina Healthcare Family. I have received your application for Coastal Bend Urgent Care LLC to contract under TAX ID number 81-1890349.  I am pleased to inform you that I have verified and placed your application in process and it is now with your designated coordinator.  Your designated coordinator will be your source of information for any questions you may have or for status checks. Every Coordinator services certain areas, based on the address information provided on the application; I have provided your Coordinators information.  Also, for an alternative route of provider/facility information, email TexasExpansionContracting@MolinaHealthcare.com  Please see your designated Coordinators information below:  EL PASO, NUECES & TRAVIS Juliana Mata Juliana.Mata@molinahealthcare.com   888-562-5442 x200249', NULL, NULL, '2021-12-21 17:45:41', '2021-12-21 17:45:41'),
(35801, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well. Please provide me with the updates on the credentialing of  the facility mentioned below with Molina Health under the Tax ID with both locations listed below.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Location 504A Houston Street, George West, TX 78022-3663  If you need any information or documents related to this please let me know. Waiting for your reply.  Thank you! Have a great weekend!', NULL, NULL, '2021-12-21 17:46:07', '2021-12-21 17:46:07'),
(35802, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub  : Enrollment Status Query - CBUC/GWMC - Molina Health  Good  afternoon,  Happy Wednesday!!  Hope you are doing well.  per information on   our system,  both facilities are in process for credentialing.  Once credentialing process is complete, we will go ahead and forward contract to be loaded  into network billing system.  thank you  for your patience', NULL, NULL, '2021-12-21 17:46:39', '2021-12-21 17:46:39'),
(35803, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from : Juliana.Mata@molinahealthcare.com  Sub : Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Tuesday!!  Hope you are doing well.  Per information on our system, both facilities are credential complete, we are waiting on execution from plan\'s president.  Once PSA is executed,  we will go ahead and forward contract to be loaded into network billing system,  this process might take 30-45 days.', NULL, NULL, '2021-12-21 17:50:13', '2021-12-21 17:50:13'),
(35804, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning Juliana!  Hope you had a great week yet. Please let us know about the execution of the Plan\'s President. Has the PSA been executed yet or not? Is that loaded into your billing system?  Eagerly, waiting to hear back from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-12-21 17:50:33', '2021-12-21 17:50:33'),
(35805, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good afternoon,  Happy Friday!!  Hope you are doing well.  Per information on our system, both locations are in process of being loaded into the network billing system, this process might take 30-45 days.  Thank you for your patience', NULL, NULL, '2021-12-21 17:51:06', '2021-12-21 17:51:06'),
(35806, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'In Process', 'Email sent to:  Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health  Good morning!  Hope this email finds you well.  Thank you for the update and prompt response. Try to escalate the loading process and let it be completed before the time period.  Have a wonderful day!', NULL, NULL, '2021-12-21 17:51:28', '2021-12-21 17:51:28'),
(35807, 11056, 28351, NULL, '2021-12-28 00:00:00.000', 'Approved', 'Email received from: Juliana.Mata@molinahealthcare.com  Sub: Enrollment Status Query - CBUC/GWMC - Molina Health   Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, service location 301 S. Hillside Drive is loaded into network billing system with effective date 12/15/2021.  Please see attached for welcome letter.  2nd service location is in process of being loaded into network billing system.  thank you for your patience.     Thank you     Juliana Mata | Associate Specialist Provider Contracts  Please see the attachment', NULL, NULL, '2021-12-21 17:51:58', '2021-12-21 17:51:58'),
(35808, 1006, 28352, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:32', '2021-05-05 09:34:32'),
