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
(11325, 1019, 19790, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Sent the following email to : Laura.Bevin@aetna.com, ChandraKumarU@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Provider:  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.', NULL, NULL, '2021-05-03 10:42:00', '2021-05-03 10:42:00'),
(11326, 1019, 19790, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to Laura.Bevin@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  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.    Jessica Hartman NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-20 08:04:21', '2021-05-20 08:04:21'),
(11327, 1019, 19790, NULL, '2021-06-15 00:00:00.000', 'In Process', 'Received the following email from Laura.Bevin@aetna.com  Good afternoon, Please see my comments below. Thank you  Melody L\'Etoile, 6466643 – CAQH application is being reviewed 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson, 6301243 – 06/01/2021 effective date 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite, 6369000 - 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 03/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767.  – address can be added via Existing Medical Provider Resources | Aetna  Kerry Smith, 6164300 – 06/01/2021 effective date 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti, 6846902 – 06/01/2021 effective date 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan, 7686597 – 01/01/2021 effective date 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland, 6785859 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767. – address can be added via Existing Medical Provider Resources | Aetna    Peggy Pionke, 6507988 – 02/01/2021 effective date 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid, 6557417 – 01/01/2021 effective date 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Laura Bevin Credentialing Senior Analyst Aetna Behavioral Health', NULL, NULL, '2021-05-31 13:10:10', '2021-05-31 13:10:10'),
(11328, 1019, 19790, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to Laura.Bevin@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  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.    Jessica Hartman NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-06-16 07:57:42', '2021-06-16 07:57:42'),
(11329, 1019, 19790, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Sent the following email to Laura.Bevin@aetna.com  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson  NPI: 1124622667  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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland  NPI: 1598163602  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.    Jonathan Schubert  NPI: 1235755505   Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Kerry Smith  NPI: 1275083230  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Jennifer Ullrich  NPI: 1710489760  Secondary Location: 100 New State Highway, Raynham, MA, 02767      Regards, Alex G.', NULL, NULL, '2021-08-24 11:12:39', '2021-08-24 11:12:39'),
(11330, 1019, 19790, NULL, '2021-09-16 00:00:00.000', 'Approved', 'Received the following email from Laura.Bevin@aetna.com  Hello,  Barbara Hignite NPI: 1982617262  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 03/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this location     Rodesia Edmundson  NPI: 1124622667  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 06/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767.  – not linked to this location  Jessica Hartman  NPI: 1326665472  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – application was not received for MA Secondary Location: 100 New State Highway, Raynham, MA, 02767.  - application was not received for MA   Lynnetta Loveland  NPI: 1598163602  Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this address     Cemetrice Muhammed NPI: 1548843410  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. – just completed the credentialing process on 08/20/2021     Jonathan Schubert  NPI: 1235755505  Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this address     Kerry Smith  NPI: 1275083230  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 – 06/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767. - 06/01/2021 effective date  Jennifer Ullrich  NPI: 1710489760  Secondary Location: 100 New State Highway, Raynham, MA, 02767 – not linked to this address  For providers who need another service location added, this can be completed via the below link  Existing Medical Provider Resources | Aetna  The MA application for Jessica Hartman can be submitted via the below link  https://cldaz.aetna.com/pocui/join-the-aetna-network  Thank you           Laura Bevin  Credentialing Senior Analyst  Aetna Behavioral Health', NULL, NULL, '2021-09-09 08:39:15', '2021-09-09 08:39:15'),
(11331, 1006, 19791, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:06:55', '2021-03-11 17:06:55'),
(11332, 1019, 19791, NULL, '2021-04-12 00:00:00.000', 'Initiated', 'Initiated thru online portal.', NULL, NULL, '2021-04-05 13:40:49', '2021-04-05 13:40:49'),
(11333, 1019, 19791, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to Laura :Laura.Bevin@aetna.com  Sub: Enrollment Status || Providers || SNBCARE || Aetna Hello Laura, Hope you\'re doing well, 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:  Barbara HIgnite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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. ', NULL, NULL, '2021-04-08 10:17:37', '2021-04-08 10:17:37'),
(11334, 1019, 19791, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Received the following the email from Laura.Bevin@aetna.com Good afternoon,  Barbara HIgnite, 6369000 – waiting to be linked    Kerry Smith, 6164300 – CAQH application is being reviewed by our Credentialing Dept.  Rodesia Edmundson – very early in the credentialing process, application was received on 04/05/2021  Justin Souliere, 6893422 - CAQH application is being reviewed by our Credentialing Dept.     Thank you', NULL, NULL, '2021-04-08 11:31:56', '2021-04-08 11:31:56'),
(11335, 3040, 19791, NULL, '2021-04-23 00:00:00.000', 'In Process', 'I had a word with Aetna representative and he said the application was received on 04/05/2021 and still in credentialing process.   It will take up to 60 Business days. ', NULL, NULL, '2021-04-16 16:12:00', '2021-04-16 16:12:00'),
(11336, 1019, 19791, NULL, '2021-05-05 00:00:00.000', 'In Process', 'Received the following email from ChandraKumarU@aetna.com Hello,  Provider Pin# 6301243                                 Provider Name: Edmundson, Rodesia S. Thank you for submitting your credentialing application to Aetna. Information needed to complete the credentialing process was missing from your application or has expired. To continue the credentialing process, please provide the following:  A current copy of your Federal Drug Enforcement Agency Registration (DEA) for the state of MA. Please forward this information to  chandrakumaru@aetna.com or fax it to 860-754-2636 mark it to my attention, within one week of the request date. Should you choose not to participate in Aetna’s network or have questions regarding this request, please call me at 855-559-2422 and my direct extension  is (491458).  Regards Udayakumar.c Credentialing Analyst, Aetna Credentialing Department. (: 855-559-2422 Ext- 491458 7: 860-754-2636 Attn: (Udaya) 8: chandrakumaru@aetna.com  Legal statement    Aetna company names          We are located at 151 Farmington Ave, Hartford, Connecticut 06156 ©2011 Aetna Inc. The Aetna name and logo are registered trademarks.', NULL, NULL, '2021-04-28 14:34:42', '2021-04-28 14:34:42'),
(11337, 1019, 19791, NULL, '2021-05-05 00:00:00.000', 'In Process', 'Sent the following email to ChandraKumarU@aetna.com Hello Chandra, I have attached the copy of her DEA License. Let me know if you need any further assistance.   Regards, Alex', NULL, NULL, '2021-04-28 14:35:49', '2021-04-28 14:35:49'),
(11338, 1019, 19791, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Sent the following email to : Laura.Bevin@aetna.com, ChandraKumarU@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Provider:  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.', NULL, NULL, '2021-05-03 10:30:34', '2021-05-03 10:30:34'),
(11339, 1019, 19791, NULL, '2021-05-27 00:00:00.000', 'In Process', 'Sent the following email to Laura.Bevin@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  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.    Jessica Hartman NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-20 08:03:14', '2021-05-20 08:03:14'),
(11340, 1019, 19791, NULL, '2021-06-15 00:00:00.000', 'In Process', 'Received the following email from Laura.Bevin@aetna.com  Good afternoon, Please see my comments below. Thank you  Melody L\'Etoile, 6466643 – CAQH application is being reviewed 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson, 6301243 – 06/01/2021 effective date 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite, 6369000 - 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 03/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767.  – address can be added via Existing Medical Provider Resources | Aetna  Kerry Smith, 6164300 – 06/01/2021 effective date 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti, 6846902 – 06/01/2021 effective date 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan, 7686597 – 01/01/2021 effective date 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland, 6785859 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767. – address can be added via Existing Medical Provider Resources | Aetna    Peggy Pionke, 6507988 – 02/01/2021 effective date 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid, 6557417 – 01/01/2021 effective date 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Laura Bevin Credentialing Senior Analyst Aetna Behavioral Health', NULL, NULL, '2021-05-31 13:07:21', '2021-05-31 13:07:21'),
(11341, 1019, 19791, NULL, '2021-06-29 00:00:00.000', 'In Process', 'Sent the following email to Laura.Bevin@aetna.com SUB: Enrollment Query || Group & Providers || SNBCARE || Aetna  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  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.    Jessica Hartman NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Carlee Rozell 1225645393 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jonathan Schubert 1235755505 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Katie Tawakol 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jennifer Ullrich 1710489760 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Justin Souliere 1710576004 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Erin Oliva 1407349632 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Melody L\'Etoile 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Rodesia Edmundson 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Barbara Hignite 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Kerry Smith 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Prisca Hefti 1508133182 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Fauzia Wali Khan 1699761965 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland 1598163602 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Peggy Pionke 1699307322 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Mahreen Rashid 1396393146 Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-06-16 07:57:35', '2021-06-16 07:57:35'),
(11342, 1019, 19791, NULL, '2021-08-31 00:00:00.000', 'Initiated', 'Sent the following email to Laura.Bevin@aetna.com  Hello, We need the enrollment application status for the following providers,   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Barbara Hignite NPI: 1982617262 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson  NPI: 1124622667  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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Lynnetta Loveland  NPI: 1598163602  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.    Jonathan Schubert  NPI: 1235755505   Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Kerry Smith  NPI: 1275083230  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Jennifer Ullrich  NPI: 1710489760  Secondary Location: 100 New State Highway, Raynham, MA, 02767      Regards, Alex G.', NULL, NULL, '2021-08-24 11:10:42', '2021-08-24 11:10:42'),
(11343, 1019, 19791, NULL, '2021-09-16 00:00:00.000', 'Approved', 'Received the following email from Laura.Bevin@aetna.com  Hello,  Barbara Hignite NPI: 1982617262  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 03/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this location     Rodesia Edmundson  NPI: 1124622667  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – 06/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767.  – not linked to this location  Jessica Hartman  NPI: 1326665472  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. – application was not received for MA Secondary Location: 100 New State Highway, Raynham, MA, 02767.  - application was not received for MA   Lynnetta Loveland  NPI: 1598163602  Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this address     Cemetrice Muhammed NPI: 1548843410  Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896. – just completed the credentialing process on 08/20/2021     Jonathan Schubert  NPI: 1235755505  Secondary Location: 100 New State Highway, Raynham, MA, 02767. – not linked to this address     Kerry Smith  NPI: 1275083230  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 – 06/01/2021 effective date Secondary Location: 100 New State Highway, Raynham, MA, 02767. - 06/01/2021 effective date  Jennifer Ullrich  NPI: 1710489760  Secondary Location: 100 New State Highway, Raynham, MA, 02767 – not linked to this address  For providers who need another service location added, this can be completed via the below link  Existing Medical Provider Resources | Aetna  The MA application for Jessica Hartman can be submitted via the below link  https://cldaz.aetna.com/pocui/join-the-aetna-network  Thank you           Laura Bevin  Credentialing Senior Analyst  Aetna Behavioral Health', NULL, NULL, '2021-09-09 08:38:03', '2021-09-09 08:38:03'),
(11344, 3046, 19792, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:07:32', '2021-03-11 17:07:32'),
(11345, 1006, 19792, NULL, '2021-05-11 00:00:00.000', 'Not Eligible', 'Received the below email for network closure .-------------------------------- MHHP Contracting 9:16 AM (7 hours ago) to me  Good morning Sherry. At this time, Corpus Christi, Texas is 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, '2021-05-04 10:38:21', '2021-05-04 10:38:21'),
(11346, 3046, 19793, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:07:37', '2021-03-11 17:07:37'),
(11347, 1006, 19793, NULL, '2021-05-11 00:00:00.000', 'Not Eligible', 'Received the below email for network closure .-------------------------------- MHHP Contracting 9:16 AM (7 hours ago) to me  Good morning Sherry. At this time, Corpus Christi, Texas is 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, '2021-05-04 10:38:24', '2021-05-04 10:38:24'),
(11348, 3046, 19794, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:07:48', '2021-03-11 17:07:48'),
(11349, 1006, 19794, NULL, '2021-05-11 00:00:00.000', 'Not Eligible', 'Received the below email for network closure .-------------------------------- MHHP Contracting 9:16 AM (7 hours ago) to me  Good morning Sherry. At this time, Corpus Christi, Texas is 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, '2021-05-04 10:38:26', '2021-05-04 10:38:26'),
(11350, 3040, 19795, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:07:49', '2021-03-11 17:07:49'),
(11351, 3040, 19795, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider enrolled in UHC.', NULL, NULL, '2021-03-24 12:35:17', '2021-03-24 12:35:17'),
(11352, 3040, 19796, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:08:33', '2021-03-11 17:08:33'),
(11353, 3040, 19796, NULL, '2021-03-31 00:00:00.000', 'Initiated', 'Email sent to: networkhelp@uhc.com,hpdemo@uhc.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned provider in UHC for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 13:22:34', '2021-03-24 13:22:34'),
(11354, 3040, 19796, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Email rcvd from: national_credentialing@uhc.com  Subject: Request for Credentialing  4/15/2021  Diego Naranjo adil@claimsmedinc.com Re: Your Credentialing Application Has Been Received  Dear Diego Naranjo:  Thank you for your interest in joining the UnitedHealthcare network. We’ve received your credentialing application and are reviewing it now to ensure we have everything needed to begin verifying your credentials.', NULL, NULL, '2021-04-16 07:46:08', '2021-04-16 07:46:08'),
(11355, 3040, 19796, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: networkhelp@uhc.com  Subject: Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Hello,   Hope you are doing well. I wanted to follow up regarding the enrollment status for the below mentioned providers.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  Provider 2: Provider Name: Wert, Jeniece K Provider NPI#  1659919702  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-01 10:56:17', '2021-06-01 10:56:17'),
(11356, 3040, 19796, NULL, '2021-06-10 00:00:00.000', 'Approved', 'Email sent to: networkhelp@uhc.com  Subject: Secure Message from jamie_edmondson@uhc.com  Thank you for contacting the Network Management Resource Team. Diego Naranjo has been added to the group agreement for Valley Med Urgent Care PLLC (All three locations) effective 5/23/2021. I do not see any requests in our system to have Jeniece K Wert added to the group.  Please let us know if we can assist further via email.  Jamie Edmondson United Healthcare Network Management Resource Team (NMRT)', NULL, NULL, '2021-06-03 10:50:54', '2021-06-03 10:50:54'),
(11357, 3040, 19797, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:08:59', '2021-03-11 17:08:59'),
(11358, 3040, 19797, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider enrolled in UHC.', NULL, NULL, '2021-03-24 12:57:54', '2021-03-24 12:57:54'),
(11359, 3040, 19799, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:12:57', '2021-03-11 17:12:57'),
(11360, 3040, 19799, NULL, '2021-03-31 00:00:00.000', 'Initiated', 'Email sent to: networkhelp@uhc.com,hpdemo@uhc.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned provider in UHC for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 13:22:39', '2021-03-24 13:22:39'),
(11361, 3040, 19799, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Email rcvd from: national_credentialing@uhc.com  Subject: Request for Credentialing  4/15/2021  Diego Naranjo adil@claimsmedinc.com Re: Your Credentialing Application Has Been Received  Dear Diego Naranjo:  Thank you for your interest in joining the UnitedHealthcare network. We’ve received your credentialing application and are reviewing it now to ensure we have everything needed to begin verifying your credentials.', NULL, NULL, '2021-04-16 07:45:55', '2021-04-16 07:45:55'),
(11362, 3040, 19799, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: networkhelp@uhc.com  Subject: Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Hello,   Hope you are doing well. I wanted to follow up regarding the enrollment status for the below mentioned providers.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  Provider 2: Provider Name: Wert, Jeniece K Provider NPI#  1659919702  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-01 10:56:37', '2021-06-01 10:56:37'),
(11363, 3040, 19799, NULL, '2021-06-10 00:00:00.000', 'Approved', 'Email sent to: networkhelp@uhc.com  Subject: Secure Message from jamie_edmondson@uhc.com  Thank you for contacting the Network Management Resource Team. Diego Naranjo has been added to the group agreement for Valley Med Urgent Care PLLC (All three locations) effective 5/23/2021. I do not see any requests in our system to have Jeniece K Wert added to the group.  Please let us know if we can assist further via email.  Jamie Edmondson United Healthcare Network Management Resource Team (NMRT)', NULL, NULL, '2021-06-03 10:51:03', '2021-06-03 10:51:03'),
(11364, 3040, 19800, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:13:23', '2021-03-11 17:13:23'),
(11365, 3040, 19800, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider enrolled in UHC.', NULL, NULL, '2021-03-24 12:57:59', '2021-03-24 12:57:59'),
(11366, 3040, 19802, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:14:37', '2021-03-11 17:14:37'),
(11367, 3040, 19802, NULL, '2021-03-31 00:00:00.000', 'Approved', 'location updated McAllen.', NULL, NULL, '2021-03-24 12:25:40', '2021-03-24 12:25:40'),
(11368, 3040, 19804, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:15:07', '2021-03-11 17:15:07'),
(11369, 3040, 19804, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider enrolled in UHC.', NULL, NULL, '2021-03-24 12:35:23', '2021-03-24 12:35:23'),
(11370, 3040, 19805, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:15:35', '2021-03-11 17:15:35'),
(11371, 3040, 19805, NULL, '2021-03-31 00:00:00.000', 'Initiated', 'Email sent to: networkhelp@uhc.com, hpdemo@uhc.com  Subject: Add Location || Valley Med Urgent Care PLLC || Hernandez, Eder Francisco || UHC ||   Greetings,   Hope you are doing well. I wanted to add the provider in the UHC for our group Valley Med Urgent Care PLLC under below location.  Provider 1: Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Additional Location: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 13:21:35', '2021-03-24 13:21:35'),
(11372, 3040, 19805, NULL, '2021-04-20 00:00:00.000', 'In Process', 'Email sent to: hpdemo@uhc.com  Subject: Add Location || Valley Med Urgent Care PLLC || Hernandez, Eder Francisco || UHC ||  Hello,   Hope you are doing well. I received an email from (Allen Andrea A) United Healthcare and the person said you need to email the below request to the demographic team. I wanted to add the provider in the UHC for our group Valley Med Urgent Care PLLC under below location.  Provider 1: Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Additional Location: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-04-13 08:27:17', '2021-04-13 08:27:17'),
(11373, 3040, 19805, NULL, '2021-04-20 00:00:00.000', 'In Process', 'Email rcvd from: andrea_allen@uhc.com  Subject: Secure Message from andrea_allen@uhc.com  Hello  Thank you for contacting UnitedHealthcare network. Based on the nature of your inquiry, your request will need to be handled by the demographic team. Please submit the request to the demographic department (hpdemo@uhc.com) for assistance.', NULL, NULL, '2021-04-13 08:28:00', '2021-04-13 08:28:00'),
(11374, 3040, 19805, NULL, '2021-04-20 00:00:00.000', 'Approved', 'EDER Effective date: 08/27/2017 ', NULL, NULL, '2021-04-13 14:34:12', '2021-04-13 14:34:12'),
(11375, 3040, 19806, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:16:03', '2021-03-11 17:16:03'),
(11376, 3040, 19806, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider is showing linked with the insurance in this location. ', NULL, NULL, '2021-03-24 12:45:23', '2021-03-24 12:45:23'),
(11377, 3040, 19807, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:16:20', '2021-03-11 17:16:20'),
(11378, 3040, 19807, NULL, '2021-03-31 00:00:00.000', 'Initiated', 'Email sent to: networkhelp@uhc.com,hpdemo@uhc.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned provider in UHC for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 13:22:43', '2021-03-24 13:22:43'),
(11379, 3040, 19807, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Email rcvd from: national_credentialing@uhc.com  Subject: Request for Credentialing  4/15/2021  Diego Naranjo adil@claimsmedinc.com Re: Your Credentialing Application Has Been Received  Dear Diego Naranjo:  Thank you for your interest in joining the UnitedHealthcare network. We’ve received your credentialing application and are reviewing it now to ensure we have everything needed to begin verifying your credentials.', NULL, NULL, '2021-04-16 07:46:00', '2021-04-16 07:46:00'),
(11380, 3040, 19807, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: networkhelp@uhc.com  Subject: Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego|| UHC ||  Hello,   Hope you are doing well. I wanted to follow up regarding the enrollment status for the below mentioned providers.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Provider 1: Provider Name: Naranjo, Diego Provider NPI#  1568929800  Provider 2: Provider Name: Wert, Jeniece K Provider NPI#  1659919702  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-01 10:56:28', '2021-06-01 10:56:28'),
(11381, 3040, 19807, NULL, '2021-06-10 00:00:00.000', 'Approved', 'Email sent to: networkhelp@uhc.com  Subject: Secure Message from jamie_edmondson@uhc.com  Thank you for contacting the Network Management Resource Team. Diego Naranjo has been added to the group agreement for Valley Med Urgent Care PLLC (All three locations) effective 5/23/2021. I do not see any requests in our system to have Jeniece K Wert added to the group.  Please let us know if we can assist further via email.  Jamie Edmondson United Healthcare Network Management Resource Team (NMRT)', NULL, NULL, '2021-06-03 10:50:59', '2021-06-03 10:50:59'),
(11382, 3040, 19808, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:16:36', '2021-03-11 17:16:36'),
(11383, 3040, 19808, NULL, '2021-03-31 00:00:00.000', 'Approved', 'Provider enrolled in UHC.', NULL, NULL, '2021-03-24 12:58:04', '2021-03-24 12:58:04'),
(11384, 3046, 19809, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:16:53', '2021-03-11 17:16:53'),
(11385, 9057, 19809, NULL, '2021-06-08 00:00:00.000', 'Initiated', 'We sent an email to: Juliana.Mata@molinahealthcare.com  Sub: Requisition for Enrollment - BAQC - Molina Health Care  Hello, Hope you are doing well, We wish to enroll our below mentioned providers, under the following group. Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  If you need any more details, please let me know.  Thank you', NULL, NULL, '2021-06-01 10:40:14', '2021-06-01 10:40:14'),
(11386, 11056, 19809, NULL, '2021-06-28 00:00:00.000', 'In Process', 'Enrollment Request form has been submitted. Waiting for the contract. Email and Contract has been attached in the group.', NULL, NULL, '2021-06-21 11:02:47', '2021-06-21 11:02:47'),