(35809, 3040, 28352, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: axhartma@texaschildrens.org   Subject:Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || TCHP ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers TCHP for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:40:46', '2021-06-07 12:40:46'),
(35810, 1006, 28352, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Hello,   I hope you\'re doing well, we want to enroll the following group and providers with TCHP, please let me know what is required to complete this request, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Katherine Paterson  Provider NPI# 1164776548  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-24 17:01:37', '2021-06-24 17:01:37'),
(35811, 1006, 28352, NULL, '2021-07-21 00:00:00.000', 'In Process', 'We received the following email from TCHP CA Contract Admin tchpnetworkmanagement@texaschildrens.org:  Sub: Enrollment Request/Status - CBUC/GWMC - TCHP  \"Please submit a letter of interest questionnaire with a w9. The application is on our website www.texaschildrenshealthplan.org *for providers\"  Replied with:  \"Hello,   Please find the attached LOI for our urgent care, do let me know if anything else is required to proceed.   Thank you. \"  The form is attached in group task for reference. ', NULL, NULL, '2021-07-14 12:47:49', '2021-07-14 12:47:49'),
(35812, 1006, 28352, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the following update from jointchp@texaschildrens.org:  Sub: Letter of Interest Questionnaire - CBUC - TCHP  \"Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.\"', NULL, NULL, '2021-08-03 16:00:52', '2021-08-03 16:00:52'),
(35813, 11056, 28352, NULL, '2021-08-26 00:00:00.000', 'In Process', 'Email sent to : jointchp@texaschildrens.org  &  tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Good evening!  Hope all is well. I want to inquire about the enrollment status of the below mentioned practice and providers. Have my applications of the below mentioned providers been reviewed or not yet?  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# : 81-1890349 Practice NPI# : 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-18 15:25:36', '2021-08-18 15:25:36'),
(35814, 11056, 28352, NULL, '2021-09-01 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,     I was able to find a submission of an LOI (attached) for provider Mercedita Flynn and a denial letter that was sent.  Please see attachments.     Let me know if you have any more questions  -Liz        Self Note  20210802037174969  Mercedita N Flynn', NULL, NULL, '2021-08-24 17:01:34', '2021-08-24 17:01:34'),
(35815, 11056, 28352, NULL, '2021-09-24 00:00:00.000', 'In Process', 'Email sent to : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP   Good morning Liz!  Hope this email finds you well. We have confirmed the NPI of the provider Mercedita Flynn from TMHP & is also attested. Therefore, please consider this application. Please see the attachment below.  If you need any documents or information regarding this feel free to contact me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-09-17 12:49:54', '2021-09-17 12:49:54'),
(35816, 11056, 28352, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email received from : tchpnetworkmanagement@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Hello,  Thank you for your interest in our health plan’s network. Your LOI has been received and communication will be sent out to you once the review has been completed.   Thank you  Liz Ramirez Contract Specialist Texas Children’s Health Plan', NULL, NULL, '2021-09-28 09:45:42', '2021-09-28 09:45:42'),
(35817, 11056, 28352, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : tchpnetworkmanagement@texaschildrens.org & bxgupta@texaschildrens.org  Sub : Enrollment Status Query - CBUC/GWMC - TCHP  Group- Coastal Bend Urgent Care, LLC   Katherine Paterson         1164776548 Please see attached denial letter  20211001038052743     Mercedita Flynn               1619166188 Please see attached denial letter  20210930038036249     Monica Gonzalez             1871132811 Please see attached denial letter  20210930038036263   No TCHP does not work with BEE county. Our apologies.  You can also check yourself on website at texaschildrens.org yourself which county TCHP serves.', NULL, NULL, '2021-10-07 10:36:33', '2021-10-07 10:36:33'),
(35818, 1006, 28353, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:32', '2021-05-05 09:34:32'),