(11387, 1006, 19809, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Sent f/u email @ \"Mata, Juliana\" Juliana.Mata@molinahealthcare.com & MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following group and providers, we already have a group contract with Molina and I wanted to know what is required to enroll the mentioned providers if they aren\'t already enrolled their information is as follows:  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  Please get back to me as soon as possible.  Thank you. \"', NULL, NULL, '2021-07-07 16:39:16', '2021-07-07 16:39:16'),
(11388, 1006, 19809, NULL, '2021-07-30 00:00:00.000', 'Approved', 'Approval email received from @ Mata, Juliana Juliana.Mata@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, facility Bay Area Quick Care is loaded into network billing system with effective date 9/1/2020, Molina does not contract individual providers to urgent care, Molina contracts facility itself.  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, '2021-07-23 15:53:13', '2021-07-23 15:53:13'),
(11389, 3046, 19810, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:00', '2021-03-11 17:17:00'),
(11390, 9057, 19810, NULL, '2021-06-08 00:00:00.000', 'Initiated', 'We sent an email to: Juliana.Mata@molinahealthcare.com  Sub: Requisition for Enrollment - BAQC - Molina Health Care  Hello, Hope you are doing well, We wish to enroll our below mentioned providers, under the following group. Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  If you need any more details, please let me know.  Thank you', NULL, NULL, '2021-06-01 10:40:05', '2021-06-01 10:40:05');
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
(11391, 11056, 19810, NULL, '2021-06-28 00:00:00.000', 'In Process', 'Enrollment Request has been submitted. Waiting for the contract. Email and Contract has been attached in the group.', NULL, NULL, '2021-06-21 11:02:29', '2021-06-21 11:02:29'),
(11392, 11056, 19810, NULL, '2021-06-28 00:00:00.000', 'In Process', 'Enrollment Request form has been submitted. Waiting for the contract. Email and Contract has been attached in the group.', NULL, NULL, '2021-06-21 11:03:44', '2021-06-21 11:03:44'),
(11393, 1006, 19810, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Sent f/u email @ \"Mata, Juliana\" Juliana.Mata@molinahealthcare.com & MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following group and providers, we already have a group contract with Molina and I wanted to know what is required to enroll the mentioned providers if they aren\'t already enrolled their information is as follows:  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  Please get back to me as soon as possible.  Thank you. \"', NULL, NULL, '2021-07-07 16:38:59', '2021-07-07 16:38:59'),
(11394, 1006, 19810, NULL, '2021-07-30 00:00:00.000', 'Approved', 'Approval email received from @ Mata, Juliana Juliana.Mata@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, facility Bay Area Quick Care is loaded into network billing system with effective date 9/1/2020, Molina does not contract individual providers to urgent care, Molina contracts facility itself.  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, '2021-07-23 15:53:24', '2021-07-23 15:53:24'),
(11395, 1006, 19811, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:04', '2021-03-11 17:17:04'),
(11396, 3040, 19811, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Email sent to: providerrelations@bcbsri.org  Subject: Group Enrollment || Spectrum Neuro Behavioral Care LLC || Group || BCBS RI ||  Greetings,   Hope you are doing well. I wanted to enroll our group Spectrum Neuro Behavioral Care LLC  in BCBS under the below location.  Practice Details:  Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Practice Address: 63 Eddie Dowling Hwy, Suite 9 North Smithfield , RI 02896-7322  Thank you  ', NULL, NULL, '2021-04-19 13:36:45', '2021-04-19 13:36:45'),
(11397, 1019, 19811, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Sent the following email to Database.Credentialing@bcbsri.org  Hello, We want the enrollment status for our group, if our group is participating with BCBS RI can you please send us the copy of the contract and the effective date, group information is mentioned below,  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-05 10:59:11', '2021-05-05 10:59:11'),
(11398, 1019, 19811, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to Database.Credentialing@bcbsri.org SUB: Enrollment Query || Group || SNBCARE || BCBS RI  Hello, We want the enrollment status for our group, if our group is participating with BCBS RI can you please send us the copy of the contract and the effective date, group information is mentioned below,  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 63 Eddie Dowling Highway, Suite 9, North Smithfield, RI, 02896.  Regards,', NULL, NULL, '2021-05-20 09:02:03', '2021-05-20 09:02:03'),
(11399, 1019, 19811, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, provider-enrollment@bcbsma.com, debra.draheim@bcbsma.com  SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA 3rd Atttempt  Hello,  We need the enrollment status for the following providers under our group, also I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I have sent couple of emails to BCBS MA regarding enrollments query.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.    Regards, Alex ', NULL, NULL, '2021-06-03 10:50:52', '2021-06-03 10:50:52'),
(11400, 1019, 19811, NULL, '2021-09-06 00:00:00.000', 'Approved', 'Unable to get the Welcome letter attached is the Signed contract eff 11/16/2020.', NULL, NULL, '2021-08-30 11:01:12', '2021-08-30 11:01:12'),
(11401, 1006, 19812, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:06', '2021-03-11 17:17:06'),
(11402, 3040, 19812, NULL, '2021-04-26 00:00:00.000', 'Initiated', 'Email sent to: providerapplicationstatus@bcbsma.com  Subject: Enrollment || Spectrum Neuro Behavioral Care LLC || Group & Providers || BCBS MA ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group and providers for our group Spectrum Neuro Behavioral Care LLC under below locations.   Practice Details: Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Primary Address: 61 Lincoln St., Suite 203, Framingham , MA 01702 Secondary Address: 100 New State Hwy. Raynham , MA 02767  Provider 1: Provider Name: Tawakol, Katie  Provider NPI# 1609222116  Provider 2: Provider Name: Rashid, Mahreen Provider NPI# 1396393146  Provider 3:   Provider Name: Hefti, Prisca Provider NPI# 1508133182  Provider 4:   Provider Name: Khan, Fauzia Wali Provider NPI# 1699761965  Provider 5:   Provider Name: Pionke, Peggy Provider NPI# 1699307322  Provider 6:   Provider Name: Ullrich, Jennifer Lee Provider NPI# 1710489760  Provider 7:   Provider Name: Schubert, Jonathan Provider NPI# 1235755505  Provider 8:   Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Provider 9:   Provider Name: Hignite, Barbara Provider NPI# 1982617262  Provider 10:   Provider Name: Loveland, Lynnetta Provider NPI# 1598163602  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-19 14:30:13', '2021-04-19 14:30:13'),
(11403, 1019, 19812, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, Debra.Draheim@bcbsma.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BCBSMA  Hello, Can you please let me know the enrollment status for the following group and providers with Blue Cross Blue Shield of Massachusetts.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-05 07:58:57', '2021-05-05 07:58:57'),
(11404, 1019, 19812, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to  providerapplicationstatus@bcbsma.com,  Debra.Draheim@bcbsma.com SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA  Hello Debra, Hope you\'re doing good, I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I sent a couple of emails to BCBS MA regarding enrollments, can you please look into my request and help out with enrollment status for our providers.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.  ', NULL, NULL, '2021-05-20 08:56:35', '2021-05-20 08:56:35'),
(11405, 1019, 19812, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, provider-enrollment@bcbsma.com, debra.draheim@bcbsma.com  SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA 3rd Atttempt  Hello,  We need the enrollment status for the following providers under our group, also I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I have sent couple of emails to BCBS MA regarding enrollments query.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.    Regards, Alex ', NULL, NULL, '2021-06-03 10:50:39', '2021-06-03 10:50:39'),
(11406, 1019, 19812, NULL, '2021-09-06 00:00:00.000', 'Approved', 'Unable to get the Welcome letter attached is the Signed contract eff 11/16/2020.', NULL, NULL, '2021-08-30 11:01:29', '2021-08-30 11:01:29'),
(11407, 3046, 19813, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:11', '2021-03-11 17:17:11'),
(11408, 9057, 19813, NULL, '2021-06-08 00:00:00.000', 'Initiated', 'We sent an email to: Juliana.Mata@molinahealthcare.com  Sub: Requisition for Enrollment - BAQC - Molina Health Care  Hello, Hope you are doing well, We wish to enroll our below mentioned providers, under the following group. Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  If you need any more details, please let me know.  Thank you', NULL, NULL, '2021-06-01 10:40:01', '2021-06-01 10:40:01'),
(11409, 11056, 19813, NULL, '2021-06-28 00:00:00.000', 'In Process', 'Enrollment Request has been submitted. Waiting for the contract. Email and Contract has been attached in the group.', NULL, NULL, '2021-06-21 11:02:00', '2021-06-21 11:02:00'),
(11410, 1006, 19813, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Sent f/u email @ \"Mata, Juliana\" Juliana.Mata@molinahealthcare.com & MHTContractrequest MHTContractrequest@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following group and providers, we already have a group contract with Molina and I wanted to know what is required to enroll the mentioned providers if they aren\'t already enrolled their information is as follows:  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Provider Name: Francis, William: NPI# 1457994436  Please get back to me as soon as possible.  Thank you. \"', NULL, NULL, '2021-07-07 16:38:53', '2021-07-07 16:38:53'),
(11411, 1006, 19813, NULL, '2021-07-30 00:00:00.000', 'Approved', 'Approval email received from @ Mata, Juliana Juliana.Mata@molinahealthcare.com:  Sub: Enrollment Status - BAQC - Molina  \"Good morning,  Happy Friday!!  Hope you are doing well.  per information on our system, facility Bay Area Quick Care is loaded into network billing system with effective date 9/1/2020, Molina does not contract individual providers to urgent care, Molina contracts facility itself.  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, '2021-07-23 15:53:33', '2021-07-23 15:53:33'),
(11412, 1006, 19814, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:40', '2021-03-11 17:17:40'),
(11413, 1006, 19814, NULL, '2021-04-19 00:00:00.000', 'Not Eligible', 'LCSW providers cannot be credentialed with BCBSRI, attached Behavioral Health Outpatient Payment Policy for reference:  \"Only independently licensed behavioral health clinicians may render services to a BCBSRI member in an outpatient professional setting. Providers with a provisional license are not eligible for credentialing. BCBSRI does not have a supervisory protocol arrangement whereby a Master’s-level clinician can render services under a supervising clinician with an independent license. BCBSRI does not allow for a Master’s-level (non-independently licensed) clinician to render services to our members in an outpatient professional setting. BCBSRI does not credential Licensed Clinical Social Workers (LCSWs).\"', NULL, NULL, '2021-04-12 17:07:12', '2021-04-12 17:07:12'),
(11414, 3040, 19815, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:17:57', '2021-03-11 17:17:57'),
(11415, 3040, 19815, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Group enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:05:35', '2021-03-22 10:05:35'),
(11416, 3046, 19816, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:18:23', '2021-03-11 17:18:23'),
(11417, 1006, 19816, NULL, '2021-04-22 00:00:00.000', 'Initiated', 'Submitted the group enrollment request:  \"Thank you for your interest in participating with MultiPlan. You should receive an application within ten to fifteen business days. If you do not receive the application, or if you have any questions upon reviewing it, please contact our Service Operations department at (800) 950-7040. You can check the status of your request anytime through the Check Nomination Status option on this page.  Nomination Tracking Number: 0415219RG\"   Attached for reference. ', NULL, NULL, '2021-04-15 07:23:05', '2021-04-15 07:23:05'),
(11418, 1006, 19816, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Received the following email from Multiplan @ pif@multiplan.com:   Sub: Multiplan Request for Information for Bay Area Quick Care PLLC - State: TX - SEID: 214290783  \"Dear Provider:  We would like to invite you to participate in MultiPlan\'s provider networks.  When you choose to join MultiPlan, the nation\'s oldest and largest independent provider network, you select an organization that delivers patient volume from a diverse base of healthcare payers, offers administrative ease, and helps you evolve with the market through a wide range of network-based solutions.  We have included a sample fee schedule for your review. You can access our Provider Handbook located under Helpful Resources in the Providers section at: www.multiplan.com  If you are interested in signing a MultiPlan Agreement and Provider Application, please REPLY to this email and COMPLETE or correct your information by typing into the form below.  ONLY use this email for the provider you nominated. If you need to nominate additional providers then please submit your provider nomination request by clicking the following link: Nominate Provider  Group Provider Demographic Information Legal Name:	Bay Area Quick Care PLLC DBA Name:	 Tax Id/EIN:	271702009	NPI #:	1437481421 Specialty:	Clinic/Center - Urgent Care	# of Providers:	 Primary Service Address:	9929 South Padre Island Drive Suite 109 City:	Corpus Christi	State:	TX	Zip:	78418 Phone:	7138936214	Fax:	 Credentialing Contact Information Name:		Title:	 Phone:		Fax:		Email:	 Authorized Signator Information Name:		Title:	 Phone:		Fax:		Email:	 If your providers already participate in CAQH, we ask that you assist us with the following:  Authorize MultiPlan to access your CAQH Application Attest to your application within 90 days Complete your CAQH Application in its entirety If your providers do not participate in CAQH, you may initiate the process by clicking the following link:CAQH  MultiPlan has implemented an electronic signature process; you will receive electronic documents for signature via DocuSign. To expedite the contracting process, please follow the instructions included in the DocuSign email. If you would like additional information about MultiPlan or the services we offer, please visit our website at:www.multiplan.com  Sincerely, Gloria Esplana Director, Network Contract Support\"', NULL, NULL, '2021-04-19 07:43:11', '2021-04-19 07:43:11'),
(11419, 9057, 19816, NULL, '2021-06-08 00:00:00.000', 'In Process', 'We sent an email to: registrar@multiplan.com Sub: Request for Enrollment Status - BAQC - Multiplan  Hello, I want to get the current status of the below mentioned group & providers  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda  NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Kindly respond to us as soon as possible.  Thank you ', NULL, NULL, '2021-05-31 16:45:11', '2021-05-31 16:45:11'),
(11420, 1006, 19816, NULL, '2021-06-24 00:00:00.000', 'In Process', 'Opened a service case through Multiplan\'s provider portal @ Service Case #7644056:   \"Hello,  Please get back to me regarding the enrollment status for the below mentioned provider and do let me know what is required to enroll our group as well.  Thank you!\"', NULL, NULL, '2021-06-17 16:52:33', '2021-06-17 16:52:33'),
(11421, 1006, 19816, NULL, '2021-07-14 00:00:00.000', 'In Process', 'As per my discussion with Multiplan, BAQC is going through enrollment as an ancillary facility which is incorrect.   Sent following email to pif@multiplan.com:  Sub: Multiplan Request for Information for Bay Area Quick Care PLLC - State: TX - SEID: 214290783  \"Hello,   I wanted to set up Bay Area Quick Care as a group, the nomination request was sent for a group contract. Please get back to me as soon as you\'re able.  Thank you. \"', NULL, NULL, '2021-07-07 12:46:30', '2021-07-07 12:46:30'),
(11422, 1006, 19816, NULL, '2021-07-30 00:00:00.000', 'In Process', 'Received following reply from @ Juarez, Mariana Mariana.Juarez@multiplan.com:  Sub: Bay Area Quick Care PLLC - State: TX - SEID: 214290783  \"Hi Brad,  Does Bay Area Quick Care have urgent care accreditations? The NPI taxonomy indicates this is an urgent care center and your website indicates Bay Area Quick Care is an urgent care center.  Mariana Juarez Provider Contracting Representative mariana.juarez@multiplan.com  MultiPlan 25550 Commercentre Drive, Suite 200 Lake Forest, CA 92630 ph: 949-672-1561 fx: 630-245-2462\"  Replied with:  \"Hello Mariana,  Bay area quick care does not have any urgentcare accreditations. Please let me know how we can proceed. Thank you.\"  ', NULL, NULL, '2021-07-23 16:26:32', '2021-07-23 16:26:32'),
(11423, 1006, 19816, NULL, '2021-08-10 00:00:00.000', 'In Process', 'We received the group contract from mark.sokel@multiplan.com:  Sub: Multiplan Agreement For Signature  \"Mark Sokel mark.sokel@multiplan.com Dear Provider:  Thank you for your interest in participating in one or more of MultiPlan’s provider networks.  An agreement for electronic signature is enclosed and includes instructions on how to sign electronically.    Credentialing documents will be sent to you in a separate communication. You will be notified of your effective date upon acceptance into the network(s).  If you have questions regarding this letter, please contact our Service Operations Department at 800-950-7040 from 8:30 a.m. to 5:30 p.m. ET. Among other things, Service Operations can answer your credentialing questions, correct erroneous information submitted in your credentialing application, or report the status of your credentialing application. If you would like additional information about MultiPlan or the services we offer, please visit our website at www.multiplan.com.  Sincerely,  Gloria Esplana Director, Network Contract Support\"  Signed and sent back. ', NULL, NULL, '2021-08-03 16:17:30', '2021-08-03 16:17:30'),
(11424, 1006, 19816, NULL, '2021-08-11 00:00:00.000', 'In Process', 'Received the following update from Mark.Sokel@multiplan.com:  Sub: Bay Area Quick Care PLLC - possible Multiplan network participation contracting - received completed Roster & W9 - submitting contract packet for Approval for processing  \"Hello Brad,  This is to confirm for you that I received your completed Roster and W9.  I had previously received your signed Multiplan network participation contract for Bay Area Quick Care PLLC.  At this point I have your Provider signed Group contract, your completed Roster and a copy of your W9.  I believe I have a complete contract packet.  Today I will be submitting your Multiplan contract packet to our QA Folks for review/Approval for processing.  If they kick it back to me for any reason, I will immediately contact you to work out whatever the issue might be.  (But I am hoping it will sail through QA).  As long as there are no issues with the contract packet, as soon as the contract is executed, a copy of the countersigned contract will be automatically emailed back to your office.  The contract has a 9/15 effective date on the Group contract.  Mark J. Sokel Provider Contracting Representative mark.sokel@multiplan.com MultiPlan  25550 Commercentre Drive, Suite 200 Lake Forest, CA 92630 ph: 949-639-3832 fx: 630-245-2491 Interoffice: *23 3832\"', NULL, NULL, '2021-08-04 12:38:19', '2021-08-04 12:38:19'),
(11425, 1006, 19816, NULL, '2021-08-17 00:00:00.000', 'In Process', 'Executed contract was received and is attached in main group task for reference. ', NULL, NULL, '2021-08-10 09:46:56', '2021-08-10 09:46:56'),
(11426, 11056, 19816, NULL, '2021-08-27 00:00:00.000', 'In Process', 'Email sent to : mark.sokel@multiplan.com  &  Mariana.Juarez@multiplan.com   registrar@multiplan.com  Sub : Notification regarding your nomination for - Bay Area Quick Care PLLC - Seid: 214290783  Good morning!  Hope this email finds you well. Please provide me with the latest enrollment updates of the below mentioned provider.  The CAQH application of the provider is authorised to multiplan.  Provider Details: Provider Name: Ramsden, Melissa Provider NPI# : 1194376228 CAQH I.D : 14570014   If you need documents or information please let me know. Waiting to hear from you soon.  Thank you! Have a great weekend!', NULL, NULL, '2021-08-20 10:13:42', '2021-08-20 10:13:42'),
(11427, 11056, 19816, NULL, '2021-09-07 00:00:00.000', 'In Process', 'Email received from : Mark.Sokel@multiplan.com  Sub : Notification regarding your nomination for - Bay Area Quick Care PLLC - Seid: 214290783  Hello Ahmed,     Multiplan’s Service Operations at 800-950-7040 can give update status on credentialing and data changes.     I checked our system and do see Melissa Ramsden attached to TIN 271702009 and the group contract with Bay Area Quick Care.  However – do confirm this with Multiplan’s Service Operations at 800-950-7040.  (as I set up group contracts and am not too much involved with Credentialing)        Mark J. Sokel  Provider Contracting Representative  mark.sokel@multiplan.com     MultiPlan  25550 Commercentre Drive, Suite 200  Lake Forest, CA 92630  ph: 949-639-3832  fx: 630-245-2491  Interoffice: *23 3832', NULL, NULL, '2021-08-30 14:44:30', '2021-08-30 14:44:30'),
(11428, 11056, 19816, NULL, '2021-09-30 00:00:00.000', 'Approved', 'Rep. : Jenifer W  Status :  Participating under Tax ID and Practice too. The address is also listed below the provider. Approved from their side.  They will be going to provide welcome letter within one or 2 weeks.  Eff date : 09/15/2021  Ref code : 7751560   Provider is also available on directory of multiplan.  Please see the attachment. ', NULL, NULL, '2021-09-23 14:54:43', '2021-09-23 14:54:43'),
(11429, 3040, 19817, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:18:53', '2021-03-11 17:18:53'),
(11430, 3040, 19817, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.   Effective Date: 12/29/2018 ', NULL, NULL, '2021-03-22 10:13:44', '2021-03-22 10:13:44'),
(11431, 3040, 19818, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:19:22', '2021-03-11 17:19:22'),
(11432, 3040, 19818, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.', NULL, NULL, '2021-03-22 10:41:04', '2021-03-22 10:41:04'),
(11433, 3046, 19819, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:19:41', '2021-03-11 17:19:41'),
(11434, 1006, 19819, NULL, '2021-05-20 00:00:00.000', 'Initiated', 'Received a re-credentialing request from Multiplan via fax, as per my discussion with them I need to send an email informing them that we use CAQH for enrollment. Email sent @ recredprocurement@multiplan.cm', NULL, NULL, '2021-05-10 09:01:25', '2021-05-10 09:01:25'),
(11435, 9057, 19819, NULL, '2021-06-08 00:00:00.000', 'In Process', 'We sent an email to: registrar@multiplan.com Sub: Request for Enrollment Status - BAQC - Multiplan  Hello, I want to get the current status of the below mentioned group & providers  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda  NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Kindly respond to us as soon as possible.  Thank you ', NULL, NULL, '2021-05-31 16:47:29', '2021-05-31 16:47:29'),
(11436, 1006, 19819, NULL, '2021-06-24 00:00:00.000', 'Approved', 'The provider is enrolled with Multiplan, approval confirmation is attached for reference.   Eff: 06/18/2018 ', NULL, NULL, '2021-06-17 16:47:54', '2021-06-17 16:47:54'),
(11437, 3046, 19820, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:19:55', '2021-03-11 17:19:55'),
(11438, 9057, 19820, NULL, '2021-06-08 00:00:00.000', 'In Process', 'We sent an email to: registrar@multiplan.com Sub: Request for Enrollment Status - BAQC - Multiplan  Hello, I want to get the current status of the below mentioned group & providers  Group Name: Bay Area Quick Care LLC NPI: 1437481421 TIN# 27-1702009 Main Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418  Provider name: Orsak, Kynda  NPI# 1528553724  Provider Name: Malowitz, Cynthia NPI# 1336173244  Provider Name: Ramsden, Melissa NPI# 1194376228  Kindly respond to us as soon as possible.  Thank you ', NULL, NULL, '2021-05-31 16:46:29', '2021-05-31 16:46:29'),
(11439, 1006, 19820, NULL, '2021-06-24 00:00:00.000', 'Approved', 'The provider is enrolled with Multiplan, approval confirmation is attached for reference.   Eff: 04/05/2019 ', NULL, NULL, '2021-06-17 16:49:20', '2021-06-17 16:49:20'),
(11440, 3040, 19821, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:20:08', '2021-03-11 17:20:08'),
(11441, 3040, 19821, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:41:54', '2021-03-22 10:41:54'),
(11442, 1006, 19822, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:20:27', '2021-03-11 17:20:27'),
(11443, 1006, 19822, NULL, '2021-04-19 00:00:00.000', 'Not Eligible', 'LCSW providers cannot be credentialed with BCBSRI, attached Behavioral Health Outpatient Payment Policy for reference:  \"Only independently licensed behavioral health clinicians may render services to a BCBSRI member in an outpatient professional setting. Providers with a provisional license are not eligible for credentialing. BCBSRI does not have a supervisory protocol arrangement whereby a Master’s-level clinician can render services under a supervising clinician with an independent license. BCBSRI does not allow for a Master’s-level (non-independently licensed) clinician to render services to our members in an outpatient professional setting. BCBSRI does not credential Licensed Clinical Social Workers (LCSWs).\" ', NULL, NULL, '2021-04-12 17:08:47', '2021-04-12 17:08:47'),