(35819, 3040, 28353, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: TXCredentialing@amerigroup.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Amerigroup for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 09:56:42', '2021-06-07 09:56:42'),
(35820, 1006, 28353, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Good Day to you.  Is this a PCP clinic or a true Urgent Care?  The latter option means that the entity bills globally.\"  Sent reply:  \"Hello,   This is a true Urgent care, please let me know how we can proceed with the request.  Thank you!\"', NULL, NULL, '2021-06-24 14:38:16', '2021-06-24 14:38:16'),
(35821, 11056, 28353, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email received from : txcredentialing@amerigroup.com  Sub : Enrollment Query || Coastal Bend Urgent Care & George West Medical Clinic - Amerigroup   Please send us a letterhead with the following and include a w9:   **Legal name / DBA  **NPI#  **Taxonomy Code  **Service locations  **Billing location  **phone / Fax / office hours / age limits  **TPI / Medicare #  **CLIA #', NULL, NULL, '2021-07-06 17:03:41', '2021-07-06 17:03:41'),
(35822, 11056, 28353, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group  Greetings,  Hope you are doing well. Here is the information you requested for and kindly see the attachments.  Practice Details: Practice  Legal name / DBA  : Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349 Taxonomy Code :  261QU0200X - Clinic/Center Urgent Care  Main practice & billing location : 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address : 504A Houston Street George West , TX 78022-3663  Practice phone : 361-226-1126 Practice  Fax :  361 542-4076 TPI / Medicare # : 588832 CLIA # : 45D2132336 Practice age limits : 0 till 100  Practice  office hours :   Monday 9AM–5PM Tuesday 9AM–5PM Wednesday 9AM–5PM Thursday 9AM–5PM Friday 9AM–5PM Saturday Closed Sunday Closed  If you have any questions or concerns feel free to contact me.  Thank you! Have a great day!', NULL, NULL, '2021-07-07 09:10:03', '2021-07-07 09:10:03'),
(35823, 1006, 28353, NULL, '2021-08-13 00:00:00.000', 'In Process', 'Sent f/u email @ txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I wanted to get an update regarding the enrollment status for the following group and providers:  Group Name: Coastal Bend Urgent Care, LLC Practice NP I# :  1427509264 Practice Tax ID# : 81-1890349  Main practice & billing location: 301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Name: Katherine Moten Provider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-08-06 13:50:47', '2021-08-06 13:50:47'),
(35824, 1006, 28353, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ TX Credentialing txcredentialing@amerigroup.com:  Sub: RE: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  \"Hello,   I hope you\'re doing well, I am still waiting on the status of my application. Please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-08-16 16:00:44', '2021-08-16 16:00:44'),
(35825, 11056, 28353, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com, latoyna.henry@amerigroup.com, Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good afternoon!  Hope you are doing well. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead! ', NULL, NULL, '2021-08-23 16:35:04', '2021-08-23 16:35:04'),
(35826, 11056, 28353, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : mpsweb@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope you are doing well. It has been so long since you haven\'t responded to our emails. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice. Please provide me with the latest updates soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider 1: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead!   Called but not received by anyone. Left out a voice mail regarding the enrollment status. ', NULL, NULL, '2021-09-03 14:04:19', '2021-09-03 14:04:19'),
(35827, 11056, 28353, NULL, '2021-09-27 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good morning!  Hope all is well with you. It had been a long since our email got responded back. We are still waiting to get the latest updates related our enrollment applications for the following providers under the Practice Tax I.D mentioned below:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Katherine Paterson Provider NPI# : 1164776548  Provider Name: Mercedita N Flynn Provider NPI# : 1619166188  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!  I had words with Kim U at 800-454-3730. She said that there is no contact no. of Amerigroup Credentialing dept. they only contact through emails.  Ref code : i-140308714', NULL, NULL, '2021-09-20 12:22:50', '2021-09-20 12:22:50'),
(35828, 11056, 28353, NULL, '2021-10-07 00:00:00.000', 'In Process', 'Email sent to : txcredentialing@amerigroup.com & Jason.Hughes@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||   Good evening!  Hope this email finds you well. Please see the location again. Please note that our facilities are located in BEEVILLE , TX & George West , TX, not in Corpus Christi.  Group Name	Coastal Bend Urgent Care, LLC Tax ID	81-1890349 Group NPI	1427509264 Primary Location	301 S HILLSIDE DR STE 4, BEEVILLE , TX 78102-5324 Secondary Location	504A Houston Street, George West , TX 78022-3663 Provider Name	NPI Katherine Paterson	1164776548 Mercedita Flynn	1619166188 Monica Gonzalez	1871132811  Please respond back to us soon with the updates. Eagerly, waiting for your response.  Thank you! Have a blessed day!', NULL, NULL, '2021-09-30 15:36:19', '2021-09-30 15:36:19'),
(35829, 11056, 28353, NULL, '2021-10-14 00:00:00.000', 'Not Eligible', 'Email received from : txcredentialing@amerigroup.com  Sub : Fwd: {EXTERNAL} Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Amerigroup ||  Good Morning,  Your request has been received for provider enrollment.  Please note that Amerigroup currently does not service the Hidalgo or the Corpus Christi Service Delivery Areas.   Hi There, those locations are within the Corpus Christi service delivery area, Amerigroup currently does not have membership down in that region.   Those areas are managed by other Medicaid Managed Care Organizations.   Thank you again for your interest.  Sincerely,', NULL, NULL, '2021-10-07 15:35:39', '2021-10-07 15:35:39'),
(35830, 1006, 28354, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:32', '2021-05-05 09:34:32'),
(35831, 1006, 28354, NULL, '2021-05-21 00:00:00.000', 'Initiated', 'Sent an email @ pdsdallas@aetna.com to verify enrollment status of provider and group:   Sub: Enrollment Status Query - CBUC - First Health  \"Hello,   I hope you\'re doing well, I wanted to get an update on the enrollment status for the following providers and group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264  Provider Name: Katherine Paterson NPI# 1164776548 Provider Name: Jennifer Tudor NPI# 1720455835 Provider Name: Mercedita Flynn NPI# 1619166188  Please get back to me as soon as possible. Also, if any of the providers or the group isn\'t enrolled, please let me know what the process is to start the enrollment.  Thank you.\"', NULL, NULL, '2021-05-05 13:42:00', '2021-05-05 13:42:00'),
(35832, 1006, 28354, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com cc \"Muchakurthi, Satish Kumar X\" MuchakurthiS@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello Bollu,   The requested information is as follows:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264 TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Katherine Paterson NPI# 1164776548 License Number: 517795  Provider Name: Jennifer Tudor NPI# 1720455835 License Number: AP128673  Please let me know how long it will take to add these providers to our TIN with the mentioned addresses, also is Mercedita Flynn already added under both mentioned service locations?  Thank you.\"', NULL, NULL, '2021-06-09 10:20:42', '2021-06-09 10:20:42'),
(35833, 1006, 28354, NULL, '2021-07-06 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com cc \"Talasila, Bala M\" TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   I wanted to check in on the status of this request, please get back to me as soon as possible.  Thank you.\"', NULL, NULL, '2021-06-29 16:59:14', '2021-06-29 16:59:14'),
(35834, 1006, 28354, NULL, '2021-08-04 00:00:00.000', 'In Process', 'Sent initiation and f/u email @ \"Bharath, Bollu\" BharathB@aetna.com & \"Talasila, Bala M\" TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   We are still waiting on the status of our initial request and here is the information for an additional provider, please get back to me as soon as possible.   Provider Name: Monica Gonzalez NPI# 1871132811 License Number: AP144421  Thank you. \"', NULL, NULL, '2021-07-28 16:27:17', '2021-07-28 16:27:17'),