(11444, 1019, 19822, NULL, '2021-10-06 00:00:00.000', 'Initiated', 'Enrollment Request sent through website see below for reference.  Thank you for your enrollment request. Within four business days of the submission of this form, you should receive an email that will serve to confirm receipt of your request. The email will also include an attachment that contains a packet of important forms such as a provider agreement, W9, EFT instructions, etc., as well as information that will help guide you through the initial credentialing process. Those forms should be completed and returned to Database.Credentialing@bcbsri.org as soon as possible. It is important to note that your application will not be considered complete until all of the required documents have been returned. Additionally, BCBSRI utilizes the CAQH application to credential providers. It is very important to ensure that you have made your CAQH accessible to BCBSRI and updated and attested to the information in CAQH within the last 120 days. If you do not receive an email response within two days after submitting this form please email Database.Credentialing@bcbsri.org to confirm the status of your submission and request that the packet be resent to you. We appreciate your interest in joining the BCBSRI network and will work to begin prompt processing of your request. However, please note the credentialing process may be discontinued if we are unable to access your CAQH application or if your CAQH application is not updated and attested to in the required timeframe, or if you do not return the provider agreement and required forms.', NULL, NULL, '2021-09-29 08:29:51', '2021-09-29 08:29:51'),
(11445, 1019, 19822, NULL, '2021-10-07 00:00:00.000', 'In Process', 'Received the following email from Database.Credentialing@bcbsri.org  Good Morning,     Request you to return back the signed contracts & W9 form ASAP to database.credentialing@bcbsri.org or you can fax it to 401-459-1369. Thank You     Regards,  Loganathan R', NULL, NULL, '2021-09-30 08:09:47', '2021-09-30 08:09:47'),
(11446, 1019, 19822, NULL, '2021-10-07 00:00:00.000', 'In Process', 'Sent the requested signed contracts and W9 form to BCBSRI @ Database.Credentialing@bcbsri.org', NULL, NULL, '2021-09-30 08:10:39', '2021-09-30 08:10:39'),
(11447, 1019, 19822, NULL, '2021-11-23 00:00:00.000', 'Approved', 'Attached is the Welcome Letter along with plans Effective date 11/04/2021', NULL, NULL, '2021-11-16 15:27:26', '2021-11-16 15:27:26'),
(11448, 3040, 19823, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:21:18', '2021-03-11 17:21:18'),
(11449, 3040, 19823, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Group enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:05:41', '2021-03-22 10:05:41'),
(11450, 1006, 19824, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:21:26', '2021-03-11 17:21:26'),
(11451, 1019, 19824, NULL, '2021-03-25 00:00:00.000', 'Initiated', 'Thank you for your enrollment request. Within four business days of the submission of this form, you should receive an email that will serve to confirm receipt of your request. The email will also include an attachment that contains a packet of important forms such as a provider agreement, W9, EFT instructions, etc., as well as information that will help guide you through the initial credentialing process. Those forms should be completed and returned to Database.Credentialing@bcbsri.org as soon as possible. It is important to note that your application will not be considered complete until all of the required documents have been returned. Additionally, BCBSRI utilizes the CAQH application to credential providers. It is very important to ensure that you have made your CAQH accessible to BCBSRI and updated and attested to the information in CAQH within the last 120 days. If you do not receive an email response within two days after submitting this form please email Database.Credentialing@bcbsri.org to confirm the status of your submission and request that the packet be resent to you. We appreciate your interest in joining the BCBSRI network and will work to begin prompt processing of your request. However, please note the credentialing process may be discontinued if we are unable to access your CAQH application or if your CAQH application is not updated and attested to in the required timeframe, or if you do not return the provider agreement and required forms.', NULL, NULL, '2021-03-18 14:54:30', '2021-03-18 14:54:30'),
(11452, 1006, 19824, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Called BCBS at (800) 230-9050, as per them we need to reach out to Credentialing department via email.   Sent an email to Database Credentialing Database.Credentialing@bcbsri.org:  Sub: Enrollment Status - Justin Souliere - BCBSRI  \"Hello,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following provider:  Group Name: Spectrum Neuro Behavioral Care LLC TIN# 83-4482753  Provider Name: Justin Souliere NPI# 1710576004  Please get back to me as soon as you\'re able to.   Thank you. \"', NULL, NULL, '2021-04-16 09:27:13', '2021-04-16 09:27:13'),
(11453, 1019, 19824, NULL, '2021-04-26 00:00:00.000', 'Not Eligible', 'Received the following message from: Database.Credentialing@bcbsri.org Good Morning, We had received provider form submission on 3/18/2021 and we are also responded 3/19/2021. Provider have only clinical social worker license. BCBSRI will not be accept this Specialty.   Regards,  Mukesh M', NULL, NULL, '2021-04-19 08:29:45', '2021-04-19 08:29:45'),
(11454, 1006, 19825, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:21:29', '2021-03-11 17:21:29'),
(11455, 1006, 19825, NULL, '2021-04-16 00:00:00.000', 'On Hold', 'The enrollment request is pending on the provider\'s RI PMHNP license to be issued. ', NULL, NULL, '2021-04-09 14:57:35', '2021-04-09 14:57:35'),
(11456, 1019, 19825, NULL, '2021-11-01 00:00:00.000', 'Not Eligible', 'Provider will no longer be working with SNBCare.', NULL, NULL, '2021-10-25 10:42:43', '2021-10-25 10:42:43'),
(11457, 3040, 19826, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:21:39', '2021-03-11 17:21:39'),
(11458, 3040, 19826, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.   Effective Date: 12/29/2018 ', NULL, NULL, '2021-03-22 10:13:38', '2021-03-22 10:13:38'),
(11459, 3040, 19827, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:21:58', '2021-03-11 17:21:58'),
(11460, 3040, 19827, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.', NULL, NULL, '2021-03-22 10:41:09', '2021-03-22 10:41:09'),
(11461, 1006, 19828, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:22:10', '2021-03-11 17:22:10'),
(11462, 1006, 19828, NULL, '2021-03-26 00:00:00.000', 'Approved', 'Welcome letter attached for reference.   Eff: 12/31/2019', NULL, NULL, '2021-03-19 11:45:17', '2021-03-19 11:45:17'),
(11463, 3040, 19829, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:22:15', '2021-03-11 17:22:15'),
(11464, 3040, 19829, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:36:00', '2021-03-22 10:36:00'),
(11465, 3040, 19830, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:22:41', '2021-03-11 17:22:41'),
(11466, 3040, 19830, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:42:00', '2021-03-22 10:42:00'),
(11467, 3040, 19831, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:23:08', '2021-03-11 17:23:08'),
(11468, 3040, 19831, NULL, '2021-03-29 00:00:00.000', 'Approved', 'The request has been approved: \"Medicare Enrollment Information Individual Name: CYNTHIA RODRIGUEZ Individual Specialty: PHYSICIAN ASSISTANT Individual National Provider Identifier (NPI): 1124282553 Individual Provider Transaction Access Number (PTAN): 1H2296 Individual PTAN Effective Date: JUNE 20th, 2020 Employer Legal Business Name (LBN): VALLEY MED URGENT CARE PLLC Employer National Provider Identifier (NPI): 1518404631 Employer Provider Transaction Access Number (PTAN): 578343 Changed Information: ENROLLMENT APPLICATION CONTACT PERSON\"', NULL, NULL, '2021-03-22 12:43:14', '2021-03-22 12:43:14'),
(11469, 1006, 19832, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:23:15', '2021-03-11 17:23:15'),
(11470, 3040, 19832, NULL, '2021-04-26 00:00:00.000', 'Initiated', 'Email sent to: providerapplicationstatus@bcbsma.com  Subject: Enrollment || Spectrum Neuro Behavioral Care LLC || Group & Providers || BCBS MA ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group and providers for our group Spectrum Neuro Behavioral Care LLC under below locations.   Practice Details: Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Primary Address: 61 Lincoln St., Suite 203, Framingham , MA 01702 Secondary Address: 100 New State Hwy. Raynham , MA 02767  Provider 1: Provider Name: Tawakol, Katie  Provider NPI# 1609222116  Provider 2: Provider Name: Rashid, Mahreen Provider NPI# 1396393146  Provider 3:   Provider Name: Hefti, Prisca Provider NPI# 1508133182  Provider 4:   Provider Name: Khan, Fauzia Wali Provider NPI# 1699761965  Provider 5:   Provider Name: Pionke, Peggy Provider NPI# 1699307322  Provider 6:   Provider Name: Ullrich, Jennifer Lee Provider NPI# 1710489760  Provider 7:   Provider Name: Schubert, Jonathan Provider NPI# 1235755505  Provider 8:   Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Provider 9:   Provider Name: Hignite, Barbara Provider NPI# 1982617262  Provider 10:   Provider Name: Loveland, Lynnetta Provider NPI# 1598163602  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-19 14:29:25', '2021-04-19 14:29:25'),
(11471, 1019, 19832, NULL, '2021-05-05 00:00:00.000', 'Not Eligible', 'Received the following email from providerapplicationstatus@bcbsma.com Thank you for your email,     BCBSMA does not currently enroll LCSW providers.     Thank you,     Network Management  Blue Cross & Blue Shield of Massachusetts  800-316-2583', NULL, NULL, '2021-04-28 07:05:22', '2021-04-28 07:05:22'),
(11472, 3040, 19833, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:23:27', '2021-03-11 17:23:27'),
(11473, 3040, 19833, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Application Tracking ID: T050120200001265 NPI ID: 1255676151 Medicare ID: 440103YNC5, 946051 Name: TERESA SAAVEDRA State: TX Form Type: 855I Date: 05/07/2020 Status: APPROVED', NULL, NULL, '2021-03-22 13:07:40', '2021-03-22 13:07:40'),
(11474, 1006, 19834, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:23:42', '2021-03-11 17:23:42'),
(11475, 3040, 19834, NULL, '2021-04-26 00:00:00.000', 'Initiated', 'Email sent to: providerapplicationstatus@bcbsma.com  Subject: Enrollment || Spectrum Neuro Behavioral Care LLC || Group & Providers || BCBS MA ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group and providers for our group Spectrum Neuro Behavioral Care LLC under below locations.   Practice Details: Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Primary Address: 61 Lincoln St., Suite 203, Framingham , MA 01702 Secondary Address: 100 New State Hwy. Raynham , MA 02767  Provider 1: Provider Name: Tawakol, Katie  Provider NPI# 1609222116  Provider 2: Provider Name: Rashid, Mahreen Provider NPI# 1396393146  Provider 3:   Provider Name: Hefti, Prisca Provider NPI# 1508133182  Provider 4:   Provider Name: Khan, Fauzia Wali Provider NPI# 1699761965  Provider 5:   Provider Name: Pionke, Peggy Provider NPI# 1699307322  Provider 6:   Provider Name: Ullrich, Jennifer Lee Provider NPI# 1710489760  Provider 7:   Provider Name: Schubert, Jonathan Provider NPI# 1235755505  Provider 8:   Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Provider 9:   Provider Name: Hignite, Barbara Provider NPI# 1982617262  Provider 10:   Provider Name: Loveland, Lynnetta Provider NPI# 1598163602  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-19 14:28:45', '2021-04-19 14:28:45'),
(11476, 1019, 19834, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, Debra.Draheim@bcbsma.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BCBSMA  Hello, Can you please let me know the enrollment status for the following group and providers with Blue Cross Blue Shield of Massachusetts.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-05 07:58:36', '2021-05-05 07:58:36'),
(11477, 1019, 19834, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to  providerapplicationstatus@bcbsma.com,  Debra.Draheim@bcbsma.com SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA  Hello Debra, Hope you\'re doing good, I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I sent a couple of emails to BCBS MA regarding enrollments, can you please look into my request and help out with enrollment status for our providers.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.  ', NULL, NULL, '2021-05-20 08:57:09', '2021-05-20 08:57:09');
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
(11478, 1019, 19834, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, provider-enrollment@bcbsma.com, debra.draheim@bcbsma.com  SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA 3rd Atttempt  Hello,  We need the enrollment status for the following providers under our group, also I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I have sent couple of emails to BCBS MA regarding enrollments query.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.    Regards, Alex ', NULL, NULL, '2021-06-03 10:53:35', '2021-06-03 10:53:35'),
(11479, 1019, 19834, NULL, '2021-07-19 00:00:00.000', 'Approved', 'Received the following email from Debra.Draheim@bcbsma.com  Hi Alex,     We apologize for the delay, I have reviewed and added the status’ for you below.  Let me know if you have any questions.  Thank you     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia-provider effective 4/28/2021 with both sites NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca-provider effective 6/21/2021 with both sites NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara-provider effective 4/1/2021 with site below NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali-provider effective 6/21/2021 with site below NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta-provider effective 2/22/2021 with site below NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen-provider effective 3/2/2021 with site below NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie-provider effective 3/25/2021 with both sites NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jessica Hartman-no record of receipt of initial credentialing request. NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Mary Gibbons-no record of receipt of maintenance to add addresses. NPI: 1942388483  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Deb Draheim, CPCS  Credentialing Manager, Provider Operations|Blue Cross Blue Shield of Massachusetts 25 Technology Place | Hingham, MA  02043|T(617) 246-7675 | F(617) 246-5055 |e-mail: Debra.Draheim@BCBSMA.com Blue Cross Blue Shield of Massachusetts', NULL, NULL, '2021-07-12 14:14:14', '2021-07-12 14:14:14'),
(11480, 1006, 19835, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:24:01', '2021-03-11 17:24:01'),
(11481, 3040, 19835, NULL, '2021-04-26 00:00:00.000', 'Initiated', 'Email sent to: providerapplicationstatus@bcbsma.com  Subject: Enrollment || Spectrum Neuro Behavioral Care LLC || Group & Providers || BCBS MA ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group and providers for our group Spectrum Neuro Behavioral Care LLC under below locations.   Practice Details: Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Primary Address: 61 Lincoln St., Suite 203, Framingham , MA 01702 Secondary Address: 100 New State Hwy. Raynham , MA 02767  Provider 1: Provider Name: Tawakol, Katie  Provider NPI# 1609222116  Provider 2: Provider Name: Rashid, Mahreen Provider NPI# 1396393146  Provider 3:   Provider Name: Hefti, Prisca Provider NPI# 1508133182  Provider 4:   Provider Name: Khan, Fauzia Wali Provider NPI# 1699761965  Provider 5:   Provider Name: Pionke, Peggy Provider NPI# 1699307322  Provider 6:   Provider Name: Ullrich, Jennifer Lee Provider NPI# 1710489760  Provider 7:   Provider Name: Schubert, Jonathan Provider NPI# 1235755505  Provider 8:   Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Provider 9:   Provider Name: Hignite, Barbara Provider NPI# 1982617262  Provider 10:   Provider Name: Loveland, Lynnetta Provider NPI# 1598163602  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-19 14:29:09', '2021-04-19 14:29:09'),
(11482, 1019, 19835, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, Debra.Draheim@bcbsma.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BCBSMA  Hello, Can you please let me know the enrollment status for the following group and providers with Blue Cross Blue Shield of Massachusetts.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-05 07:58:14', '2021-05-05 07:58:14'),
(11483, 1019, 19835, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to  providerapplicationstatus@bcbsma.com,  Debra.Draheim@bcbsma.com SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA  Hello Debra, Hope you\'re doing good, I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I sent a couple of emails to BCBS MA regarding enrollments, can you please look into my request and help out with enrollment status for our providers.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.   Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.  ', NULL, NULL, '2021-05-20 08:55:54', '2021-05-20 08:55:54'),
(11484, 1019, 19835, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, provider-enrollment@bcbsma.com, debra.draheim@bcbsma.com  SUB: Enrollment Query || Group & Provider || SNBCARE || BCBS MA 3rd Atttempt  Hello,  We need the enrollment status for the following providers under our group, also I want to bring this in your knowledge that I\'m not receiving timely responses on my queries as I have sent couple of emails to BCBS MA regarding enrollments query.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 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: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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.    Regards, Alex ', NULL, NULL, '2021-06-03 10:51:48', '2021-06-03 10:51:48'),
(11485, 1019, 19835, NULL, '2021-07-19 00:00:00.000', 'Approved', 'Received the following email from Debra.Draheim@bcbsma.com  Hi Alex,     We apologize for the delay, I have reviewed and added the status’ for you below.  Let me know if you have any questions.  Thank you     Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Individual Providers:  Edmundson, Rodesia-provider effective 4/28/2021 with both sites NPI: 1124622667 Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca-provider effective 6/21/2021 with both sites NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara-provider effective 4/1/2021 with site below NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali-provider effective 6/21/2021 with site below NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta-provider effective 2/22/2021 with site below NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen-provider effective 3/2/2021 with site below NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie-provider effective 3/25/2021 with both sites NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Jessica Hartman-no record of receipt of initial credentialing request. NPI: 1326665472 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Mary Gibbons-no record of receipt of maintenance to add addresses. NPI: 1942388483  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Deb Draheim, CPCS  Credentialing Manager, Provider Operations|Blue Cross Blue Shield of Massachusetts 25 Technology Place | Hingham, MA  02043|T(617) 246-7675 | F(617) 246-5055 |e-mail: Debra.Draheim@BCBSMA.com Blue Cross Blue Shield of Massachusetts', NULL, NULL, '2021-07-12 13:54:21', '2021-07-12 13:54:21'),
(11486, 3040, 19836, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:24:45', '2021-03-11 17:24:45'),
(11487, 3040, 19836, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.   Effective Date: 12/29/2018  ', NULL, NULL, '2021-03-22 10:13:28', '2021-03-22 10:13:28'),
(11488, 1006, 19837, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:24:58', '2021-03-11 17:24:58'),
(11489, 1019, 19837, NULL, '2021-04-08 00:00:00.000', 'Not Eligible', 'Ineligible because her License is LCSW', NULL, NULL, '2021-04-01 15:53:54', '2021-04-01 15:53:54'),
(11490, 1019, 19837, NULL, '2021-04-09 00:00:00.000', 'New/Not Initiated', 'Sent the following email to : ProviderApplicationStatus@bcbsma.com  Sub: Enroll Provider || SNBCARE || Kerry Smith || BCBS MA  Hello, We wanted to enroll the below mentioned provider in Blue Cross Blue Shield MA, under our group. Can you let us know if you do enroll in these types of providers. Group Information: Spectrum Neuro Behavioral Care LLC Tax ID: 834482753 NPI: 1356906572 Individual Provider: Kerry Smith NPI: 1275083230 Speciality: Licensed Clinical Social Worker', NULL, NULL, '2021-04-02 09:37:36', '2021-04-02 09:37:36'),
(11491, 1019, 19837, NULL, '2021-04-09 00:00:00.000', 'Initiated', NULL, NULL, NULL, '2021-04-02 14:23:43', '2021-04-02 14:23:43'),
(11492, 1019, 19837, NULL, '2021-04-19 00:00:00.000', 'Not Eligible', 'Received the following email from providerapplicationstatus@bcbsma.com Thank you for your email,     BCBSMA does not currently enroll LCSW providers.     Thank you,     Network Management  Blue Cross & Blue Shield of Massachusetts  800-316-2583', NULL, NULL, '2021-04-12 08:10:46', '2021-04-12 08:10:46'),
(11493, 1006, 19838, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:25:00', '2021-03-11 17:25:00'),
(11494, 1019, 19838, NULL, '2021-04-12 00:00:00.000', 'Initiated', 'Enrollment application faxed to 617-246-5053. see attached', NULL, NULL, '2021-04-05 14:51:29', '2021-04-05 14:51:29'),
(11495, 1019, 19838, NULL, '2021-04-14 00:00:00.000', 'In Process', 'Received the email to signed the contract , so contract has been signed and sent back. see attachment for reference.', NULL, NULL, '2021-04-07 10:26:16', '2021-04-07 10:26:16'),
(11496, 1019, 19838, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to francine.riordan@bcbsma.com, providerapplicationstatus@bcbsma.com  Sub: Enrollment Status || Providers || SNBCARE || BCBS MA 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:  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.', NULL, NULL, '2021-04-08 10:50:12', '2021-04-08 10:50:12'),
(11497, 1019, 19838, NULL, '2021-04-22 00:00:00.000', 'In Process', 'Received the following email from Debra.Draheim@bcbsma.com  Hi Alex,  Kerry Smith, I am not showing anything in process for this provider.  Did you complete the online contract application?  I have cc’d our Network Management area to help with this request. Rodesia Edmundson, PNP (128848)-is in our credentialing process we received the request to credential on 4/12/2021.  Deb Draheim, CPCS  Credentialing Manager, Provider Operations|Blue Cross Blue Shield of Massachusetts', NULL, NULL, '2021-04-15 07:35:04', '2021-04-15 07:35:04'),
(11498, 3040, 19838, NULL, '2021-04-26 00:00:00.000', 'Initiated', 'Email sent to: providerapplicationstatus@bcbsma.com  Subject: Enrollment || Spectrum Neuro Behavioral Care LLC || Group & Providers || BCBS MA ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group and providers for our group Spectrum Neuro Behavioral Care LLC under below locations.   Practice Details: Practice Name: Spectrum Neuro Behavioral Care LLC Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Primary Address: 61 Lincoln St., Suite 203, Framingham , MA 01702 Secondary Address: 100 New State Hwy. Raynham , MA 02767  Provider 1: Provider Name: Tawakol, Katie  Provider NPI# 1609222116  Provider 2: Provider Name: Rashid, Mahreen Provider NPI# 1396393146  Provider 3:   Provider Name: Hefti, Prisca Provider NPI# 1508133182  Provider 4:   Provider Name: Khan, Fauzia Wali Provider NPI# 1699761965  Provider 5:   Provider Name: Pionke, Peggy Provider NPI# 1699307322  Provider 6:   Provider Name: Ullrich, Jennifer Lee Provider NPI# 1710489760  Provider 7:   Provider Name: Schubert, Jonathan Provider NPI# 1235755505  Provider 8:   Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Provider 9:   Provider Name: Hignite, Barbara Provider NPI# 1982617262  Provider 10:   Provider Name: Loveland, Lynnetta Provider NPI# 1598163602  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-19 14:29:41', '2021-04-19 14:29:41'),
(11499, 1019, 19838, NULL, '2021-05-05 00:00:00.000', 'In Process', 'Received the following email from ProviderApplicationStatus@bcbsma.com  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:  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767. We did not receive a contracting application for this provider.  We need to know when you faxed back the application to us and which fax number?  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  The providers contract was received back on 4/7/21, and the provider is now pending credentialing.  Please 60 days processing time.', NULL, NULL, '2021-04-28 11:51:16', '2021-04-28 11:51:16'),
(11500, 1019, 19838, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Sent the following email to providerapplicationstatus@bcbsma.com, Debra.Draheim@bcbsma.com  SUB: Enrollment Query || Group & Providers || SNBCARE || BCBSMA  Hello, Can you please let me know the enrollment status for the following group and providers with Blue Cross Blue Shield of Massachusetts.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Edmundson, Rodesia NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hefti, Prisca NPI: 1508133182 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Tawakol, Katie NPI: 1609222116 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.      Regards,', NULL, NULL, '2021-05-05 07:57:55', '2021-05-05 07:57:55'),
(11501, 1019, 19838, NULL, '2021-05-12 00:00:00.000', 'Approved', 'Welcome Letter attached. Eff 04/28/2021', NULL, NULL, '2021-05-05 08:27:23', '2021-05-05 08:27:23'),
(11502, 3040, 19839, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:25:05', '2021-03-11 17:25:05'),
(11503, 3040, 19839, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare.', NULL, NULL, '2021-03-22 10:41:16', '2021-03-22 10:41:16'),
(11504, 3040, 19840, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:25:41', '2021-03-11 17:25:41'),
(11505, 3040, 19840, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare. ', NULL, NULL, '2021-03-22 10:42:05', '2021-03-22 10:42:05'),
(11506, 1006, 19841, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:25:53', '2021-03-11 17:25:53'),
(11507, 1019, 19841, NULL, '2021-04-29 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, '2021-04-22 15:57:09', '2021-04-22 15:57:09'),
(11508, 1019, 19841, NULL, '2021-04-30 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, '2021-04-23 06:47:16', '2021-04-23 06:47:16'),
(11509, 1019, 19841, 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 08:40:14', '2021-05-20 08:40:14'),
(11510, 1019, 19841, 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 11:18:34', '2021-06-05 11:18:34'),
(11511, 1019, 19841, 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 08:03:01', '2021-06-24 08:03:01'),
(11512, 1019, 19841, 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 10:21:22', '2021-08-30 10:21:22'),
(11513, 3040, 19842, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:02', '2021-03-11 17:26:02'),
(11514, 3040, 19842, NULL, '2021-03-29 00:00:00.000', 'Approved', 'The request has been approved: \"Medicare Enrollment Information Individual Name: CYNTHIA RODRIGUEZ Individual Specialty: PHYSICIAN ASSISTANT Individual National Provider Identifier (NPI): 1124282553 Individual Provider Transaction Access Number (PTAN): 1H2296 Individual PTAN Effective Date: JUNE 20th, 2020 Employer Legal Business Name (LBN): VALLEY MED URGENT CARE PLLC Employer National Provider Identifier (NPI): 1518404631 Employer Provider Transaction Access Number (PTAN): 578343 Changed Information: ENROLLMENT APPLICATION CONTACT PERSON\"', NULL, NULL, '2021-03-22 12:43:19', '2021-03-22 12:43:19'),
(11515, 3040, 19843, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:25', '2021-03-11 17:26:25'),
(11516, 3040, 19843, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Application Tracking ID: T050120200001265 NPI ID: 1255676151 Medicare ID: 440103YNC5, 946051 Name: TERESA SAAVEDRA State: TX Form Type: 855I Date: 05/07/2020 Status: APPROVED', NULL, NULL, '2021-03-22 13:07:38', '2021-03-22 13:07:38'),
(11517, 1006, 19844, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:25', '2021-03-11 17:26:25'),
(11518, 1006, 19844, NULL, '2021-04-29 00:00:00.000', 'Approved', 'The provider is enrolled with Beacon, the welcome letter and location confirmation are attached for reference.   Eff: 11/06/2020', NULL, NULL, '2021-04-22 16:44:25', '2021-04-22 16:44:25'),
(11519, 3046, 19845, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:35', '2021-03-11 17:26:35'),
(11520, 9057, 19845, NULL, '2021-06-08 00:00:00.000', 'Not Eligible', 'Received following email from: mydavis@texaschildrens.org RE: Need status-BAQC Good Afternoon,   LOI’s are reviewed at the end of the following month they are submitted. I did take a look at what was submitted and noticed  the physical address listed on the LOI is in Corpus Christi which is outside of our current service area. Texas Children’s Health Plan is not licensed for CHIP and STAR in Nueces County. I provided a map of the current service area for reference.  Please let me know if you have any questions.', NULL, NULL, '2021-06-01 08:31:01', '2021-06-01 08:31:01'),
(11521, 3046, 19846, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:42', '2021-03-11 17:26:42'),
(11522, 9057, 19846, NULL, '2021-06-08 00:00:00.000', 'Not Eligible', 'Received following email from: mydavis@texaschildrens.org RE: Need status-BAQC Good Afternoon,   LOI’s are reviewed at the end of the following month they are submitted. I did take a look at what was submitted and noticed  the physical address listed on the LOI is in Corpus Christi which is outside of our current service area. Texas Children’s Health Plan is not licensed for CHIP and STAR in Nueces County. I provided a map of the current service area for reference.  Please let me know if you have any questions.', NULL, NULL, '2021-06-01 08:32:01', '2021-06-01 08:32:01'),
(11523, 3046, 19847, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:26:51', '2021-03-11 17:26:51'),
(11524, 9057, 19847, NULL, '2021-06-08 00:00:00.000', 'Not Eligible', 'Received following email from: mydavis@texaschildrens.org RE: Need status-BAQC Good Afternoon,   LOI’s are reviewed at the end of the following month they are submitted. I did take a look at what was submitted and noticed  the physical address listed on the LOI is in Corpus Christi which is outside of our current service area. Texas Children’s Health Plan is not licensed for CHIP and STAR in Nueces County. I provided a map of the current service area for reference.  Please let me know if you have any questions.', NULL, NULL, '2021-06-01 08:32:12', '2021-06-01 08:32:12'),
(11525, 3040, 19848, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:27:46', '2021-03-11 17:27:46'),
(11526, 3040, 19848, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:50:30', '2021-03-22 15:50:30'),
(11527, 3046, 19849, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:27:59', '2021-03-11 17:27:59'),
(11528, 9057, 19849, NULL, '2021-06-04 00:00:00.000', 'Initiated', 'We sent email to KMoten4@humana.com Sub: Certification and Enrollment Status - BAQC - Tricare  Hello Ketherine, Hope you are doing well, Kindly verify if the below mentioned providers are certified or not, if they are certified then we wish to enroll them under the following group.  Group Details Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name: Melissa Ramsden NPI# 1194376228  Also we want to know the credentialing status of the below mentioned providers under the above mentioned group.  Provider Details Provider Name: Cynthia Malowitz NPI# 1336173244  Provider Name: Kynda Orsak NPI# 1528553724  Provider Name: William Francis NPI# 1457994436  Waiting for your kind response  Thank you  ', NULL, NULL, '2021-05-28 13:44:34', '2021-05-28 13:44:34'),
(11529, 1006, 19849, NULL, '2021-06-23 00:00:00.000', 'In Process', 'We received the following reply from Katherine from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Certification and Enrollment Status - BAQC - Tricare  \"Provider Name: Melissa Ramsden – please provide a credentialing application with the following documents: CV, DEA, Malpractice Insurance, License.  Provider Name: Cynthia Malowitz -  cred eff: 11/25/2019  Provider Name: Kynda Orsak – submitted for credentialing, please allow 90 days.  Provider Name: William Francis – cred eff: 2/2/2021\"  Will approve group enrollment once all providers are enrolled with Tricare. ', NULL, NULL, '2021-06-16 14:23:23', '2021-06-16 14:23:23'),
(11530, 1006, 19849, NULL, '2021-06-23 00:00:00.000', 'In Process', 'We received the following reply from Katherine from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Certification and Enrollment Status - BAQC - Tricare  \"Provider Name: Melissa Ramsden – please provide a credentialing application with the following documents: CV, DEA, Malpractice Insurance, License.  Provider Name: Cynthia Malowitz -  cred eff: 11/25/2019  Provider Name: Kynda Orsak – submitted for credentialing, please allow 90 days.  Provider Name: William Francis – cred eff: 2/2/2021\"  Will approve group enrollment once all providers are enrolled with Tricare. ', NULL, NULL, '2021-06-16 14:23:23', '2021-06-16 14:23:23'),
(11531, 1006, 19849, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Sent f/u email @ Katherine Moten KMoten4@humana.com:  Sub: Enrollment Status - BAQC - Tricare  \"Hello Katherine,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following providers under the mentioned group:   Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name: Melissa Ramsden NPI# 1194376228  Provider Name: Kynda Orsak NPI# 1528553724  Please get back to me as soon as you\'re able to.  Thank you. \"', NULL, NULL, '2021-07-07 12:20:43', '2021-07-07 12:20:43'),
(11532, 1006, 19849, NULL, '2021-08-03 00:00:00.000', 'In Process', 'Received the following update from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Enrollment Status - BAQC - Tricare  \"Good Morning,  Please see updates below:  Provider Name: Melissa Ramsden – please provide a credentialing application with all documents. NPI# 1194376228  Provider Name: Kynda Orsak – provider is showing affiliated to the group. NPI# 1528553724  Respectfully, Katherine Moten TRICARE Community Liaison II Humana T 502-318-5250 F 210-239-0401 kmoten4@humana.com HumanaMilitary.com\"  Replied: \"Hello Katherine,  I appreciate the update, can you please let me know what the effective date is for Kynda Orsak and the group itself? Also, please send us the credentialing application so I can send it to you.   Thank you.\"', NULL, NULL, '2021-07-27 16:38:12', '2021-07-27 16:38:12'),
(11533, 1006, 19849, NULL, '2021-08-11 00:00:00.000', 'Approved', 'Received the following approval confirmation from KMoten4@humana.com:  Sub: Secured: RE: Secured: RE: Enrollment Status - BAQC - Tricare  \"Kynda Orsak was credentialed on 6/3/21 and shows affiliated with the group eff: 12/14/2018.  Respectfully, Katherine Moten TRICARE Community Liaison II Humana  T 502-318-5250  F 210-239-0401 kmoten4@humana.com HumanaMilitary.com\"', NULL, NULL, '2021-08-04 12:50:07', '2021-08-04 12:50:07'),
(11534, 3040, 19850, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:28:09', '2021-03-11 17:28:09'),
(11535, 3040, 19850, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:53:02', '2021-03-22 15:53:02'),
(11536, 3046, 19851, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:28:28', '2021-03-11 17:28:28'),
(11537, 9057, 19851, NULL, '2021-06-04 00:00:00.000', 'Initiated', 'We sent email to KMoten4@humana.com Sub: Certification and Enrollment Status - BAQC - Tricare  Hello Ketherine, Hope you are doing well, Kindly verify if the below mentioned providers are certified or not, if they are certified then we wish to enroll them under the following group.  Group Details Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name: Melissa Ramsden NPI# 1194376228  Also we want to know the credentialing status of the below mentioned providers under the above mentioned group.  Provider Details Provider Name: Cynthia Malowitz NPI# 1336173244  Provider Name: Kynda Orsak NPI# 1528553724  Provider Name: William Francis NPI# 1457994436  Waiting for your kind response  Thank you  ', NULL, NULL, '2021-05-28 13:44:58', '2021-05-28 13:44:58'),
(11538, 1006, 19851, NULL, '2021-06-23 00:00:00.000', 'Approved', 'We received the following reply from Katherine from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Certification and Enrollment Status - BAQC - Tricare  \"Provider Name: Melissa Ramsden – please provide a credentialing application with the following documents: CV, DEA, Malpractice Insurance, License.  Provider Name: Cynthia Malowitz -  cred eff: 11/25/2019  Provider Name: Kynda Orsak – submitted for credentialing, please allow 90 days.  Provider Name: William Francis – cred eff: 2/2/2021\"', NULL, NULL, '2021-06-16 14:23:50', '2021-06-16 14:23:50'),
(11539, 3046, 19852, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:28:37', '2021-03-11 17:28:37'),
(11540, 9057, 19852, NULL, '2021-06-04 00:00:00.000', 'Initiated', 'We sent email to KMoten4@humana.com Sub: Certification and Enrollment Status - BAQC - Tricare  Hello Ketherine, Hope you are doing well, Kindly verify if the below mentioned providers are certified or not, if they are certified then we wish to enroll them under the following group.  Group Details Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name: Melissa Ramsden NPI# 1194376228  Also we want to know the credentialing status of the below mentioned providers under the above mentioned group.  Provider Details Provider Name: Cynthia Malowitz NPI# 1336173244  Provider Name: Kynda Orsak NPI# 1528553724  Provider Name: William Francis NPI# 1457994436  Waiting for your kind response  Thank you  ', NULL, NULL, '2021-05-28 13:45:25', '2021-05-28 13:45:25'),
(11541, 1006, 19852, NULL, '2021-06-23 00:00:00.000', 'In Process', 'We received the following reply from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Certification and Enrollment Status - BAQC - Tricare  \"Provider Name: Melissa Ramsden – please provide a credentialing application with the following documents: CV, DEA, Malpractice Insurance, License.  Provider Name: Cynthia Malowitz -  cred eff: 11/25/2019  Provider Name: Kynda Orsak – submitted for credentialing, please allow 90 days.  Provider Name: William Francis – cred eff: 2/2/2021\"  The request for credentialing is in process. ', NULL, NULL, '2021-06-16 14:35:03', '2021-06-16 14:35:03'),
(11542, 1006, 19852, NULL, '2021-07-14 00:00:00.000', 'In Process', 'Sent f/u email @ Katherine Moten KMoten4@humana.com:  Sub: Enrollment Status - BAQC - Tricare  \"Hello Katherine,   I hope you\'re doing well, I wanted to get an update regarding the enrollment status for the following providers under the mentioned group:   Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name: Melissa Ramsden NPI# 1194376228  Provider Name: Kynda Orsak NPI# 1528553724  Please get back to me as soon as you\'re able to.  Thank you. \"', NULL, NULL, '2021-07-07 12:20:49', '2021-07-07 12:20:49'),
(11543, 1006, 19852, NULL, '2021-08-03 00:00:00.000', 'In Process', 'Received the following update from Katherine Moten KMoten4@humana.com:  Sub: Secured: RE: Enrollment Status - BAQC - Tricare  \"Good Morning,  Please see updates below:  Provider Name: Melissa Ramsden – please provide a credentialing application with all documents. NPI# 1194376228  Provider Name: Kynda Orsak – provider is showing affiliated to the group. NPI# 1528553724  Respectfully, Katherine Moten TRICARE Community Liaison II Humana T 502-318-5250 F 210-239-0401 kmoten4@humana.com HumanaMilitary.com\"  Replied: \"Hello Katherine,  I appreciate the update, can you please let me know what the effective date is for Kynda Orsak and the group itself? Also, please send us the credentialing application so I can send it to you.   Thank you.\"', NULL, NULL, '2021-07-27 16:38:23', '2021-07-27 16:38:23'),
(11544, 1006, 19852, NULL, '2021-08-11 00:00:00.000', 'Approved', 'Received the following approval confirmation from KMoten4@humana.com:  Sub: Secured: RE: Secured: RE: Enrollment Status - BAQC - Tricare  \"Kynda Orsak was credentialed on 6/3/21 and shows affiliated with the group eff: 12/14/2018.  Respectfully, Katherine Moten TRICARE Community Liaison II Humana  T 502-318-5250  F 210-239-0401 kmoten4@humana.com HumanaMilitary.com\"', NULL, NULL, '2021-08-04 12:50:13', '2021-08-04 12:50:13'),
(11545, 3040, 19853, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:28:49', '2021-03-11 17:28:49'),
(11546, 3040, 19853, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Railroad PTAN: P02029104 Effective Date: 11/01/2017', NULL, NULL, '2021-03-22 15:54:04', '2021-03-22 15:54:04'),
(11547, 3040, 19854, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:29:20', '2021-03-11 17:29:20'),
(11548, 3040, 19854, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Medicare Railroad initiated online.   Reference Number: 21081001378  Please see attachment ', NULL, NULL, '2021-03-22 16:06:25', '2021-03-22 16:06:25'),
(11549, 3040, 19854, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:33:29', '2021-04-12 16:33:29'),
(11550, 3046, 19855, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:29:38', '2021-03-11 17:29:38'),
(11551, 1006, 19855, NULL, '2021-05-11 00:00:00.000', 'Approved', 'The group is already enrolled with Triwest effective as of 8/22/2019.   Welcome letter is attached in group task for reference.  ', NULL, NULL, '2021-05-04 10:24:30', '2021-05-04 10:24:30'),
(11552, 3046, 19856, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:29:46', '2021-03-11 17:29:46'),
(11553, 1006, 19856, NULL, '2021-05-11 00:00:00.000', 'Approved', 'The group is already enrolled with Triwest effective as of 8/22/2019.   Welcome letter is attached in group task for reference.  ', NULL, NULL, '2021-05-04 10:25:18', '2021-05-04 10:25:18'),
(11554, 3046, 19857, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:29:53', '2021-03-11 17:29:53'),
(11555, 1006, 19857, NULL, '2021-05-11 00:00:00.000', 'Approved', 'The group is already enrolled with Triwest effective as of 8/22/2019.   Welcome letter is attached in group task for reference.  ', NULL, NULL, '2021-05-04 10:25:21', '2021-05-04 10:25:21'),
(11556, 3040, 19858, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:29:58', '2021-03-11 17:29:58'),
(11557, 3040, 19858, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Task approved e.d 04/24/2020 welcome letter Ptan attached ', NULL, NULL, '2021-03-22 16:11:55', '2021-03-22 16:11:55'),
(11558, 3040, 19859, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:30:26', '2021-03-11 17:30:26'),
(11559, 3040, 19859, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider is now showing linked with medicare railroad and effective date is 08/01/2020 ', NULL, NULL, '2021-03-22 16:14:50', '2021-03-22 16:14:50'),
(11560, 3040, 19860, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:30:52', '2021-03-11 17:30:52'),
(11561, 3040, 19860, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Request initiated online.   Please see attachment  Reference number: 21081001397', NULL, NULL, '2021-03-22 16:23:21', '2021-03-22 16:23:21'),
(11562, 3040, 19860, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:33:47', '2021-04-12 16:33:47'),
(11563, 3040, 19861, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:08', '2021-03-11 17:31:08'),
(11564, 3040, 19861, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Request initiated online.   Please see attachment   Reference Number: 21081001401', NULL, NULL, '2021-03-22 16:30:13', '2021-03-22 16:30:13'),
(11565, 3040, 19861, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:34:02', '2021-04-12 16:34:02'),
(11566, 3046, 19862, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:10', '2021-03-11 17:31:10'),
(11567, 9057, 19862, NULL, '2021-06-07 00:00:00.000', 'Initiated', 'We sent an email to: Sub: Enrollment Status - BAQC - UHC   Hello, We wanted to know if the following two providers are enrolled with UHC, and what their effective dates are? Please send us the copies of their welcome letters as well. Their information is as follows::  Group Details  Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name:  Orsak, Kynda NPI:: 1528553724 Provider Name: Malowitz, Cynthia NPI:   1336173244 Kindly response us as soon as possible.  Thank you  ', NULL, NULL, '2021-05-31 08:55:39', '2021-05-31 08:55:39'),
(11568, 1006, 19862, NULL, '2021-06-23 00:00:00.000', 'In Process', 'Sent f/u email @ NMRT networkhelp@uhc.com:  Sub:  Enrollment Status - BAQC - UHC  \"Hello,  I wanted to get an update regarding the enrollment status for the following group and providers:  Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name:  Orsak, Kynda NPI: 1528553724 Provider Name: Malowitz, Cynthia NPI: 1336173244  Provider Name: Ramsden, Melissa NPI: 1194376228  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-16 14:49:12', '2021-06-16 14:49:12');
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
(11569, 1006, 19862, NULL, '2021-06-25 00:00:00.000', 'Approved', 'We received the following approval confirmation email @ NMRT networkhelp@uhc.com:  Sub: Secure Message from japarker@uhc.com  \"Greetings,  Thank you for contacting the Network Management Resource Team. The provider has been linked to the TIN below. I’ve included the product roster showing the demographic information, lines of business, and effective dates.   Reviewing the provider MELISSA L RAMSDEN  record, it shows credentialing was completed/approved and the provider effective date is 07/27/2021.   Unfortunately, since the contracts were just loaded, it’s not available to send out as a report. Feel free to check back in 2 weeks. We’ll be happy to send it over or you can check under My Practice Profile by following the instructions in the attachment.  Did you know that you can get a product listing at any time from our website? Please see the attached handout for more information. If you have further questions regarding this system, please feel free to contact the LINK help desk (866-842-3278, option 1).    Please let us know if we can assist further.  Sincerely,  Janice P Associate Network Contractor Provider Operations Network Management Resource Team (NMRT)\"  Approval confirmation is attached for reference. ', NULL, NULL, '2021-06-18 14:43:57', '2021-06-18 14:43:57'),
(11570, 3046, 19863, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:36', '2021-03-11 17:31:36'),
(11571, 9057, 19863, NULL, '2021-06-07 00:00:00.000', 'Initiated', 'We sent an email to: Sub: Enrollment Status - BAQC - UHC   Hello, We wanted to know if the following two providers are enrolled with UHC, and what their effective dates are? Please send us the copies of their welcome letters as well. Their information is as follows::  Group Details  Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name:  Orsak, Kynda NPI:: 1528553724 Provider Name: Malowitz, Cynthia NPI:   1336173244 Kindly response us as soon as possible.  Thank you  ', NULL, NULL, '2021-05-31 08:56:45', '2021-05-31 08:56:45'),
(11572, 1006, 19863, NULL, '2021-06-23 00:00:00.000', 'In Process', 'Sent f/u email @ NMRT networkhelp@uhc.com:  Sub:  Enrollment Status - BAQC - UHC  \"Hello,  I wanted to get an update regarding the enrollment status for the following group and providers:  Group Name: Bay Area Quick Care PLLC TIN# 27-1702009 NPI# 1437481421 Group Address: 9929 South Padre Island Drive, Suite 109, Corpus Christi, TX 78418-5148  Provider Name:  Orsak, Kynda NPI: 1528553724 Provider Name: Malowitz, Cynthia NPI: 1336173244  Provider Name: Ramsden, Melissa NPI: 1194376228  Please get back to me as soon as possible.  Thank you!\"', NULL, NULL, '2021-06-16 14:49:21', '2021-06-16 14:49:21'),
(11573, 1006, 19863, NULL, '2021-06-25 00:00:00.000', 'Approved', 'We received the following approval confirmation email @ NMRT networkhelp@uhc.com:  Sub: Secure Message from japarker@uhc.com  \"Greetings,  Thank you for contacting the Network Management Resource Team. The provider has been linked to the TIN below. I’ve included the product roster showing the demographic information, lines of business, and effective dates.   Reviewing the provider MELISSA L RAMSDEN  record, it shows credentialing was completed/approved and the provider effective date is 07/27/2021.   Unfortunately, since the contracts were just loaded, it’s not available to send out as a report. Feel free to check back in 2 weeks. We’ll be happy to send it over or you can check under My Practice Profile by following the instructions in the attachment.  Did you know that you can get a product listing at any time from our website? Please see the attached handout for more information. If you have further questions regarding this system, please feel free to contact the LINK help desk (866-842-3278, option 1).    Please let us know if we can assist further.  Sincerely,  Janice P Associate Network Contractor Provider Operations Network Management Resource Team (NMRT)\"  Approval confirmation is attached for reference. ', NULL, NULL, '2021-06-18 14:43:41', '2021-06-18 14:43:41'),
(11574, 3040, 19864, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:45', '2021-03-11 17:31:45'),
(11575, 3040, 19864, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Group enrolled in Medicare Railroad.', NULL, NULL, '2021-03-22 15:45:33', '2021-03-22 15:45:33'),
(11576, 1006, 19865, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:47', '2021-03-11 17:31:47'),
(11577, 1019, 19865, NULL, '2021-03-26 00:00:00.000', 'Initiated', NULL, NULL, NULL, '2021-03-19 16:17:10', '2021-03-19 16:17:10'),
(11578, 1019, 19865, NULL, '2021-03-26 00:00:00.000', 'New/Not Initiated', 'Dear Alex Garrett,  PLEASE SAVE THIS EMAIL FOR FUTURE REFERENCE.  Thank you for submitting your application. You may review your application or check on your application status at any time by clicking the link below.  Upon receipt, Beacon will review your application materials to ensure that you satisfy all provider selection criteria. In the event that a discrepancy in information is discovered through the Primary Source Verification(“PSV”) process, Beacon will contact you and request that you clarify the discrepancy in writing within 10 calendar days of notification. Beacon will communicate to you any adverse information that may be reported by a third party through the PSV process.  https://join.beaconhealthoptions.com/validate/BDE8937038E40EAAE053A17D86624349    Please be aware that we may reach out to you via phone or email for any additional or missing information. Any delay in response will impact the overall processing time of the application.  Thank you,  Beacon Health Options Provider Enrollment Team', NULL, NULL, '2021-03-19 16:22:30', '2021-03-19 16:22:30'),
(11579, 1019, 19865, NULL, '2021-04-14 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-04-07 09:59:15', '2021-04-07 09:59:15'),
(11580, 1019, 19865, NULL, '2021-04-21 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, '2021-04-14 07:07:12', '2021-04-14 07:07:12'),
(11581, 1019, 19865, NULL, '2021-04-21 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, '2021-04-14 08:10:31', '2021-04-14 08:10:31'),
(11582, 1019, 19865, NULL, '2021-04-29 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, '2021-04-22 15:53:55', '2021-04-22 15:53:55'),
(11583, 1019, 19865, NULL, '2021-05-10 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, '2021-05-03 12:46:11', '2021-05-03 12:46:11'),
(11584, 1019, 19865, 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 08:36:44', '2021-05-20 08:36:44'),
(11585, 1019, 19865, 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 11:18:28', '2021-06-05 11:18:28'),
(11586, 1019, 19865, 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 08:02:55', '2021-06-24 08:02:55'),
(11587, 1019, 19865, NULL, '2021-08-10 00:00:00.000', 'Approved', 'Received the welcome letter from dataentry@beaconhealthoptions.com, Eff 07/27/2021.  See attached for reference.', NULL, NULL, '2021-08-03 14:11:38', '2021-08-03 14:11:38'),
(11588, 1006, 19866, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:31:49', '2021-03-11 17:31:49'),
(11589, 1006, 19866, NULL, '2021-04-16 00:00:00.000', 'On Hold', 'The enrollment request is pending on the provider\'s RI PMHNP license to be issued. ', NULL, NULL, '2021-04-09 14:57:41', '2021-04-09 14:57:41'),
(11590, 1019, 19866, NULL, '2021-11-01 00:00:00.000', 'Not Eligible', 'Provider will no longer be working with SNBCare.', NULL, NULL, '2021-10-25 10:42:21', '2021-10-25 10:42:21'),
(11591, 3040, 19867, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:32:13', '2021-03-11 17:32:13'),