(35835, 1006, 28354, NULL, '2021-08-23 00:00:00.000', 'In Process', 'Sent f/u email @ \"Bharath, Bollu\" BharathB@aetna.com & TalasilaB@aetna.com:  Sub: RE: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  \"Hello,   We still have not received any updates regarding the status of enrollment for the following providers under the mentioned group:  Group Name: Coastal Bend Urgent Care, LLC NPI# 1427509264 TIN# 81-1890349  Primary Address: 301 S HILLSIDE DR STE 4, BEEVILLE, TX 78102-5324 Secondary Address: 504A Houston Street, George West, TX 78022-3663  Provider Name: Mercedita Flynn NPI# 1619166188 License Number: AP118292  Provider Name: Katherine Paterson NPI# 1164776548 License Number: 517795  Provider Name: Monica Gonzalez NPI# 1871132811 License Number: AP144421  Please get back to me as soon as possible.  Thank you. \" ', NULL, NULL, '2021-08-16 12:18:35', '2021-08-16 12:18:35'),
(35836, 11056, 28354, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email sent to : MadirajuP@aetna.com, \"Sidley, Jeanette\" SidleyJ1@firsthealth.com, PDS Dallas  pdsdallas@aetna.com  Sub : Re: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059   Good afternoon!  Hope you are doing well. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice:  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# : 1619166188  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great week ahead! ', NULL, NULL, '2021-08-23 17:02:22', '2021-08-23 17:02:22'),
(35837, 11056, 28354, NULL, '2021-09-11 00:00:00.000', 'In Process', 'Email sent to : BharathB@aetna.com  Sub : Re: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 13005059  Good afternoon!  Hope you are doing well. It has been so long since you haven\'t responded to our emails. I am still waiting for the enrollment status for my applications of the below mentioned providers and practice. Please provide me with the latest updates soon.  Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324 Secondary Address: 504A Houston Street George West , TX 78022-3663  Provider Details: Provider Name: Paterson, Katherine Provider NPI# : 1164776548  Provider Name: Monica Gonzalez Provider NPI# : 1871132811  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.  Thank you! Have a great weekend! ', NULL, NULL, '2021-09-03 14:15:11', '2021-09-03 14:15:11'),
(35838, 11056, 28354, NULL, '2021-09-21 00:00:00.000', 'In Process', 'Email received from : DillikarA@aetna.com  Sub : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hi,  Please find the status of below provider as per requested.   S.no  Provider Name  NPI  Cpd Id  TIN  Effective Date  Status  1  Paterson, Katherine D  1164776548  2815476  811890349  -  Tax Id not found  2  Monica Gonzalez  1871132811  811890349  -  Provider not found    Regards, Bharath', NULL, NULL, '2021-09-14 13:22:29', '2021-09-14 13:22:29'),
(35839, 11056, 28354, NULL, '2021-10-05 00:00:00.000', 'In Process', 'Email sent to : DillikarA@aetna.com  Sub  : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hey Bharath!  Hope this email finds you well. Please guide and assist me regarding how to solve the below highlighted issues.  In the meantime, please do not hesitate to reach out if you have any questions or concerns.  Thank you! Have a great day!', NULL, NULL, '2021-09-28 12:39:13', '2021-09-28 12:39:13'),
(35840, 11056, 28354, NULL, '2021-10-13 00:00:00.000', 'In Process', 'Email received from : SidleyJ1@firsthealth.com  Sub : RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hello Ahmed,  I hope that this email finds you well! I apologize that I have not been able to respond sooner, my son has been ill so I have been in and out of the office.  This is the new group agreement that we established that will become effective 11/1/21. It is still in the implementation stages but will be complete before the effective date. All providers listed on the roster you provided to me will be linked to the new agreement once effective.   I hope that this helps clarify.  Take care!  Jeanette Sidley Network Relations Consultant', NULL, NULL, '2021-10-06 15:02:17', '2021-10-06 15:02:17'),