(11592, 3040, 19867, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:50:35', '2021-03-22 15:50:35'),
(11593, 3040, 19868, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:32:36', '2021-03-11 17:32:36'),
(11594, 3040, 19868, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:53:06', '2021-03-22 15:53:06'),
(11595, 1006, 19869, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:32:51', '2021-03-11 17:32:51'),
(11596, 1006, 19869, NULL, '2021-03-26 00:00:00.000', 'Approved', 'The provider is approved, approval confirmation attached for reference.  ', NULL, NULL, '2021-03-19 11:52:23', '2021-03-19 11:52:23'),
(11597, 3040, 19870, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:33:27', '2021-03-11 17:33:27'),
(11598, 3040, 19870, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Medicare Railroad initiated online.   Reference Number: 21081001378  Please see attachment ', NULL, NULL, '2021-03-22 16:06:31', '2021-03-22 16:06:31'),
(11599, 3040, 19870, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:33:35', '2021-04-12 16:33:35'),
(11600, 3040, 19871, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:34:21', '2021-03-11 17:34:21'),
(11601, 1006, 19871, NULL, '2021-05-07 00:00:00.000', 'Initiated', 'Submitted an online enrollment form for group enrollment:  \"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.\"  Form attached in main group task.', NULL, NULL, '2021-04-30 16:12:28', '2021-04-30 16:12:28'),
(11602, 3040, 19871, NULL, '2021-06-08 00:00:00.000', 'In Process', 'I had a word with (Liya) Wellcare representative and she sent the request to provider rep. department and they will contact us regarding the enrollment.   Ref: 507756828 ', NULL, NULL, '2021-06-01 12:53:31', '2021-06-01 12:53:31'),
(11603, 3040, 19871, NULL, '2021-06-25 00:00:00.000', 'On Hold', 'We sent the ancillary contract request for group. For more details please see group task. ', NULL, NULL, '2021-06-18 16:23:17', '2021-06-18 16:23:17'),
(11604, 3040, 19871, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email sent to: ProspectiveProviderTX@wellcare.com  Subject; Enrollment Status || Valley Med Urgent Care PLLC || Group || Wellcare ||  Hello,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group in our group Valley Med Urgent Care PLLC under the below locations. As we submitted an online form.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-07-20 11:18:20', '2021-07-20 11:18:20'),
(11605, 3040, 19871, NULL, '2021-08-03 00:00:00.000', 'Approved', 'Email rcvd from: ProspectiveProviderTX@wellcare.com  Subject:  Enrollment Status || Valley Med Urgent Care PLLC || Group || Wellcare ||  Good Afternoon,  We have completed the request for the following providers:  Provider 1: Provider Name: Escobar, Angiollet Solis Provider NPI# 1962917997  Provider 2: Provider Name: Rodriguez, Cynthia Provider NPI# 1124282553  Provider 3: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 4: Provider Name: Potter, Deborah Provider NPI# 1861914053  Provider 5: Provider Name: Wright, Larry Donald Provider NPI# 1033769765  Provider 6: Provider Name: Wert, Jeniece K Provider NPI# 1659919702  Provider 7: Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please let us know if you have any questions.  Thanks   Network Management – Texas | www.wellcare.com | www.superiorhealthplan.com', NULL, NULL, '2021-07-27 14:13:18', '2021-07-27 14:13:18'),
(11606, 3040, 19872, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:34:36', '2021-03-11 17:34:36'),
(11607, 3040, 19872, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Request initiated online.   Please see attachment   Reference Number: 21081001401', NULL, NULL, '2021-03-22 16:30:03', '2021-03-22 16:30:03'),
(11608, 3040, 19872, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:34:07', '2021-04-12 16:34:07'),
(11609, 1006, 19873, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:34:41', '2021-03-11 17:34:41'),
(11610, 1019, 19873, NULL, '2021-04-12 00:00:00.000', 'Approved', 'Welcome Letter Attached.', NULL, NULL, '2021-04-05 09:57:09', '2021-04-05 09:57:09'),
(11611, 3040, 19874, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:35:08', '2021-03-11 17:35:08'),
(11612, 3040, 19874, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Group enrolled in Medicare Railroad.', NULL, NULL, '2021-03-22 15:45:43', '2021-03-22 15:45:43'),
(11613, 3040, 19875, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:35:27', '2021-03-11 17:35:27'),
(11614, 3040, 19875, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:50:40', '2021-03-22 15:50:40'),
(11615, 3040, 19876, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:35:46', '2021-03-11 17:35:46'),
(11616, 3040, 19876, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Medicare Railroad. ', NULL, NULL, '2021-03-22 15:53:11', '2021-03-22 15:53:11'),
(11617, 1006, 19877, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:35:55', '2021-03-11 17:35:55'),
(11618, 1019, 19877, NULL, '2021-04-14 00:00:00.000', 'Initiated', 'Enrollment Application faxed to Network Operations at (866) 612-7790', NULL, NULL, '2021-03-31 14:53:46', '2021-03-31 14:53:46'),
(11619, 1019, 19877, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com Sub: Enrollment Status || Kerry Smith|| SNBCARE || Beacon  HelloCan you please let me know about the enrollment status for the following provider under our group. Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI:  Kerry SmithNPI: 1275083230Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Regards, Alex ', NULL, NULL, '2021-04-08 10:41:34', '2021-04-08 10:41:34'),
(11620, 1019, 19877, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Received the following email from provider.relations@beaconhealthoptions.com Good Afternoon,     I can confirm the application was received via fax on 3.31.21 and is currently being processed. Once a completed application is received it takes an additional 45 days for credentialing to be completed. It is with the credentialing department at this time. Please allow more time. Once completed a welcome letter with be sent out.     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', NULL, NULL, '2021-04-08 13:16:35', '2021-04-08 13:16:35'),
(11621, 1019, 19877, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to provider.relations@beaconhealthoptions.com Hello Sarah, Can you please put a request to Expediate this application becasue we have waited for a long time now, we were submitting enrollment application thru your portal but last week we got to know that we were supposed to fill CAQH forms, so we did that now, due to this issue we already are in a big loss now as we have 300+ active patients of BEACON in our organization.  Regards, Alex', NULL, NULL, '2021-04-08 13:51:06', '2021-04-08 13:51:06'),
(11622, 3040, 19877, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Still in process', NULL, NULL, '2021-04-19 08:51:55', '2021-04-19 08:51:55'),
(11623, 1019, 19877, NULL, '2021-05-10 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, '2021-05-03 12:35:36', '2021-05-03 12:35:36'),
(11624, 1019, 19877, NULL, '2021-05-10 00:00:00.000', 'Approved', 'Received the Welcome Letter for Beacon Health Options, Effective date 04/30/2021.', NULL, NULL, '2021-05-03 15:36:10', '2021-05-03 15:36:10'),
(11625, 1006, 19878, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:35:56', '2021-03-11 17:35:56'),
(11626, 1019, 19878, NULL, '2021-04-13 00:00:00.000', 'Initiated', 'CAQH Application faxed to Network Operations at (866) 612-7790. ', NULL, NULL, '2021-04-06 08:29:26', '2021-04-06 08:29:26'),
(11627, 1019, 19878, NULL, '2021-04-21 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, '2021-04-14 07:07:01', '2021-04-14 07:07:01'),
(11628, 1019, 19878, NULL, '2021-04-21 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, '2021-04-14 08:09:56', '2021-04-14 08:09:56'),
(11629, 1019, 19878, NULL, '2021-05-10 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, '2021-05-03 11:44:29', '2021-05-03 11:44:29'),
(11630, 1019, 19878, NULL, '2021-05-17 00:00:00.000', 'Approved', 'Welcome Letter attached, effective date 05/07/2021.', NULL, NULL, '2021-05-10 10:08:20', '2021-05-10 10:08:20'),
(11631, 3040, 19879, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:36:06', '2021-03-11 17:36:06'),
(11632, 3040, 19879, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Railroad PTAN: P02029104 Effective Date: 11/01/2017', NULL, NULL, '2021-03-22 15:54:09', '2021-03-22 15:54:09'),
(11633, 3040, 19880, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:36:27', '2021-03-11 17:36:27'),
(11634, 3040, 19880, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Medicare Railroad initiated online.   Reference Number: 21081001378  Please see attachment ', NULL, NULL, '2021-03-22 16:06:36', '2021-03-22 16:06:36'),
(11635, 3040, 19880, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:33:41', '2021-04-12 16:33:41'),
(11636, 3040, 19881, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:37:00', '2021-03-11 17:37:00'),
(11637, 3040, 19881, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Task approved e.d 04/24/2020 welcome letter Ptan attached ', NULL, NULL, '2021-03-22 16:12:00', '2021-03-22 16:12:00'),
(11638, 3040, 19882, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:37:27', '2021-03-11 17:37:27'),
(11639, 1006, 19882, NULL, '2021-05-07 00:00:00.000', 'Initiated', 'Submitted an online enrollment form for group enrollment:  \"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.\"  Form attached in main group task.', NULL, NULL, '2021-04-30 16:13:31', '2021-04-30 16:13:31'),
(11640, 3040, 19882, NULL, '2021-06-08 00:00:00.000', 'In Process', 'I had a word with (Liya) Wellcare representative and she sent the request to provider rep. department and they will contact us regarding the enrollment.   Ref: 507756828', NULL, NULL, '2021-06-01 12:54:20', '2021-06-01 12:54:20'),
(11641, 3040, 19882, NULL, '2021-06-25 00:00:00.000', 'On Hold', 'We sent the ancillary contract request for group. For more details please see group task. ', NULL, NULL, '2021-06-18 16:23:07', '2021-06-18 16:23:07'),
(11642, 3040, 19882, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email sent to: ProspectiveProviderTX@wellcare.com  Subject; Enrollment Status || Valley Med Urgent Care PLLC || Group || Wellcare ||  Hello,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned group in our group Valley Med Urgent Care PLLC under the below locations. As we submitted an online form.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice Tax-ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166      Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-07-20 11:18:19', '2021-07-20 11:18:19'),
(11643, 3040, 19882, NULL, '2021-08-03 00:00:00.000', 'Approved', 'Email rcvd from: ProspectiveProviderTX@wellcare.com  Subject:  Enrollment Status || Valley Med Urgent Care PLLC || Group || Wellcare ||  Good Afternoon,  We have completed the request for the following providers:  Provider 1: Provider Name: Escobar, Angiollet Solis Provider NPI# 1962917997  Provider 2: Provider Name: Rodriguez, Cynthia Provider NPI# 1124282553  Provider 3: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 4: Provider Name: Potter, Deborah Provider NPI# 1861914053  Provider 5: Provider Name: Wright, Larry Donald Provider NPI# 1033769765  Provider 6: Provider Name: Wert, Jeniece K Provider NPI# 1659919702  Provider 7: Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please let us know if you have any questions.  Thanks   Network Management – Texas | www.wellcare.com | www.superiorhealthplan.com', NULL, NULL, '2021-07-27 14:13:19', '2021-07-27 14:13:19'),
(11644, 1006, 19883, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:37:53', '2021-03-11 17:37:53'),
(11645, 3040, 19883, NULL, '2021-04-26 00:00:00.000', 'In Process', 'I had a word with (Hailey) Cigna representative and she said we will rcvd the copy of the contract in 3 to 5 business days.   Ref: Hailey F 04/19/2021', NULL, NULL, '2021-04-19 15:43:44', '2021-04-19 15:43:44'),
(11646, 1019, 19883, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com SUB: Enrollment Status || Group & Providers || SNBCARE || CIGNA  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 Providers:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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. Secondary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Tertiary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Tawakol, Katie NPI: 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.      Hefti, Prisca NPI: 1508133182 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.  Regards,', NULL, NULL, '2021-05-20 09:28:20', '2021-05-20 09:28:20'),
(11647, 1019, 19883, NULL, '2021-05-28 00:00:00.000', 'Approved', 'Received the Updated contract with all servicing addresses linked under group, effective 05/20/2021 attached is the Contract Amendment', NULL, NULL, '2021-05-21 08:18:45', '2021-05-21 08:18:45'),
(11648, 3040, 19884, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:38:07', '2021-03-11 17:38:07'),
(11649, 3040, 19884, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Request initiated online.   Please see attachment  Reference number: 21081001397', NULL, NULL, '2021-03-22 16:23:22', '2021-03-22 16:23:22'),
(11650, 3040, 19884, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:33:51', '2021-04-12 16:33:51'),
(11651, 3040, 19885, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:38:28', '2021-03-11 17:38:28'),
(11652, 3040, 19885, NULL, '2021-03-29 00:00:00.000', 'In Process', 'Request initiated online.   Please see attachment   Reference Number: 21081001401', NULL, NULL, '2021-03-22 16:30:10', '2021-03-22 16:30:10'),
(11653, 3040, 19885, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider enrolled with Medicare Railroad.   Please see attachment.', NULL, NULL, '2021-04-12 16:34:11', '2021-04-12 16:34:11'),
(11654, 1006, 19886, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:38:48', '2021-03-11 17:38:48'),
(11655, 3040, 19886, NULL, '2021-04-26 00:00:00.000', 'Approved', 'Provider participating with Cigna. Effective date: 12/07/2017  Ref: KIM K 04/19/2021', NULL, NULL, '2021-04-19 15:58:59', '2021-04-19 15:58:59'),
(11656, 3046, 19887, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:39:22', '2021-03-11 17:39:22'),
(11657, 3040, 19887, NULL, '2021-04-12 00:00:00.000', 'Not Eligible', 'We only have one provider only under the practice so that\'s why we can\'t add the practice on provider directory.   Thanks ', NULL, NULL, '2021-04-05 10:37:47', '2021-04-05 10:37:47'),
(11658, 1006, 19887, NULL, '2021-04-15 00:00:00.000', 'Not Eligible', 'A group contract requires at least 2 providers working in the group. ', NULL, NULL, '2021-04-08 16:16:27', '2021-04-08 16:16:27');
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
(11659, 11056, 19887, NULL, '2021-07-19 00:00:00.000', 'Initiated', 'Email sent to : Machado-petrys@aetna.com  Sub : Enrollment Request - BHUCC - Aetna  Greetings,  Hope all is well. I wanted to enroll the Practice Best Health Urgent Care & Clinic in Aetna. Kindly guide me the procedure for group contract and now it have 2 providers mentioned below :  Practice Details: Practice Name : Best Health Urgent Care & Clinic Practice Tax ID # : 84-4737737 Practice NPI # : 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242  Provider Details: Provider 1: Provider Name : Tann, Shametria Provider NPI # : 1124615612  Provider 2: Provider Name : Cyriaque, Stephane Provider NPI # : 1780192633  If you need any details please let me know. Waiting for your response.  Thank you! Have a Great Day!', NULL, NULL, '2021-07-12 14:04:15', '2021-07-12 14:04:15'),
(11660, 11056, 19887, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email sent to : Machado-petrys@aetna.com   & PDSDallas@aetna.com  Sub : Enrollment Request - BHUCC - Aetna  Greetings,  Hope all is well. I wanted to enroll the Practice Best Health Urgent Care & Clinic in Aetna. Kindly guide me the procedure for group contract and now it have 2 providers mentioned below :  Practice Details: Practice Name : Best Health Urgent Care & Clinic Practice Tax ID # : 84-4737737 Practice NPI # : 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242  Provider Details: Provider 1: Provider Name : Tann, Shametria Provider NPI # : 1124615612  Provider 2: Provider Name : Cyriaque, Stephane Provider NPI # : 1780192633  If you need any details please let me know. Waiting for your response.  Thank you! Have a Great Day!', NULL, NULL, '2021-07-19 15:05:18', '2021-07-19 15:05:18'),
(11661, 11056, 19887, NULL, '2021-08-03 00:00:00.000', 'In Process', 'I have called at AETNA. They said that both of the providers are enrolled with AETNA  Shametria Tann eff date is : 08/01/2021 Stephane eff date is : 07/15/2020 And are loaded under Tax ID and are In-Network.  For the group we have fax the LOI and W-9 at 859-4558650.', NULL, NULL, '2021-07-26 15:53:31', '2021-07-26 15:53:31'),
(11662, 11056, 19887, NULL, '2021-08-03 00:00:00.000', 'In Process', 'Email received from : RequardtD@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  Hello, the Provider Data Services Department does not send welcome letters.  Please remove PDS Dallas from all future conversation emails.  PDS received the original request, as well as, two more emails  Sylvia, can you help with this?  I will send you information on separate copy.   Denise Requardt | Senior Consultant, Provider Data Services / Shared Services Dept p 469-329-2050 Dallas, Tx   Our Common Purpose:  Advocate for our members’ best health by helping them get the most from their benefits, building trust and always providing a clear path to care', NULL, NULL, '2021-07-27 08:32:07', '2021-07-27 08:32:07'),
(11663, 11056, 19887, NULL, '2021-08-03 00:00:00.000', 'In Process', 'Email received from : RequardtD@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  Hello, the Provider Data Services Department does not send welcome letters.  Please remove PDS Dallas from all future conversation emails.  PDS received the original request, as well as, two more emails  Sylvia, can you help with this?  I will send you information on separate copy.   Denise Requardt | Senior Consultant, Provider Data Services / Shared Services Dept p 469-329-2050 Dallas, Tx   Our Common Purpose:  Advocate for our members’ best health by helping them get the most from their benefits, building trust and always providing a clear path to care', NULL, NULL, '2021-07-27 08:32:07', '2021-07-27 08:32:07'),
(11664, 11056, 19887, NULL, '2021-08-11 00:00:00.000', 'In Process', 'Email received from :   Machado-PetryS@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  We do not credential the group, if you are seeking a group agreement we will have to review network necessity, please also note that we do not offer mid-level groups as it appears you only have 2 mid-levels for this request, thank you.', NULL, NULL, '2021-08-04 08:59:34', '2021-08-04 08:59:34'),
(11665, 11056, 19887, NULL, '2021-08-18 00:00:00.000', 'In Process', 'Email sent to : Machado-PetryS@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  Good Afternoon Sylvia D!  Hope you are doing well. How many more providers do you require for the group enrollment? Kindly review your network necessity and assist me related to the group agreement soon.   Waiting for your response.   Thank you! Have a wonderful week ahead!', NULL, NULL, '2021-08-10 15:01:48', '2021-08-10 15:01:48'),
(11666, 11056, 19887, NULL, '2021-08-24 00:00:00.000', 'In Process', 'Email received from : Machado-PetryS@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna   We need a physician on staff, are you billing as an Urgent care?', NULL, NULL, '2021-08-16 16:21:57', '2021-08-16 16:21:57'),
(11667, 11056, 19887, NULL, '2021-08-30 00:00:00.000', 'In Process', 'Email sent to : Machado-PetryS@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  Hey Sylvia D!  Hope you are doing well. Yeah, We are billing as an Urgent Care. The supervising physician for the staff is mentioned below :   Physician: Physician Name : Segun Adeoye Physician NPI# : 1629418025  If you need any information or documents feel free to reach out to me soon. Waiting for your response.  Thank you! Have a great day! ', NULL, NULL, '2021-08-23 14:05:53', '2021-08-23 14:05:53'),
(11668, 11056, 19887, NULL, '2021-09-08 00:00:00.000', 'Not Eligible', 'Email received from : Machado-PetryS@aetna.com  Sub : REVIEW REQUESTED: Enrollment Request - BHUCC - Aetna  Ahmed,  I apologize if the information is not understood.  You can not bill PCP services as an Urgent Care We can not load a mid-level as a PCP without an actual physician on staff. We can not offer a group agreement for mid-level providers only less than 5 unless we have a network need and at the time you have only provided 2 providers. We can not issue a group and Urgent care agreement under the same TID as this will cause claims issues.   Another Email regarding it:  Ahmed, you have to meet criteria, in the meantime while the Rep reaches out to you, I will go ahead and take a step further, see attached criteria for Urgent care contracts, if you meet it, most likely you will get a contract, if you don’t meet criteria, then we will not be able to contract you as an Urgent care.  Another email :   We do not credential the group, if you are seeking a group agreement we will have to review network necessity, please also note that we do not offer mid-level groups as it appears you only have 2 mid-levels for this request, thank you.  Ahmed, please note, if you are billing as an Urgent care, this is facility billing.  You will not be offered a group agreement, it will cause claims issues, so you can only bill as one or the other.  Under this tin, you will not be offered a group agreement, and if your billing as an urgent care the tin will pay at the facility rate.  The request was forwarded to that dept, they will reach out.  Thank you.   Please see the attachment. ', NULL, NULL, '2021-08-31 16:10:38', '2021-08-31 16:10:38'),
(11669, 3040, 19888, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:39:36', '2021-03-11 17:39:36'),
(11670, 3040, 19888, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Address is updated for the group in the provider directory. Proof is attached. ', NULL, NULL, '2021-03-22 16:38:56', '2021-03-22 16:38:56'),
(11671, 1006, 19889, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:03', '2021-03-11 17:40:03'),
(11672, 1006, 19889, NULL, '2021-04-16 00:00:00.000', 'On Hold', 'The enrollment request is pending on the provider\'s RI PMHNP license to be issued. ', NULL, NULL, '2021-04-09 14:57:45', '2021-04-09 14:57:45'),
(11673, 1019, 19889, NULL, '2021-11-01 00:00:00.000', 'Not Eligible', 'Provider will no longer be working with SNBCare.', NULL, NULL, '2021-10-25 10:42:52', '2021-10-25 10:42:52'),
(11674, 1006, 19890, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:05', '2021-03-11 17:40:05'),
(11675, 1019, 19890, NULL, '2021-04-06 00:00:00.000', 'Initiated', 'Your application has been received, your CBP ID is CBP-0000205606. A recruiter will process your application and provide onboarding instructions within 20 business days. The process to join the Cigna Network can take up to 90 days. To check the status of your application, please email behavioralcontracting@cigna.com. ', NULL, NULL, '2021-03-23 15:19:56', '2021-03-23 15:19:56'),
(11676, 1019, 19890, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com Sub: Enrollment Status || Providers || SNBCARE || CIGNA  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:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Regards, Alex', NULL, NULL, '2021-04-08 11:17:02', '2021-04-08 11:17:02'),
(11677, 1019, 19890, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Received the following email from: BehavioralContracting@cigna.com SUB: Enrollment Status || Providers || SNBCARE || CIGNA   Hi, Please see below for the provider status update.  Justin Souliere- Received application will process shortly. Kerry Smith- Received application will process shortly. Rodesia Edmundson- Received application will process shortly. Carlee Rozell- Credentialing status  Kiara   Cigna Behavioral NCU   E: BehavioralContracting@cigna.com', NULL, NULL, '2021-04-14 07:22:49', '2021-04-14 07:22:49'),
(11678, 3040, 19890, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Email sent to: BehavioralContracting@cigna.com  Subject: Enrollment Status || Spectrum Neuro Behavioral Care || Providers || Cigna ||  Greetings,   Hope you are doing well. Please advise me the enrollment status for the below mentioned providers for our group Spectrum Neuro Behavioral Care under below locations.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI: Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Thanks  ', NULL, NULL, '2021-04-19 10:06:58', '2021-04-19 10:06:58'),