(35841, 11056, 28354, NULL, '2021-10-21 00:00:00.000', 'In Process', 'Email received from : SidleyJ1@firsthealth.com  Sub : RE: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Good morning Ahmed,  I hope that this email finds you well! Thank you for the well wishes, we are hoping he starts to feel better soon.  I have attached a copy of the signed agreement to this email. I apologize if the system did not automatically send it to you when it was signed on our side.  The contract is currently in implementation with our Data Team. I will send over the welcome letter once I have your group ID.  As always, please do not hesitate to reach out if you have any questions or concerns.  Take care! Jeanette', NULL, NULL, '2021-10-14 15:38:55', '2021-10-14 15:38:55'),
(35842, 11056, 28354, NULL, '2021-10-29 00:00:00.000', 'In Process', 'Email sent to : SidleyJ1@firsthealth.com  Sub : Re: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Good morning Jeanette!  Hope this email finds you well. He will feel better soon. He is in my prayers.  Bundle of thanks for your prompt responses. And I am grateful to you for that.  Whenever the implementation is completed, please provide the welcome letter soon.   Thank you! Have a wonderful & blessed weekend ahead!', NULL, NULL, '2021-10-22 12:10:39', '2021-10-22 12:10:39'),
(35843, 11056, 28354, NULL, '2021-11-16 00:00:00.000', 'In Process', 'Email sent to: sidleyj1@firsthealth.com  Sub : Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135   Good morning Jeanette!  Hope you & your son both are doing great. Please provide me with the latest updates about the implementation as well as on the welcome letters too. Kindly do the needful soon.  Please get back to me soon.  Thank you! Take Care!', NULL, NULL, '2021-11-09 15:27:34', '2021-11-09 15:27:34'),
(35844, 11056, 28354, NULL, '2021-12-01 00:00:00.000', 'In Process', 'Email received from:  sidleyj1@firsthealth.com  Sub:  Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hello,  It is with great pleasure to welcome you to the First Health Network. I would like to personally thank you for all of your time and efforts during the contracting process. You should have already received your fully executed copy of the First Health Agreement.  I would like to take a moment to share what to expect next and share important resources with you in order to allow a smooth process as your contract is implemented and beyond.  Next steps:  * While your contract is completely executed, your contract is currently in the process of being implemented in our system and your practitioners may still need to undergo the credentialing process. Please ensure you have updated your CAQH applications and attestations to ensure there will be no delays.  * Please send your provider group additions or terminations to the following email address: pdsdallas@aetna.com. You may reference your CPD ID # 1073945 (which becomes effective 11/01/2021).  * To check on the status of your requests, please contact either our Provider Services department at 800-226-5116 or you can send an inquiry via email to firsthealthcustomerservicemailbox@aetna.com.     * The Provider Services 800-line can also be contacted for questions related to provider effective dates, fee schedules, claim issues, ect. If they are unable to resolve your issue, they will document your concern & Contact information and route it to the appropriate department.     * For credentialing inquiries please contact 800-353-1232. It has been a pleasure working with you and I look forward to a mutually beneficial relationship.     Please feel free to forward this information to anyone that you feel would benefit.     Thank you,  Jeanette Sidley Network Relations Consultant  750 Riverpoint Drive West Sacramento, CA 95605  Phone: 916-374-4876 SidleyJ1@firsthealth.com TX, CO, KS, OK and MI', NULL, NULL, '2021-11-24 10:38:56', '2021-11-24 10:38:56'),
(35845, 11056, 28354, NULL, '2021-12-16 00:00:00.000', 'Approved', 'Email received from:  sidleyj1@firsthealth.com  Sub:  RE: [SEND SECURE] RE: Status: [EXTERNAL] Enrollment Status Query - CBUC - First Health Case 16106135  Hello Ahmed,  Eff date: 11/01/2021  It is with great pleasure to welcome you to the First Health Network. I would like to personally thank you for all of your time and efforts during the contracting process. You should have already received your fully executed copy of the First Health Agreement.  Thank you,  Jeanette Sidley Network Relations Consultant  750 Riverpoint Drive West Sacramento, CA 95605  Phone: 916-374-4876 SidleyJ1@firsthealth.com TX, CO, KS, OK and MI   The agreement has been attached. Please see the attachment.', NULL, NULL, '2021-12-09 13:59:42', '2021-12-09 13:59:42'),