(11679, 1019, 19890, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Received the following Email from Wendy.Pridgen@cigna.com  Justin Souliere Thank you for requesting to join Cigna Behavioral Health. As your recruiter, I will personally assist you through our new onboarding process and while you are out of network. *Incomplete steps below will cause delays.  You will receive an email every time we verify if these steps have been complete so that we can forward the request to the credentialing team. Therefore, there is no need to email me back. All status inquiries will go to the Provider Line.   Initial Step - Online Request to Join the Network We have received the provider’s online request to join the Cigna Behavioral Health Network.  Step 1 – Onboard Packet  Your Cigna Onboarding Packet was just sent via DocuSign to your credentialing email. If you have not received it, please allow 5-10 minutes for the packet to arrive and/or check your junk/spam folder.  Please follow the instructions inside of DocuSign to complete your packet. * Onboard Packet is only accepted via DocuSign. * Provider must sign their own packet containing their own fee schedule. * Please make sure that the provider self-introduction contains at least one short sentence. Questionnaire is a useful resource, but it is optional and you can’t clear answers.  Photo is optional.  Step 2 – CAQH  Once you have completed Onboarding Packet via DocuSign, please review your CAQH to ensure that it is current and all questions accurate (See below).  û  CAQH documents are not accepted via email. The request information must be accessible to obtain via CAQH.  Even if no changes are required, you still must re-attest all forms to ensure it will not expire during this process. Insurance and License(s) expiration date must valid for 60+ days in order to proceed.   In addition, you will want to ensure that the “Credentialing Information” is entered and correct.  Once your signed packet has been received, I will begin verifying your credentials that been entered and current through the following steps:  ·         Verifying CAQH ·   Complete CAQH application with a current Attestation, even if no changes are required. ·         Attestation expires every 120 days. ·         State Attestations/Authorizations may apply- please see required forms for your state on CAQH ·         Credentialing Information ·         Current Liability Insurance (valid for 60+ days from today) ·         Upload your proof of liability insurance (COI) ·         Current Professional License and National Certificate (valid for 60+ days) in the same state as your service location(s). ·         Upload your license and certificates  Education History ·         List ALL COLLEGE DEGREES and CERTIFICATES  obtained ·         Must include school, start and end dates, degree level, major or area of training ·         Undergrad will be accepted in place of employment if you graduated less than 5 years ago ·         Training (enter all information) ·         5 Years of Consecutive Work History without gaps over 5 months (min red: starting from 2/2016) ·         Gaps over 5 months will require a “Work History Gap Explanation” Ø  Gaps includes anything outside of your field of practice (i.e. parenting, non-career related, academics) ·         Current Resumes/CVs containing month/year formatting be accepted  as long as it is dated within the last 2 years ·         Upload any supporting documents (ex: insurance, license, current resume containing month/year , ANCC, DEA)   Step 3 – NPI ·         Verifying your National Provider Identifier (NPI)           Must be current ·         NPI  1: Provider NPI  ·         NPI  2: Group NPI (must be the corresponding entity for the Pay To and Tax ID) Ø  NPI 2 (Group) is not associated with the Tax Payer, please call me to correct. NPI 2 and Tax Payer should be associated with the same entity. Ø  Please call ONLY IF you entered the wrong information on the online information form.  I will send out emailed communication to your credentialing contact for any required updates. Once complete, your Onboarding Packet will be sent for processing within the Credentialing department.  Status Updates Provider Service @ 800.926.2273   If you have any questions, please let me know. I look forward to working with you.        Thank you in advance,     Wendy Pridgen  Cigna Behavioral Health National Contracting Unit | Provider Relations Analyst  T: 903-337-2409  |  E: Wendy.Pridgen@Cigna.com', NULL, NULL, '2021-05-05 14:41:26', '2021-05-05 14:41:26'),
(11680, 1019, 19890, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Received the following email from wendy.pridgen@cigna.com  Thank you for your interest in becoming a part of our behavioral health care professional network. We are pleased to extend a Cigna Behavioral Onboarding Packet to you. Please review and complete the attached documents within the next 10 business days and submit them electronically via DocuSign with your signature. Once received, we will review your credentialing information via online source verification systems. Please note: You will not be considered in network until your credentials are verified and you receive notification from Cigna that your Onboarding is complete. If you have any questions, please contact me directly using the contact information located at the bottom of this email. Thank you, Wendy Pridgen', NULL, NULL, '2021-05-05 14:42:17', '2021-05-05 14:42:17'),
(11681, 1019, 19890, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Completed the Onboarding contract form  online attached is the copy for ref.', NULL, NULL, '2021-05-05 14:43:10', '2021-05-05 14:43:10'),
(11682, 1019, 19890, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com SUB: Enrollment Status || Group & Providers || SNBCARE || CIGNA  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 Providers:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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. Secondary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Tertiary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Tawakol, Katie NPI: 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.      Hefti, Prisca NPI: 1508133182 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.  Regards,', NULL, NULL, '2021-05-20 09:25:32', '2021-05-20 09:25:32'),
(11683, 1019, 19890, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to panplais.lor@cigna.com ​ SUB: Group Roster || Group & Providers || SNBCARE || CIGNA   Hello Pa,  Can you please send me our group provider roster ASAP. I have mentioned the group information below.  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.    Regards, Alex', NULL, NULL, '2021-06-03 15:36:09', '2021-06-03 15:36:09'),
(11684, 1019, 19890, NULL, '2021-06-29 00:00:00.000', 'Not Eligible', 'Received the following email from Wendy.Pridgen@cigna.com  SUB: Cigna Behavioral Health Process Stop  Justin Souliere  Thank you for applying to join Cigna Behavioral. Unfortunately, at this time your process has been stopped during the Provider Verification stage of credentialing due to the following: License Type is not accept in RI. Must be LICSW  A letter containing the details of the process stop was sent to cred contact fax number/primary mailing address. If you have any further questions, please include the confidential email/mailing address where you wish to be contacted.   Kind Regards,  PROVIDER OPERATIONS  Wendy Pridgen  Cigna Behavioral Health NCU | Provider Relations Associate Analyst  T: 903-337-2409 | F: 860-687.7281 | E: Wendy.Pridgen@Cigna.com', NULL, NULL, '2021-06-15 10:50:36', '2021-06-15 10:50:36'),
(11685, 3040, 19891, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:07', '2021-03-11 17:40:07'),
(11686, 3040, 19891, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Ambetter.   Please see attachment ', NULL, NULL, '2021-03-22 16:59:06', '2021-03-22 16:59:06'),
(11687, 3046, 19892, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:22', '2021-03-11 17:40:22'),
(11688, 1006, 19892, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:11:31', '2021-04-16 10:11:31'),
(11689, 3040, 19893, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:27', '2021-03-11 17:40:27'),
(11690, 3040, 19893, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to add the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248   Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  If you need any additional information pleae feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-03-23 08:35:22', '2021-03-23 08:35:22'),
(11691, 3040, 19893, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-05-03 13:05:10', '2021-05-03 13:05:10'),
(11692, 3040, 19893, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject:Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Hello,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under the locations below. As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-06-01 14:45:28', '2021-06-01 14:45:28'),
(11693, 3040, 19893, NULL, '2021-06-28 00:00:00.000', 'Approved', 'Provider is added under the location. Please see attachment. ', NULL, NULL, '2021-06-21 14:46:14', '2021-06-21 14:46:14'),
(11694, 1006, 19894, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:45', '2021-03-11 17:40:45'),
(11695, 3040, 19894, NULL, '2021-04-26 00:00:00.000', 'In Process', 'I had a word with (Hailey) Cigna representative and she said we will rcvd the copy of the contract in 3 to 5 business days.   Ref: Hailey F 04/19/2021', NULL, NULL, '2021-04-19 15:43:48', '2021-04-19 15:43:48'),
(11696, 1019, 19894, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com SUB: Enrollment Status || Group & Providers || SNBCARE || CIGNA  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 Providers:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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. Secondary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Tertiary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Tawakol, Katie NPI: 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.      Hefti, Prisca NPI: 1508133182 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.  Regards,', NULL, NULL, '2021-05-20 09:28:33', '2021-05-20 09:28:33'),
(11697, 1019, 19894, NULL, '2021-05-28 00:00:00.000', 'Approved', 'Received the Updated contract with all servicing addresses linked under group, effective 05/20/2021 attached is the Contract Amendment', NULL, NULL, '2021-05-21 08:19:59', '2021-05-21 08:19:59'),
(11698, 3040, 19895, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:40:54', '2021-03-11 17:40:54'),
(11699, 3040, 19895, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:17', '2021-03-23 08:33:17'),
(11700, 3040, 19895, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note: Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment. ', NULL, NULL, '2021-05-03 13:11:28', '2021-05-03 13:11:28'),
(11701, 3040, 19895, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:20:02', '2021-05-27 09:20:02'),
(11702, 3040, 19895, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-06-15 14:49:21', '2021-06-15 14:49:21'),
(11703, 11056, 19895, NULL, '2021-07-08 00:00:00.000', 'In Process', 'Email received from : SHP.NetworkDevelopment@superiorhealthplan.com  Sub : Need to Enroll Provider || Valley Med Urgent Care PLLC || Ambetter ||  Hello,  We received your completed application on June 3., 2012 for Mr. Naranjo.  It is currently in credentialing.  Please note that we will notify you of acceptance / participation status within 90 days of receipt of completed application.  Upon completion of this provider’s enrollment, your agreement will be executed and welcome packet will be sent.  Sincerely, Lucy Escobar Project Coordinator II, Contract Management', NULL, NULL, '2021-07-01 11:09:43', '2021-07-01 11:09:43'),
(11704, 3040, 19895, NULL, '2021-07-29 00:00:00.000', 'In Process', 'Email sent to; SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-07-22 08:55:22', '2021-07-22 08:55:22'),
(11705, 3040, 19895, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-08-27 16:46:31', '2021-08-27 16:46:31'),
(11706, 3040, 19895, NULL, '2021-09-10 00:00:00.000', 'Approved', 'Email rcvd from: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject; RE: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Hello  We received your completed application on 6/3/21. Your effective date is 9/1/21 and will be receiving a welcome packet shortly', NULL, NULL, '2021-09-03 11:08:29', '2021-09-03 11:08:29'),
(11707, 1006, 19896, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:41:23', '2021-03-11 17:41:23'),
(11708, 3040, 19896, NULL, '2021-04-26 00:00:00.000', 'Approved', 'Provider is participating with Cigna. Effective Date: 01/06/2020  Ref: KIM K 04/19/2021', NULL, NULL, '2021-04-19 15:52:53', '2021-04-19 15:52:53'),
(11709, 3040, 19897, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:41:40', '2021-03-11 17:41:40'),
(11710, 3040, 19897, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:04', '2021-03-23 08:33:04'),
(11711, 3040, 19897, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note:  Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment ', NULL, NULL, '2021-05-03 13:15:29', '2021-05-03 13:15:29'),
(11712, 3040, 19897, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:20:06', '2021-05-27 09:20:06'),
(11713, 3040, 19897, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I received an email from your side the below mentioned providers now participating with Ambetter. Can you please send me the welcome letter.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-15 14:55:49', '2021-06-15 14:55:49'),
(11714, 3040, 19897, NULL, '2021-06-23 00:00:00.000', 'Approved', 'Email rcvd from: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Good morning,              The letter will be mailed. Please allow time for letter to be mailed to you.  Thank you,  Credentialing Department | Superior Health Plan 5900 E. Ben White Blvd | Austin, TX 78741 Phone: 800-820-5686 |Fax: 866-702-4831', NULL, NULL, '2021-06-16 09:27:43', '2021-06-16 09:27:43'),
(11715, 1006, 19898, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:42:20', '2021-03-11 17:42:20'),
(11716, 1019, 19898, NULL, '2021-04-13 00:00:00.000', 'Initiated', 'Thank you for your interest in joining the Cigna Behavioral Health network. We have received your application. A Cigna Recruiter will process your application and provide onboarding instructions within 20 business days. Please notate the confirmation number. If you have any questions or concerns, please email us at BehavioralContracting@cigna.com or call Provider Services at 1.800.926.2273.  ', NULL, NULL, '2021-04-06 09:09:36', '2021-04-06 09:09:36'),
(11717, 1019, 19898, NULL, '2021-04-13 00:00:00.000', 'Initiated', 'Your application has been received, your CBP ID is CBP-0000207830. A recruiter will process your application and provide onboarding instructions within 20 business days. The process to join the Cigna Network can take up to 90 days. To check the status of your application, please email behavioralcontracting@cigna.com. ', NULL, NULL, '2021-04-06 09:12:08', '2021-04-06 09:12:08'),
(11718, 1019, 19898, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com Sub: Enrollment Status || Providers || SNBCARE || CIGNA  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:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Regards, Alex', NULL, NULL, '2021-04-08 11:16:37', '2021-04-08 11:16:37'),
(11719, 1019, 19898, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Received the following email from: BehavioralContracting@cigna.com SUB: Enrollment Status || Providers || SNBCARE || CIGNA   Hi, Please see below for the provider status update.  Justin Souliere- Received application will process shortly. Kerry Smith- Received application will process shortly. Rodesia Edmundson- Received application will process shortly. Carlee Rozell- Credentialing status  Kiara   Cigna Behavioral NCU   E: BehavioralContracting@cigna.com', NULL, NULL, '2021-04-14 07:22:35', '2021-04-14 07:22:35'),
(11720, 3040, 19898, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Email sent to: BehavioralContracting@cigna.com  Subject: Enrollment Status || Spectrum Neuro Behavioral Care || Providers || Cigna ||  Greetings,   Hope you are doing well. Please advise me the enrollment status for the below mentioned providers for our group Spectrum Neuro Behavioral Care under below locations.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI: Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Thanks  ', NULL, NULL, '2021-04-19 10:07:03', '2021-04-19 10:07:03'),
(11721, 1019, 19898, NULL, '2021-05-25 00:00:00.000', 'In Process', 'Received the following email from lacretia.jacobs@cigna.com  Thank you for your interest in becoming a part of our behavioral health care professional network. We are pleased to extend a Cigna Behavioral On-boarding Packet to you. Please review and complete the attached documents within the next 10 business days and submit them electronically via DocuSign with your signature. Once received, we will review your credentialing information via online source verification systems. Please note: You will not be considered in network until your credentials are verified and you receive notification from Cigna that your On-boarding is complete. If you have any questions, please contact me directly using the contact information located at the bottom of this email.  Thank you, LaCretia Jacobs', NULL, NULL, '2021-05-18 09:11:38', '2021-05-18 09:11:38'),
(11722, 1019, 19898, NULL, '2021-05-25 00:00:00.000', 'In Process', 'Received the following email from lacretia.jacobs@cigna.com Hello  Thank you for applying to Cigna Behavioral Health. As your recruiter, I will personally assist you through our new onboarding process.  Your Cigna Onboarding Packet was just sent via DocuSign to your credentialing email. If you have not received it, please allow 5-10 minutes for the packet to arrive and/or check your junk/spam folder. Please follow the instructions inside of DocuSign to complete your packet. Please make sure that the provider self-introduction contains at least one short sentence, but the photo is optional.  Once you have completed Onboarding Packet via DocuSign, I will begin verifying your credentials through the following steps: Verifying CAQH Complete CAQH application with a current Attestation State Attestations/Authorizations may apply- please see required forms for your state on CAQH Current license (valid for 60+ days) in the same state as your service location(s). Medical Doctors, Nurse Practitioners, and Physician Assistants are required to have specific board certifications, training, and/or education related to behavioral health/psych. Education – Cigna requires ALL Graduate education information be completed in CAQH. Must include the following:   Highest Level of Education –including School Name, Degree, Start date & End date Prescribers – Must include Internship/Residency/Fellowship information. Specialty Information – including Primary Specialty Current Liability Insurance (valid for 60+ days) Current Work History (not practice locations) 5 years of work history/education/training is required This includes anything outside of your field of practice Education History including undergrad will be accepted in place of employment if you graduated less than 5 years ago Anything over a 6 month gap will require a “work history gap explanation” Resumes/CVs containing month/year formatting can substitute for the data application Verifying your NPI I will send out emailed communication to your credentialing contact for any required updates. Once complete, your Onboarding Packet will be sent for processing within the Credentialing department.  If you have any questions, please let me know. I look forward to working with you.   Thanks you,  LaCretia Jacobs Provider Relations Analyst | Cigna Behavioral Health National Contracting Unit T: 903.337.4867 |F: 855.238.0636 E: LaCretia.Jacobs@Cigna.com', NULL, NULL, '2021-05-18 09:12:33', '2021-05-18 09:12:33'),
(11723, 1019, 19898, NULL, '2021-05-25 00:00:00.000', 'In Process', 'Sent the following email to lacretia.jacobs@cigna.com SUB: MA 15091874 Rodesia Edmundson Cigna behavioral Contract BID  Hello LaCretia, Hope you are doing good, I have signed the documents, let me know if anything else is required.', NULL, NULL, '2021-05-18 09:13:35', '2021-05-18 09:13:35');
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
(11724, 1019, 19898, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com SUB: Enrollment Status || Group & Providers || SNBCARE || CIGNA  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 Providers:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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. Secondary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Tertiary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Tawakol, Katie NPI: 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.      Hefti, Prisca NPI: 1508133182 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.  Regards,', NULL, NULL, '2021-05-20 09:24:42', '2021-05-20 09:24:42'),
(11725, 1019, 19898, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to panplais.lor@cigna.com ​ SUB: Group Roster || Group & Providers || SNBCARE || CIGNA   Hello Pa,  Can you please send me our group provider roster ASAP. I have mentioned the group information below.  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.    Regards, Alex', NULL, NULL, '2021-06-03 15:36:01', '2021-06-03 15:36:01'),
(11726, 1019, 19898, NULL, '2021-07-22 00:00:00.000', 'Approved', 'Provider enrolled with Cigna effective date 07/13/2021. Attached is the Welcome Letter for Ref.  ', NULL, NULL, '2021-07-15 08:12:56', '2021-07-15 08:12:56'),
(11727, 1006, 19899, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:42:21', '2021-03-11 17:42:21'),
(11728, 1019, 19899, NULL, '2021-04-08 00:00:00.000', 'Initiated', 'Received the following message from : behavioralcontracting@cigna.com  Sub: You have successfully submitted your application our application has been received, your CBP ID is CBP-0000207301. A recruiter will process your application and provide onboarding instructions within 20 business days. The process to join the Cigna Network can take up to 90 days. To check the status of your application, please email behavioralcontracting@cigna.com. ', NULL, NULL, '2021-04-01 17:09:38', '2021-04-01 17:09:38'),
(11729, 1019, 19899, NULL, '2021-04-15 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com Sub: Enrollment Status || Providers || SNBCARE || CIGNA  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:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Regards, Alex', NULL, NULL, '2021-04-08 11:16:13', '2021-04-08 11:16:13'),
(11730, 1019, 19899, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Received the following email from: BehavioralContracting@cigna.com SUB: Enrollment Status || Providers || SNBCARE || CIGNA   Hi, Please see below for the provider status update.  Justin Souliere- Received application will process shortly. Kerry Smith- Received application will process shortly. Rodesia Edmundson- Received application will process shortly. Carlee Rozell- Credentialing status  Kiara   Cigna Behavioral NCU   E: BehavioralContracting@cigna.com', NULL, NULL, '2021-04-14 07:22:28', '2021-04-14 07:22:28'),
(11731, 3040, 19899, NULL, '2021-04-26 00:00:00.000', 'In Process', 'Email sent to: BehavioralContracting@cigna.com  Subject: Enrollment Status || Spectrum Neuro Behavioral Care || Providers || Cigna ||  Greetings,   Hope you are doing well. Please advise me the enrollment status for the below mentioned providers for our group Spectrum Neuro Behavioral Care under below locations.   Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Individual NPI: Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 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.  Thanks  ', NULL, NULL, '2021-04-19 10:07:13', '2021-04-19 10:07:13'),
(11732, 1019, 19899, NULL, '2021-06-01 00:00:00.000', 'In Process', 'Sent the following email to BehavioralContracting@cigna.com SUB: Enrollment Status || Group & Providers || SNBCARE || CIGNA  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 Providers:  Carlee Rozell NPI: 1225645393 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI: 1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702 Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. 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. Secondary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Tertiary Location: 100 New State Highway, Raynham, MA, 02767.    Hignite, Barbara NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.    Loveland, Lynnetta NPI: 1598163602 Location: 100 New State Highway, Raynham, MA, 02767.   Tawakol, Katie NPI: 1609222116 Secondary Location: 100 New State Highway, Raynham, MA, 02767.     Rashid, Mahreen NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.    Khan, Fauzia Wali NPI: 1699761965 Location: 100 New State Highway, Raynham, MA, 02767.    Pionke, Peggy NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.      Hefti, Prisca NPI: 1508133182 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.  Regards,', NULL, NULL, '2021-05-20 09:25:06', '2021-05-20 09:25:06'),
(11733, 1019, 19899, NULL, '2021-06-10 00:00:00.000', 'In Process', 'Received the following email from julia.perkins@cigna.com SUB: MA 15087992 KERRY SMITH Cigna behavioral Contract BID  Thank you for your interest in becoming a part of our behavioral health care professional network. We are pleased to extend a Cigna Behavioral On-boarding Packet to you. Please review and complete the attached documents within the next 10 business days and submit them electronically via DocuSign with your signature. Once received, we will review your credentialing information via online source verification systems. Please note: You will not be considered in network until your credentials are verified and you receive notification from Cigna that your On-boarding is complete. If you have any questions, please contact me directly using the contact information located at the bottom of this email.  Thank you,  Julia Perkins ', NULL, NULL, '2021-05-25 07:58:04', '2021-05-25 07:58:04'),
(11734, 1019, 19899, NULL, '2021-06-10 00:00:00.000', 'In Process', 'Signed the On Boarding Packet online thru Doc Sign Attached is the copy for reference.', NULL, NULL, '2021-05-25 07:59:09', '2021-05-25 07:59:09'),
(11735, 1019, 19899, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to panplais.lor@cigna.com ​ SUB: Group Roster || Group & Providers || SNBCARE || CIGNA   Hello Pa,  Can you please send me our group provider roster ASAP. I have mentioned the group information below.  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.    Regards, Alex', NULL, NULL, '2021-06-03 15:35:53', '2021-06-03 15:35:53'),
(11736, 1019, 19899, NULL, '2021-11-23 00:00:00.000', 'Not Eligible', 'Received the following email from Julia.Perkins@evernorth.com  KERRY SMITH holds a Licensed Certified Social Worker which is Not accepted in the state of ma.     Helena Halterman– provider is in que for credentialing at current time there is no action needed from the provider or your office.     Dina Filoteo Nichols-Packet sent – your assigned Evernorth Recruiter has reviewed your Provider Information Form and has sent your onboarding packet via DocuSign. Please review, and sign.     Eliza Rodrigues- I do not show an application on file.', NULL, NULL, '2021-11-16 15:10:26', '2021-11-16 15:10:26'),
(11737, 3040, 19900, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:42:36', '2021-03-11 17:42:36'),
(11738, 3040, 19900, NULL, '2021-03-29 00:00:00.000', 'Approved', 'Provider enrolled in Ambetter.   Please see attachment ', NULL, NULL, '2021-03-22 16:58:56', '2021-03-22 16:58:56'),
(11739, 1006, 19901, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:43:11', '2021-03-11 17:43:11'),
(11740, 1006, 19901, NULL, '2021-04-29 00:00:00.000', 'Approved', 'Group is enrolled with CCA, executed contract, and location confirmation attached for reference.   Eff: 11/01/2019', NULL, NULL, '2021-04-22 15:52:27', '2021-04-22 15:52:27'),
(11741, 3040, 19902, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:43:11', '2021-03-11 17:43:11'),
(11742, 3040, 19902, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:15', '2021-03-23 08:33:15'),
(11743, 3040, 19902, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note: Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment. ', NULL, NULL, '2021-05-03 13:11:32', '2021-05-03 13:11:32'),
(11744, 3040, 19902, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:19:53', '2021-05-27 09:19:53'),
(11745, 3040, 19902, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-06-15 14:49:16', '2021-06-15 14:49:16'),
(11746, 11056, 19902, NULL, '2021-07-08 00:00:00.000', 'In Process', 'Email received from : SHP.NetworkDevelopment@superiorhealthplan.com  Sub : Need to Enroll Provider || Valley Med Urgent Care PLLC || Ambetter ||  Hello,  We received your completed application on June 3., 2012 for Mr. Naranjo.  It is currently in credentialing.  Please note that we will notify you of acceptance / participation status within 90 days of receipt of completed application.  Upon completion of this provider’s enrollment, your agreement will be executed and welcome packet will be sent.  Sincerely, Lucy Escobar Project Coordinator II, Contract Management', NULL, NULL, '2021-07-01 11:10:19', '2021-07-01 11:10:19'),
(11747, 3040, 19902, NULL, '2021-07-29 00:00:00.000', 'In Process', 'Email sent to; SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-07-22 08:55:24', '2021-07-22 08:55:24'),
(11748, 3040, 19902, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-08-27 16:46:31', '2021-08-27 16:46:31'),
(11749, 3040, 19902, NULL, '2021-09-10 00:00:00.000', 'Approved', 'Email rcvd from: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject; RE: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Hello  We received your completed application on 6/3/21. Your effective date is 9/1/21 and will be receiving a welcome packet shortly', NULL, NULL, '2021-09-03 11:08:30', '2021-09-03 11:08:30'),
(11750, 3040, 19903, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:43:49', '2021-03-11 17:43:49'),
(11751, 3040, 19903, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:09', '2021-03-23 08:33:09'),
(11752, 3040, 19903, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note:  Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment ', NULL, NULL, '2021-05-03 13:15:34', '2021-05-03 13:15:34'),
(11753, 3040, 19903, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:19:57', '2021-05-27 09:19:57'),
(11754, 3040, 19903, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I received an email from your side the below mentioned providers now participating with Ambetter. Can you please send me the welcome letter.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-15 14:55:44', '2021-06-15 14:55:44'),
(11755, 3040, 19903, NULL, '2021-06-23 00:00:00.000', 'Approved', 'Email rcvd from: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Good morning,              The letter will be mailed. Please allow time for letter to be mailed to you.  Thank you,  Credentialing Department | Superior Health Plan 5900 E. Ben White Blvd | Austin, TX 78741 Phone: 800-820-5686 |Fax: 866-702-4831', NULL, NULL, '2021-06-16 09:27:49', '2021-06-16 09:27:49'),
(11756, 1006, 19904, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:44:35', '2021-03-11 17:44:35'),
(11757, 1019, 19904, NULL, '2021-04-06 00:00:00.000', 'Initiated', 'Sent following email to PNMDepartment@commonwealthcare.org, Credentialing@commonwealthcare.org  Sub: HCAS Provider Enrollment - Kerry Smith - CCA - SNBCARE Hello,   Please find the attached enrollment form for our provider and expedite the enrollment process as much as possible. Do let me know how long it will take to get her added to our group.     Regards, Alex G.', NULL, NULL, '2021-03-30 13:15:14', '2021-03-30 13:15:14'),
(11758, 3040, 19904, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Email sent to: PNMDepartment@commonwealthcare.org, Credentialing@commonwealthcare.org  Subject: HCAS Provider Enrollment - Kerry Smith - CCA - SNBCARE  Greetings,   Hope you are doing great. I wanted to know the enrollment status for the below mentioned providers. The form was sent out on 03/30/2021.   Practice Name: Spectrum Neuro Behavioral Care Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Practice Address: 61 Lincoln St., Suite 203, Framingham , MA 01702  Provider Name: Smith, Kerry R Provider NPI# 1275083230  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-04-16 15:23:07', '2021-04-16 15:23:07'),
(11759, 1019, 19904, NULL, '2021-04-30 00:00:00.000', 'In Process', 'Received the following email from PNMDepartment@commonwealthcare.org  Hello, The Provider Kerry Smith, LCSW is effective from  03/30/2021 at 61 Lincoln St Suite 203, Framingham and 100 New State Hwy, Raynham  under  Spectrum Neuro Behavioral Care LLC  Thank you, Aravindrajan Bangaru Provider Network Management', NULL, NULL, '2021-04-23 07:04:47', '2021-04-23 07:04:47'),
(11760, 1019, 19904, NULL, '2021-04-30 00:00:00.000', 'In Process', 'Sent the following email to PNMDepartment@commonwealthcare.org  Hello Aravindrajan, Can you please send me the copy of the contract for the following provider, under our group, as she is not showing on the provider directory.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753  Provider Name: Kerry Smith NPI: 1275083230  Regards, Alex', NULL, NULL, '2021-04-23 07:06:25', '2021-04-23 07:06:25'),
(11761, 1019, 19904, NULL, '2021-04-30 00:00:00.000', 'In Process', 'Called CCA @ (866) 610-2273 Spoken with Rep Valarie conversation is mentioned below  Spoke with Valerie as per her Kerry is showing In Network in there systems with effective date 03/30/2021 for both locations.  Ref# 04/23/2021 - Valarie', NULL, NULL, '2021-04-23 09:44:16', '2021-04-23 09:44:16'),
(11762, 1019, 19904, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to Credentialing@commonwealthcare.org, PNMDepartment@commonwealthcare.org  SUB: Enrollment Query || Group & Providers || SNBCARE || CCA Hello, We want the enrollment status for our Group and Providers under our group, also please provide us the effective dates for the providers as well.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753   Locations: Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Prisca Hefti NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.  Fauzia Wali Khan NPI: 1699761965 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.  Peggy Pionke NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.  Mahreen Rashid NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1356906572 Location: 100 New State Highway, Raynham, MA, 02767.  Jonathan Schubert NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI:1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Katie Tawakol NPI: 1609222116 Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Location: 100 New State Highway, Raynham, MA, 02767.', NULL, NULL, '2021-06-03 16:08:23', '2021-06-03 16:08:23'),
(11763, 1019, 19904, NULL, '2021-06-28 00:00:00.000', 'Approved', 'Received the following email from PNMDepartment@commonwealthcare.org  Hello,  The Provider Kerry Smith, LCSW is effective from  03/30/2021 at 61 Lincoln St Suite 203, Framingham and 100 New State Hwy, Raynham  under  Spectrum Neuro Behavioral Care LLC  Thank you, Aravindrajan Bangaru Provider Network Management Commonwealth Care Alliance 2 Avenue De Lafayette 5th Floor Boston MA 02111', NULL, NULL, '2021-06-21 09:08:37', '2021-06-21 09:08:37'),
(11764, 1006, 19905, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:44:36', '2021-03-11 17:44:36'),
(11765, 1019, 19905, NULL, '2021-04-13 00:00:00.000', 'Initiated', 'Sent following email to PNMDepartment@commonwealthcare.org, Credentialing@commonwealthcare.org  Sub: HCAS Provider Enrollment - Rodesia Edmundson - CCA - SNBCARE Hello,   Please find the attached enrollment form for our provider and expedite the enrollment process as much as possible. Do let me know how long it will take to get her added to our group.   Alex G.', NULL, NULL, '2021-04-06 09:40:38', '2021-04-06 09:40:38'),
(11766, 3040, 19905, NULL, '2021-04-23 00:00:00.000', 'In Process', 'Email sent to: PNMDepartment@commonwealthcare.org, Credentialing@commonwealthcare.org   Subject: HCAS Provider Enrollment - Edmundson, Rodesia Sharese - CCA - SNBCARE  Greetings,   Hope you are doing great. I wanted to know the enrollment status for the below mentioned providers. The form was sent out on 03/30/2021.   Practice Name: Spectrum Neuro Behavioral Care Practice Tax ID# 83-4482753 Practice NPI# 1356906572 Practice Address: 61 Lincoln St., Suite 203, Framingham , MA 01702  Provider Name: Edmundson, Rodesia Sharese Provider NPI# 1124622667  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-04-16 15:48:45', '2021-04-16 15:48:45'),
(11767, 1019, 19905, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Sent the following email to Credentialing@commonwealthcare.org, PNMDepartment@commonwealthcare.org  SUB: Enrollment Query || Group & Providers || SNBCARE || CCA Hello, We want the enrollment status for our Group and Providers under our group, also please provide us the effective dates for the providers as well.  Group Information: Spectrum Neuro Behavioral Care NPI: 1356906572 TAX ID: 834482753   Locations: Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Individual Providers:  Melody L\'Etoile NPI: 1942687108 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Rodesia Edmundson NPI: 1124622667 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Prisca Hefti NPI: 1508133182 Location: 100 New State Highway, Raynham, MA, 02767.  Barbara Hignite NPI: 1982617262 Location: 100 New State Highway, Raynham, MA, 02767.  Fauzia Wali Khan NPI: 1699761965 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.  Peggy Pionke NPI: 1699307322 Location: 100 New State Highway, Raynham, MA, 02767.  Mahreen Rashid NPI: 1396393146 Location: 100 New State Highway, Raynham, MA, 02767.  Carlee Rozell NPI: 1356906572 Location: 100 New State Highway, Raynham, MA, 02767.  Jonathan Schubert NPI: 1235755505 Location: 100 New State Highway, Raynham, MA, 02767.  Kerry Smith NPI:1275083230 Primary Location: 61 Lincoln Street, Suite 203, Framingham, MA, 01702. Secondary Location: 100 New State Highway, Raynham, MA, 02767.  Katie Tawakol NPI: 1609222116 Location: 100 New State Highway, Raynham, MA, 02767.  Jennifer Ullrich NPI: 1710489760 Location: 100 New State Highway, Raynham, MA, 02767.', NULL, NULL, '2021-06-03 16:08:14', '2021-06-03 16:08:14'),
(11768, 1019, 19905, NULL, '2021-06-28 00:00:00.000', 'Approved', 'See Attached for the email SS received from CCA for Approval Confirmation.  Also spoken with Rep Gilsen F, as per rep the provider is linked under both (Framingham & Raynham) locations.  Call ref #: Gislen F - 06/21/2021 ', NULL, NULL, '2021-06-21 08:52:09', '2021-06-21 08:52:09'),
(11769, 3040, 19906, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:44:39', '2021-03-11 17:44:39'),
(11770, 3040, 19906, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to add the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248   Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  If you need any additional information pleae feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-03-23 08:34:13', '2021-03-23 08:34:13'),
(11771, 3040, 19906, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-05-03 13:05:22', '2021-05-03 13:05:22'),
(11772, 3040, 19906, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject:Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Hello,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under the locations below. As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-06-01 14:45:36', '2021-06-01 14:45:36'),
(11773, 3040, 19906, NULL, '2021-06-28 00:00:00.000', 'Approved', 'Provider is added under the location. Please see attachment. ', NULL, NULL, '2021-06-21 14:46:19', '2021-06-21 14:46:19'),
(11774, 3046, 19907, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:44:59', '2021-03-11 17:44:59'),
(11775, 1006, 19907, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:11:39', '2021-04-16 10:11:39'),
(11776, 3040, 19908, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:45:03', '2021-03-11 17:45:03'),
(11777, 3040, 19908, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to add the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248   Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  If you need any additional information pleae feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-03-23 08:35:30', '2021-03-23 08:35:30'),
(11778, 3040, 19908, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Greetings,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under below locations.  As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-05-03 13:05:15', '2021-05-03 13:05:15'),
(11779, 3040, 19908, NULL, '2021-06-08 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject:Add Provider in Additional Locations || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Ambetter ||  Hello,  Hope you are doing well. I wanted to check the status for the providers in Ambetter for our group Valley Med Urgent Care PLLC under the locations below. As per Ambetter provider directory the provider is showing in all three locations but as per call center representative the provider is showing under only one location (2534 Boca Chica Blvd Brownsville , TX 78521-3496). For your reference I attached the screenshot.   Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID#  81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address:  800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-06-01 14:45:39', '2021-06-01 14:45:39'),
(11780, 3040, 19908, NULL, '2021-06-28 00:00:00.000', 'Approved', 'Provider is added under the location. Please see attachment. ', NULL, NULL, '2021-06-21 14:46:08', '2021-06-21 14:46:08'),
(11781, 3040, 19909, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:45:30', '2021-03-11 17:45:30'),
(11782, 3040, 19909, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:14', '2021-03-23 08:33:14'),
(11783, 3040, 19909, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note: Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment. ', NULL, NULL, '2021-05-03 13:11:35', '2021-05-03 13:11:35'),
(11784, 3040, 19909, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:20:11', '2021-05-27 09:20:11'),
(11785, 3040, 19909, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-06-15 14:49:11', '2021-06-15 14:49:11'),
(11786, 11056, 19909, NULL, '2021-07-08 00:00:00.000', 'In Process', 'Email received from : SHP.NetworkDevelopment@superiorhealthplan.com  Sub : Need to Enroll Provider || Valley Med Urgent Care PLLC || Ambetter ||  Hello,  We received your completed application on June 3., 2012 for Mr. Naranjo.  It is currently in credentialing.  Please note that we will notify you of acceptance / participation status within 90 days of receipt of completed application.  Upon completion of this provider’s enrollment, your agreement will be executed and welcome packet will be sent.  Sincerely, Lucy Escobar Project Coordinator II, Contract Management', NULL, NULL, '2021-07-01 11:10:26', '2021-07-01 11:10:26'),
(11787, 3040, 19909, NULL, '2021-07-29 00:00:00.000', 'In Process', 'Email sent to; SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-07-22 08:55:25', '2021-07-22 08:55:25'),
(11788, 3040, 19909, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject: Re: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in Ambetter in our group under the below locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-08-27 16:46:29', '2021-08-27 16:46:29'),
(11789, 3040, 19909, NULL, '2021-09-10 00:00:00.000', 'Approved', 'Email rcvd from: SHP-NETWORKDEVELOPMENT@superiorhealthplan.com  Subject; RE: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Hello  We received your completed application on 6/3/21. Your effective date is 9/1/21 and will be receiving a welcome packet shortly', NULL, NULL, '2021-09-03 11:08:30', '2021-09-03 11:08:30'),
(11790, 3046, 19910, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:45:46', '2021-03-11 17:45:46'),
(11791, 3040, 19910, NULL, '2021-04-12 00:00:00.000', 'Approved', 'Group has an urgent care contract. No need to add individual provider. ', NULL, NULL, '2021-04-05 13:30:38', '2021-04-05 13:30:38'),
(11792, 3040, 19911, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:46:05', '2021-03-11 17:46:05');
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
(11793, 3040, 19911, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in Ambetter for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks  ', NULL, NULL, '2021-03-23 08:33:12', '2021-03-23 08:33:12'),
(11794, 3040, 19911, NULL, '2021-05-10 00:00:00.000', 'In Process', 'Thank You For Your Request!  Important to Note:  Prior to a new provider’s provision of services and receipt of claims reimbursement, program enrollment must be confirmed on requests for Superior Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP and/or Long-Term Services and Supports (LTSS) programs.  Superior will notify you of acceptance or non-acceptance to our network no later than 90 days from receipt of a complete application for participation.  If additional information is required to process your request, a Superior representative will contact you soon.  Please see attachment ', NULL, NULL, '2021-05-03 13:15:38', '2021-05-03 13:15:38'),
(11795, 3040, 19911, NULL, '2021-06-03 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. As per your request I submitted the online form for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-05-27 09:20:16', '2021-05-27 09:20:16'),
(11796, 3040, 19911, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Need to Enroll Provider || Valley Med Urgent Care PLLC || Naranjo, Diego, Lira, Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers. Can you please advise me that you received the request or not?  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you   ', NULL, NULL, '2021-06-15 14:48:33', '2021-06-15 14:48:33'),
(11797, 3040, 19911, NULL, '2021-06-22 00:00:00.000', 'In Process', 'Email sent to: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Greetings,  Hope you are doing well. I received an email from your side the below mentioned providers now participating with Ambetter. Can you please send me the welcome letter.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting for your response.   Thank you ', NULL, NULL, '2021-06-15 14:55:39', '2021-06-15 14:55:39'),
(11798, 3040, 19911, NULL, '2021-06-23 00:00:00.000', 'Approved', 'Email rcvd from: Credentialing@superiorhealthplan.com  Subject: Welcome Letter || Valley Med Urgent Care PLLC || Arturo Alejandro || Ambetter ||  Good morning,              The letter will be mailed. Please allow time for letter to be mailed to you.  Thank you,  Credentialing Department | Superior Health Plan 5900 E. Ben White Blvd | Austin, TX 78741 Phone: 800-820-5686 |Fax: 866-702-4831', NULL, NULL, '2021-06-16 09:27:54', '2021-06-16 09:27:54'),
(11799, 3046, 19912, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:46:57', '2021-03-11 17:46:57'),
(11800, 1006, 19912, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:11:45', '2021-04-16 10:11:45'),
(11801, 3040, 19913, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:47:15', '2021-03-11 17:47:15'),
(11802, 3040, 19913, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Superior Health plan. Approval Confirmation is attached. ', NULL, NULL, '2021-03-23 08:52:40', '2021-03-23 08:52:40'),
(11803, 3046, 19914, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:47:51', '2021-03-11 17:47:51'),
(11804, 1006, 19914, NULL, '2021-04-15 00:00:00.000', 'Not Eligible', 'Not eligible to be enrolled outside of Florida. ', NULL, NULL, '2021-04-08 16:13:07', '2021-04-08 16:13:07'),
(11805, 3040, 19915, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:47:52', '2021-03-11 17:47:52'),
(11806, 3040, 19915, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: AM.Houston@superiorhealthplan.com, SHP.NetworkDevelopment@superiorhealthplan.com, SHPNetwork.DevelopmentNPRContracting@superiorhealthplan.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Greetings,  Hope you are doing well. I wanted to add the providers in the Superior Health plan for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166', NULL, NULL, '2021-03-23 09:13:50', '2021-03-23 09:13:50'),
(11807, 3040, 19915, NULL, '2021-04-21 00:00:00.000', 'Approved', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject:  Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Good Afternoon,  Provider: Hernandez, Eder Francisco –was updated to display under both Practice address, please allow 48hr to update.  Below please find snap shot of Provider Homero Garcia loaded with the requested address.   ', NULL, NULL, '2021-04-14 15:43:07', '2021-04-14 15:43:07'),
(11808, 3040, 19916, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:48:19', '2021-03-11 17:48:19'),
(11809, 3040, 19916, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: AM.Houston@superiorhealthplan.com, SHP.NetworkDevelopment@superiorhealthplan.com, SHPNetwork.DevelopmentNPRContracting@superiorhealthplan.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Greetings,  Hope you are doing well. I wanted to add the providers in the Superior Health plan for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166', NULL, NULL, '2021-03-23 09:14:24', '2021-03-23 09:14:24'),
(11810, 3040, 19916, NULL, '2021-04-21 00:00:00.000', 'Approved', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject:  Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Good Afternoon,  Provider: Hernandez, Eder Francisco –was updated to display under both Practice address, please allow 48hr to update.  Below please find snap shot of Provider Homero Garcia loaded with the requested address.   ', NULL, NULL, '2021-04-14 15:43:10', '2021-04-14 15:43:10'),
(11811, 3040, 19917, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:48:46', '2021-03-11 17:48:46'),
(11812, 3040, 19917, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:15:51', '2021-03-23 09:15:51'),
(11813, 3040, 19917, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Kindly disregard the Garcia Homero form that was sent out mistakenly. Please find the attached provider contracting form for Naranjo Diego.   If you need any additional information please let me know. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 12:15:32', '2021-03-24 12:15:32'),
(11814, 3040, 19917, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-14 14:56:39', '2021-04-14 14:56:39'),
(11815, 1006, 19917, NULL, '2021-04-28 00:00:00.000', 'In Process', 'We received the following update from Daniel Velez Daniel.Velez@superiorhealthplan.com:  Sub: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  \"Good Afternoon,  Diego Naranjo NPI: 1568929800 TIN 815123542 is within Credentialing.  Please allow additional time to process and feel free to proceed requesting status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA  Superior HealthPlan  3900 North 10th Street, Ste 600 McAllen, TX 78501 Direct 1-877-278-4268 Option 3 Fax: 1-866-390-1892  Daniel.Velez@superiorhealthplan.com | SuperiorHealthPlan.com\"', NULL, NULL, '2021-04-21 09:49:13', '2021-04-21 09:49:13'),
(11816, 3040, 19917, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Please advise me the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-05-05 08:18:37', '2021-05-05 08:18:37'),
(11817, 3040, 19917, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,   Hope you are doing well. I already sent the application for Naranjo, Diego on 03/24/2021 the same day I sent the application for Lira, Arturo A. The application was sent on SHP.NetworkDevelopment@superiorhealthplan.com.   Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-05-31 10:41:05', '2021-05-31 10:41:05'),
(11818, 3040, 19917, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  Provider 1 Provider Name: Naranjo, Diego Provider NPI# 1568929800  Tax ID# 81-5123542', NULL, NULL, '2021-05-31 10:41:55', '2021-05-31 10:41:55'),
(11819, 3040, 19917, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  I received a notification from our contract department, “Provider needs to submit an application“.  The packet was sent on 3/24/2021, please respond to their email with the complete application.', NULL, NULL, '2021-05-31 10:42:56', '2021-05-31 10:42:56'),
(11820, 3040, 19917, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Afternoon,  Below please find status for the following providers.  Provider 1: Currently under Credentialing, please allow additional time to process. Provider Name: Naranjo, Diego Provider NPI# 1568929800 Tax ID# 81-5123542  Provider 2: Provider Effective Date 5/1/2021, displays under all three locations. Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502 Tax ID# 81-5123542  Respectfully,  Daniel Velez', NULL, NULL, '2021-05-31 10:44:19', '2021-05-31 10:44:19'),
(11821, 3040, 19917, NULL, '2021-06-24 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO  Good Morning,  Thank you for providing the information, the information was sent to our Contracting department.  Please allow time to review and feel free to continue to request for status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA', NULL, NULL, '2021-06-17 15:24:25', '2021-06-17 15:24:25'),
(11822, 3040, 19917, NULL, '2021-07-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject;Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-07-05 14:28:35', '2021-07-05 14:28:35'),
(11823, 3040, 19917, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning Adil,  Provider Diego Naranjo NPI# 1568929800 Tax ID# 81-5123542 is currently under Credentialing.  Please allow additional time for credentialing and feel free to request status updates.', NULL, NULL, '2021-07-20 07:13:15', '2021-07-20 07:13:15'),
(11824, 3040, 19917, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO   Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you  ', NULL, NULL, '2021-08-27 13:16:15', '2021-08-27 13:16:15'),