(35846, 1006, 28355, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:32', '2021-05-05 09:34:32'),
(35847, 3040, 28355, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: info@usamco.com  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || MCO ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in MCO for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-07 12:10:34', '2021-06-07 12:10:34'),
(35848, 1006, 28355, NULL, '2021-07-01 00:00:00.000', 'In Process', 'Sent f/u email @ info@usamco.com:  Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hello,  I hope you\'re doing well, we wanted to verify if the following group and providers were enrolled under MCO and if not what the procedure would be to enroll them, the information is as follows:  Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4, Beeville, TX 78102-5324 Secondary Practice Address: 504A Houston Street, George West, TX 78022-3663 Provider Name: Katherine PatersonProvider NPI# 1164776548  Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  Please get back to me as soon as possible.   Thank you!\"', NULL, NULL, '2021-06-24 16:41:32', '2021-06-24 16:41:32'),
(35849, 1006, 28355, NULL, '2021-07-20 00:00:00.000', 'Approved', 'We received the following approval confirmation email from ProviderMarketingInfo ProviderMarketingInfo@usamco.com:   Sub: Enrollment Status/Request - CBUC/GWMC - MCO  \"Hi Brad,  I show that there is an active agreement with TIN 81-1890349 since 2/22/17 under the name Beeville Medical Clinic and the two DBA’s Coastal Bend Urgent Care LLC and Coastal Bend Long Term Care.  I show two addresses under this agreement, 600 S Hillside Dr and 301 S Hillside Dr Ste 4.  I have CC’ed our Provider Relations department on this email and they will be able to add the 504 A Houston St address below.  With regards to the providers, as the agreement is as an Ancillary group, you do not need to add/credential new providers. Any provider billing under the TIN and one of the addresses on file will be counted as in-network.  Please let me know if you have any further questions.  Sarah Cozzetto Lead Network Development Coordinator\"', NULL, NULL, '2021-07-13 17:14:12', '2021-07-13 17:14:12'),
(35850, 1006, 28356, NULL, NULL, 'New/Not Initiated', '', NULL, NULL, '2021-05-05 09:34:32', '2021-05-05 09:34:32'),
(35851, 3040, 28356, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Email sent to: providerservices@memorialhermann.org  Subject: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned group and providers in Memorial Hermann for our group under the below locations.   Practice Details: Practice Name: Coastal Bend Urgent Care, LLC Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 301 S HILLSIDE DR STE 4 BEEVILLE , TX 78102-5324  Practice Name: George West Medical Clinic Practice Tax ID# 81-1890349 Practice NPI# 1427509264 Practice Address: 504A Houston Street George West , TX 78022-3663  Provider 1: Provider Name: Rabagos, Katherine Provider NPI# 1134415631  Provider 2:   Provider Name: Flynn, Mercedita N Provider NPI# 1619166188  Provider 3:   Provider Name: Tudor, Jennifer M Provider NPI# 1720455835  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-06-07 12:13:25', '2021-06-07 12:13:25'),
(35852, 1006, 28356, NULL, '2021-07-01 00:00:00.000', 'In Process', 'We received the following reply from MH Health Provider Relations ProviderServices@memorialhermann.org:  Sub: Enroll Group & Providers || Coastal Bend Urgent Care & George West Medical Clinic || Group & Providers || Memorial Hermann ||  \"Good Morning,  You will need to complete the Request for Application form online. You can do that by going here https://healthplan.memorialhermann.org/-/media/memorial-hermann/healthplan/files/providers/health-plan-request-to-participate.ashx?la=en&hash=27F819BE45E95E2EA8789FB1902B4D2F and completing the request to participate form online and forwarding to the email on the form.  Regards, Jo\"  The form is filled out and sent out to them and attached to the main group task for reference.   Sent to MHHP Contracting MHHPContracting@memorialhermann.org:  \"Hello,   Please find the attached network participation form for our group, please let me know if anything else is needed for this request.  Thank you!\"', NULL, NULL, '2021-06-24 16:50:05', '2021-06-24 16:50:05');