(11825, 3040, 19917, NULL, '2021-09-08 00:00:00.000', 'Approved', 'Email rcvd from: ECMExecutionTeam@superiorhealthplan.com  Subject: DIEGO NARANJO WELCOME LETTER  DIEGO NARANJO  VALLEY MED URGENT CARE PLLC  VMUC@CLAIMSMEDINC.COM        Welcome to the Superior HealthPlan network. We are excited to have you as a partner of our growing network of high quality health care professionals. You play a key role as we pursue our commitment to improve the health and well-being of the members we serve.Your records were reviewed and approved by our credentialing committee. You are now able to provide covered services to Superior members.     Your effective date is: 09/01/2021                                                     C/38186   ', NULL, NULL, '2021-09-01 13:50:45', '2021-09-01 13:50:45'),
(11826, 3046, 19918, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:48:53', '2021-03-11 17:48:53'),
(11827, 1006, 19918, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:11:51', '2021-04-16 10:11:51'),
(11828, 3046, 19919, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:48:55', '2021-03-11 17:48:55'),
(11829, 3040, 19919, NULL, '2021-04-12 00:00:00.000', 'New/Not Initiated', 'For a group contract at least need 2 providers under the Tax ID after that we can do the group contract for Practice. ', NULL, NULL, '2021-04-05 14:28:55', '2021-04-05 14:28:55'),
(11830, 1006, 19919, NULL, '2021-04-15 00:00:00.000', 'Not Eligible', 'For a group contract at least need 2 providers under the Tax ID after that we can do the group contract for Practice.  ', NULL, NULL, '2021-04-08 16:13:46', '2021-04-08 16:13:46'),
(11831, 11056, 19919, NULL, '2021-09-22 00:00:00.000', 'Initiated', 'Email sent to : TXProviderUpdateSubmission@bcbstx.com &  AncillaryContracting_SE@bcbstx.com  Sub : Re: Enrollment Status || Best Health Urgent Care & Clinic - BCBS || : Case Number - 02536362 : Case Number - 02684335  Good afternoon!  Hope you are doing well. I wanted to know the enrollment procedure to enroll the below mentioned practice as soon as possible with Blue Cross Blue Shield.  Practice Details: Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242  If you require any documents or information in this regard please let me know. Waiting for your response.  Thank you! Have a wonderful day!', NULL, NULL, '2021-09-15 16:43:39', '2021-09-15 16:43:39'),
(11832, 11056, 19919, NULL, '2021-09-22 00:00:00.000', 'In Process', 'Email received from : ancillarycontracting_se@bcbstx.com  Sub : Re: Enrollment Status || Best Health Urgent Care & Clinic - BCBS || : Case Number - 02536362 : Case Number - 02684335  Case Number 02871944  Provider Name  Case Status : In progress  State Texas  Case Type : Email  Subject Line of Email : Enrollment Query - Best Health Urgent Care & Clinic - BCBS  Case Received Date : 09/15/2021  For questions and concerns contact : txproviderupdatesubmission@bcbstx.com ', NULL, NULL, '2021-09-15 17:02:53', '2021-09-15 17:02:53'),
(11833, 11056, 19919, NULL, '2021-09-28 00:00:00.000', 'In Process', 'Email received from: txintaketeampiermailbox@bcbstx.com  Sub : SECURE - BCBSTX - ADDRESS UPDATE REQUEST - BEEVILLE MEDICAL CLINIC : Case Number - 02898280  Thank you for contacting Blue Cross and Blue Shield of Texas.  This email is confirmation we have received your inquiry, case number is 02898280.  We will respond to your inquiry in the order it was received.To check the status of your case, please click on status checker.    Sincerely, Blue Cross and Blue Shield of Texas', NULL, NULL, '2021-09-21 09:27:59', '2021-09-21 09:27:59'),
(11834, 11056, 19919, NULL, '2021-09-28 00:00:00.000', 'In Process', 'Email received from :  TXProviderUpdateSubmission@bcbstx.com  Sub  : Enrollment Query - Best Health Urgent Care & Clinic - BCBS : Case Number - 02871944  Good Afternoon,  I have researched your request and see that we currently have an active Professional Provider Group under the Name, Address, Tax Id and Type 2 NPI you mentioned.  Best Health Urgent Care & Clinic Group record # 00ND43  You currently have two active NP providers in the group.  If you wish to add more providers to this group, you will need to submit a Provider Onboarding application via our website.  I have included the link and instructions below for your convenience.  Submit the Provider Onboarding Form here: https://pedi-uxui.bcbstx.com/TX On page 1 – Select Participation      a.  Submitter Information           i.  Complete the required fields marked with an * for the person submitting the application           ii.  Choose one of the options                1.  I wish to participate in-network                2.  I wish to participate out-of-network           iii.  Click – Continue to Enter Your Information On page 2 – Enter Your Information      a.  Enter Your Information           i.  Choose \"Add Providers to an Existing Contracted Group/Clinic\" from the available options                1.  When you select this option, to the right will appear a box – Provider Roster Instructions                     a.  Download the Roster and save to your computer to complete with the provider(s) information, then attach when submitting the application online.  **  If you are trying to set up a Facility Group record, please contact our Facility area at TXFPS@bcbstx.com for the correct forms and any questions you may have.  Thank you,  Network Operations & Solution Delivery Blue Cross Blue Shield of Texas    We have act accordingly as the email suggested.', NULL, NULL, '2021-09-21 09:41:22', '2021-09-21 09:41:22'),
(11835, 11056, 19919, NULL, '2021-10-01 00:00:00.000', 'Approved', 'Approval Email received from : TXFPS@bcbstx.com  Sub : RE: Enrollment Query - Best Health Urgent Care & Clinic - BCBS Case 02900124  Hello, Ahmed:  We already have professional record 00ND43 setup for your group effective 4/21/2019. If you are wanting a Facility/Ancillary record setup as well please send in the completed attached Request Form. Attached is the form to apply for a facility/ancillary record with BCBSTX.  It can be faxed or emailed back with a signed W-9 and a copy of the facility\'s license to the contact information on the form.  Once your request is completed, any out-of-network claims rejected before this Provider ID was established can be resubmitted, and you can set up electronic billing by contacting Availity at (800) 282-4548.  If you wish to apply for network participation, you can contact your network representative once the record has been created to begin that process.  If you are applying for a provider record as Long Term Support Services (LTSS) provided by the state, a different form is required.  Please call (855) 212-1615 or email TexasMedicaidNetworkDepartment@bcbstx.com for that information.  If you are applying for a provider record as a Pharmacy, a different department is responsible for establishing those records.  Please contact Pharmacy Programs at (888) 277-5510.  Thank you,     Facility Provider Services  BlueCross BlueShield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company  Fax: 972-766-7315 | Email: TXFPS@bcbstx.com  Eff date is 4/21/2019   Please see the attachment.', NULL, NULL, '2021-09-24 17:13:26', '2021-09-24 17:13:26'),
(11836, 3040, 19920, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:49:22', '2021-03-11 17:49:22'),
(11837, 3040, 19920, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:16:07', '2021-03-23 09:16:07'),
(11838, 3040, 19920, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject:  Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Hope you are doing well. Please find the attached provider contracting form as per previous email requested.   If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-03-24 12:18:02', '2021-03-24 12:18:02'),
(11839, 3040, 19920, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider participating with Superior Healthplan. Effective Date: 05/01/2021  Please see attachment. ', NULL, NULL, '2021-04-12 14:22:35', '2021-04-12 14:22:35'),
(11840, 3040, 19921, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:50:25', '2021-03-11 17:50:25'),
(11841, 3040, 19921, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Superior Health plan. Approval Confirmation is attached. ', NULL, NULL, '2021-03-23 08:52:41', '2021-03-23 08:52:41'),
(11842, 3040, 19922, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:50:55', '2021-03-11 17:50:55'),
(11843, 3040, 19922, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Superior Health plan.   Please see attachment. ', NULL, NULL, '2021-03-23 08:59:29', '2021-03-23 08:59:29'),
(11844, 3040, 19923, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:51:29', '2021-03-11 17:51:29'),
(11845, 3040, 19923, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:15:56', '2021-03-23 09:15:56'),
(11846, 3040, 19923, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Kindly disregard the Garcia Homero form that was sent out mistakenly. Please find the attached provider contracting form for Naranjo Diego.   If you need any additional information please let me know. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 12:15:37', '2021-03-24 12:15:37'),
(11847, 3040, 19923, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-14 14:56:44', '2021-04-14 14:56:44'),
(11848, 1006, 19923, NULL, '2021-04-28 00:00:00.000', 'In Process', 'We received the following update from Daniel Velez Daniel.Velez@superiorhealthplan.com:  Sub: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  \"Good Afternoon,  Diego Naranjo NPI: 1568929800 TIN 815123542 is within Credentialing.  Please allow additional time to process and feel free to proceed requesting status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA  Superior HealthPlan  3900 North 10th Street, Ste 600 McAllen, TX 78501 Direct 1-877-278-4268 Option 3 Fax: 1-866-390-1892  Daniel.Velez@superiorhealthplan.com | SuperiorHealthPlan.com\"', NULL, NULL, '2021-04-21 09:49:08', '2021-04-21 09:49:08'),
(11849, 3040, 19923, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Please advise me the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-05-05 08:18:27', '2021-05-05 08:18:27'),
(11850, 3040, 19923, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,   Hope you are doing well. I already sent the application for Naranjo, Diego on 03/24/2021 the same day I sent the application for Lira, Arturo A. The application was sent on SHP.NetworkDevelopment@superiorhealthplan.com.   Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-05-31 10:41:08', '2021-05-31 10:41:08'),
(11851, 3040, 19923, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  Provider 1 Provider Name: Naranjo, Diego Provider NPI# 1568929800  Tax ID# 81-5123542', NULL, NULL, '2021-05-31 10:41:47', '2021-05-31 10:41:47'),
(11852, 3040, 19923, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  I received a notification from our contract department, “Provider needs to submit an application“.  The packet was sent on 3/24/2021, please respond to their email with the complete application.', NULL, NULL, '2021-05-31 10:42:48', '2021-05-31 10:42:48'),
(11853, 3040, 19923, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Afternoon,  Below please find status for the following providers.  Provider 1: Currently under Credentialing, please allow additional time to process. Provider Name: Naranjo, Diego Provider NPI# 1568929800 Tax ID# 81-5123542  Provider 2: Provider Effective Date 5/1/2021, displays under all three locations. Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502 Tax ID# 81-5123542  Respectfully,  Daniel Velez', NULL, NULL, '2021-05-31 10:44:11', '2021-05-31 10:44:11'),
(11854, 3040, 19923, NULL, '2021-06-24 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO  Good Morning,  Thank you for providing the information, the information was sent to our Contracting department.  Please allow time to review and feel free to continue to request for status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA', NULL, NULL, '2021-06-17 15:24:20', '2021-06-17 15:24:20'),
(11855, 3040, 19923, NULL, '2021-07-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject;Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-07-05 14:28:28', '2021-07-05 14:28:28'),
(11856, 3040, 19923, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning Adil,  Provider Diego Naranjo NPI# 1568929800 Tax ID# 81-5123542 is currently under Credentialing.  Please allow additional time for credentialing and feel free to request status updates.', NULL, NULL, '2021-07-20 07:13:14', '2021-07-20 07:13:14'),
(11857, 3040, 19923, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO   Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you  ', NULL, NULL, '2021-08-27 13:16:16', '2021-08-27 13:16:16'),
(11858, 3040, 19923, NULL, '2021-09-08 00:00:00.000', 'Approved', 'Email rcvd from: ECMExecutionTeam@superiorhealthplan.com  Subject: DIEGO NARANJO WELCOME LETTER  DIEGO NARANJO  VALLEY MED URGENT CARE PLLC  VMUC@CLAIMSMEDINC.COM        Welcome to the Superior HealthPlan network. We are excited to have you as a partner of our growing network of high quality health care professionals. You play a key role as we pursue our commitment to improve the health and well-being of the members we serve.Your records were reviewed and approved by our credentialing committee. You are now able to provide covered services to Superior members.     Your effective date is: 09/01/2021                                                     C/38186   ', NULL, NULL, '2021-09-01 13:50:43', '2021-09-01 13:50:43'),
(11859, 3040, 19924, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:52:09', '2021-03-11 17:52:09'),
(11860, 3040, 19924, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:16:13', '2021-03-23 09:16:13'),
(11861, 3040, 19924, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject:  Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Hope you are doing well. Please find the attached provider contracting form as per previous email requested.   If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 12:18:07', '2021-03-24 12:18:07'),
(11862, 3040, 19924, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider participating with Superior Healthplan. Effective Date: 05/01/2021  Please see attachment. ', NULL, NULL, '2021-04-12 14:22:40', '2021-04-12 14:22:40'),
(11863, 3040, 19925, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:52:48', '2021-03-11 17:52:48'),
(11864, 3040, 19925, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Address is updated for the group in the provider directory. Proof is attached.  ', NULL, NULL, '2021-03-23 08:45:42', '2021-03-23 08:45:42'),
(11865, 3040, 19926, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:53:15', '2021-03-11 17:53:15'),
(11866, 3040, 19926, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Superior Health plan. Approval Confirmation is attached. ', NULL, NULL, '2021-03-23 08:52:39', '2021-03-23 08:52:39'),
(11867, 3040, 19927, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:53:38', '2021-03-11 17:53:38'),
(11868, 3040, 19927, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Superior Health plan.   Please see attachment. ', NULL, NULL, '2021-03-23 08:59:35', '2021-03-23 08:59:35'),
(11869, 3040, 19928, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:53:58', '2021-03-11 17:53:58'),
(11870, 3040, 19928, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: AM.Houston@superiorhealthplan.com, SHP.NetworkDevelopment@superiorhealthplan.com, SHPNetwork.DevelopmentNPRContracting@superiorhealthplan.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Greetings,  Hope you are doing well. I wanted to add the providers in the Superior Health plan for our group Valley Med Urgent Care PLLC under below locations.  Provider 1: Provider Name: Garcia, Homero Provider NPI# 1730564857  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248  Provider 2:   Provider Name: Hernandez, Eder Francisco Provider NPI# 1386956852  Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Practice Address: 800 E Alton Gloor Blvd  Brownsville , TX 78526-4248 Practice Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166', NULL, NULL, '2021-03-23 09:14:34', '2021-03-23 09:14:34'),
(11871, 3040, 19928, NULL, '2021-04-21 00:00:00.000', 'Approved', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject:  Location Addition || Valley Med Urgent Care PLLC || Garcia, Homero, Hernandez, Eder Francisco || Superior Health ||  Good Afternoon,  Provider: Hernandez, Eder Francisco –was updated to display under both Practice address, please allow 48hr to update.  Below please find snap shot of Provider Homero Garcia loaded with the requested address.   ', NULL, NULL, '2021-04-14 15:43:11', '2021-04-14 15:43:11'),
(11872, 3046, 19929, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:54:11', '2021-03-11 17:54:11'),
(11873, 3040, 19929, NULL, '2021-04-12 00:00:00.000', 'New/Not Initiated', 'Pending enrollment because at least 2 providers need to be in-network with the group. ', NULL, NULL, '2021-04-05 13:42:04', '2021-04-05 13:42:04'),
(11874, 1006, 19929, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Pending enrollment because at least 2 providers need to be in-network with the group.  ', NULL, NULL, '2021-04-16 10:00:53', '2021-04-16 10:00:53'),
(11875, 1006, 19929, NULL, '2021-06-04 00:00:00.000', 'In Process', 'Currently only Segun is enrolled with Cigna for BHUCC, Stephane enrollment is in process after it was re-initiated. ', NULL, NULL, '2021-05-28 09:00:12', '2021-05-28 09:00:12'),
(11876, 3040, 19929, NULL, '2021-06-16 00:00:00.000', 'On Hold', 'Waiting for the Cyriaque, Stephane & Tann, Shametria.   ', NULL, NULL, '2021-06-09 13:52:18', '2021-06-09 13:52:18'),
(11877, 11056, 19929, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Email sent to :  intake_pdm@cigna.com   Sub : Credentialing Status Request- CIGNA - BEST HEALTH URGENT CARE & CLINIC  Good morning!  Hope you are doing well. Could you Please let me know the current status of Credentialing.I have mentioned the details below.  Practice:   Practice Name : Best Health Urgent Care & Clinic Practice TIN # : 84-4737737 Practice  NPI# :1013540962  Provider : Provider Name : Stephane Cyriaque Provider NPI: 1780192633  Provider Name : Tann, Shametria Provider NPI: 1124615612    Do let me know if you need any information.   Thank You!', NULL, NULL, '2021-06-28 12:14:21', '2021-06-28 12:14:21'),
(11878, 11056, 19929, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Email received from : 9PSSCENT@cigna.com   & intake_pdm@cigna.com  Sub : Credentialing Status Request- CIGNA - BEST HEALTH URGENT CARE & CLINIC   The credentialing process typically takes 60 to 90 days to complete.  However, we are experiencing a higher than normal volume of credentialing request, which may result in some delays in processing your application.  We will do our best to process your application as soon as possible.  You will receive an email once you have been approved and credentialed as a network-participating provider with your effective date, or to notify you that you have not been approved.   Thank you.', NULL, NULL, '2021-07-12 16:44:52', '2021-07-12 16:44:52'),
(11879, 11056, 19929, NULL, '2021-07-26 00:00:00.000', 'In Process', 'Email sent to  : intake_pdm@cigna.com  Sub :  Credentialing Status Request- CIGNA - BEST HEALTH URGENT CARE & CLINIC  Good evening!  Hope you are doing well. Could you Please let me know the current status of our Credentialing request and inform us as soon as possible.I have mentioned the details below of our group and providers :  Practice:   Practice Name : Best Health Urgent Care & Clinic Practice TIN # : 84-4737737 Practice  NPI# :1013540962  Providers : Provider Name : Stephane Cyriaque Provider NPI: 1780192633  Provider Name : Tann, Shametria Provider NPI: 1124615612    Do let me know if you need any information. Waiting to hear from you soon.   Thank You!', NULL, NULL, '2021-07-19 12:51:41', '2021-07-19 12:51:41'),
(11880, 11056, 19929, NULL, '2021-08-04 00:00:00.000', 'In Process', 'Email received from : 	PDMCOGZ@cigna.com  Sub  : FW: [External] Credentialing Status Request- CIGNA - BEST HEALTH URGENT CARE & CLINIC  Hi Team,     Kindly handle this request.  Work id - W202107121793247  NPI-1780192633  NPI-1124615612     \"We have forwarded your request to the Providers Service Unit which is the correct department for proper handling.  For all future status request please submit directly to PSSCentral@Cigna.com.\"', NULL, NULL, '2021-07-28 11:42:21', '2021-07-28 11:42:21'),
(11881, 11056, 19929, NULL, '2021-08-11 00:00:00.000', 'In Process', 'Email sent to : PSSCentral@cigna.com  Sub : Credentialing Status Request- CIGNA - BHUCC  Good evening!  Hope you are doing well. Could you Please let me know the current status of our Credentialing request and inform us as soon as possible.I have mentioned the details below of our group and providers :  Practice:   Practice Name : Best Health Urgent Care & Clinic Practice TIN # : 84-4737737 Practice  NPI# :1013540962  Providers : Provider Name : Stephane Cyriaque Provider NPI: 1780192633  Provider Name : Tann, Shametria Provider NPI: 1124615612    Do let me know if you need any information. Waiting to hear from you soon.   Thank You! Have a great day!', NULL, NULL, '2021-08-03 15:31:40', '2021-08-03 15:31:40'),
(11882, 11056, 19929, NULL, '2021-08-17 00:00:00.000', 'In Process', 'Email sent to :   PSSCentral@cigna.com   &   DiscoverCigna@information.cigna.com  Sub : Credentialing Status Request- CIGNA - BHUCC  Good evening!  Hope you are doing well. Could you Please let me know the current status of our Credentialing request and inform us as soon as possible.I have mentioned the details below of our group and providers :  Practice:   Practice Name : Best Health Urgent Care & Clinic Practice TIN # : 84-4737737 Practice  NPI# :1013540962  Providers : Provider Name : Stephane Cyriaque Provider NPI: 1780192633  Provider Name : Tann, Shametria Provider NPI: 1124615612    Do let me know if you need any information. Waiting to hear from you soon.   Thank You! Have a great day!', NULL, NULL, '2021-08-10 09:42:48', '2021-08-10 09:42:48');
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
(11883, 11056, 19929, NULL, '2021-08-24 00:00:00.000', 'In Process', 'Email sent to :   PSSCentral@cigna.com   &   DiscoverCigna@information.cigna.com  Sub :   Good evening!  Hope you are doing well. Could you Please let me know the current status of our Credentialing request and inform us as soon as possible.I have mentioned the details below of our group and providers :  Practice:   Practice Name : Best Health Urgent Care & Clinic Practice TIN # : 84-4737737 Practice  NPI# :1013540962  Providers : Provider Name : Stephane Cyriaque Provider NPI: 1780192633  Provider Name : Tann, Shametria Provider NPI: 1124615612    Do let me know if you need any information. Waiting to hear from you soon.   Thank You! Have a great day!', NULL, NULL, '2021-08-16 17:08:16', '2021-08-16 17:08:16'),
(11884, 11056, 19929, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email received from : JENNIFER.PEREZ@cigna.com  Sub : Enrollment Status Query - BHUCC - Cigna Healthspring  HI Ahmed,     I’m unsure if you received my previous message, however in order to enroll in Cigna-Medicare we would need the following form filled out. We would need this for Nasa Health Clinic, Nasa Urgent Clinic and BHUCC.        Thank you,', NULL, NULL, '2021-08-23 14:33:10', '2021-08-23 14:33:10'),
(11885, 11056, 19929, NULL, '2021-09-07 00:00:00.000', 'In Process', 'Email received from : Michele.Wasson@cigna.com  Sub : SHAMETRIA TANN NP - PARTICIPATION REQUEST  Hello,     Thank you for your credentialing request.  Upon review, verification of hospital privileges is needed. The requirement selected below must be met per the specialty requested:     __x__Provider must have their own active admitting privileges at a Cigna participating hospital or…  Provider has an arrangement with a Cigna participating provider that will admit on their behalf to a Cigna participating hospital or…  Provider has an arrangement with a Hospitalist group to admit on their behalf at a Cigna participating hospital.        ____Provider must have their own active admitting privileges at a Cigna participating hospital, birthing center or surgery center.           Please complete and return the attached verification form to my attention so that further processing of the application can continue.      Thank you     ConnectedCare PROVIDER OPERATIONS  Michele Wasson  Network Solutions & Operations | Provider Services Senior Analyst  Fax 855.757.9700     “Don’t let circumstances or situations define your life.  Use your sweat equity” – Inky Johnson', NULL, NULL, '2021-08-31 09:05:44', '2021-08-31 09:05:44'),
(11886, 11056, 19929, NULL, '2021-09-09 00:00:00.000', 'In Process', 'Email received from : michele.wasson@cigna.com &  DiscoverCigna@information.cigna.com  Sub : Cigna Credentialing Status Update: Application Received  Re:	Reference number 12729352 for SHAMETRIA TANN, NP Application to participate in the Cigna medical network Dear BRAD PETERSON,  Thank you for submitting an application for one of your providers to join a Cigna network. We have received your application and are in the process of reviewing it.  What happens next?  Once the application review is complete, we will begin the credentialing process. This usually takes 90 business days from the date we receive your completed application. In some states, individual mandates may affect turnaround time. We will contact you if there is any missing information.  Once the credentialing process is complete, we’ll let you know if you’ve been approved as a participating provider in the network(s) for which you\'ve applied.  Sincerely,  Cigna  1.800.882.4462  or email OnboardingStatus@Cigna.com.', NULL, NULL, '2021-09-02 10:43:11', '2021-09-02 10:43:11'),
(11887, 11056, 19929, NULL, '2021-09-15 00:00:00.000', 'In Process', 'Email received from : 9PSSCENT@Cigna.com  Sub : FW: [External] Re: SHAMETRIA TANN NP - PARTICIPATION REQUEST  Hello,   Thank you for contacting Cigna.  Your application is currently in process and was received on 08/23/2021.  Your application reference number is BID 12729352   The credentialing process typically takes 60 business days to complete.  However, we are experiencing a higher than normal volume of credentialing request, which may result in some delays in processing your application. Currently, the process can take 90-120 days. We will do our best to process your application as soon as possible.  You will receive an email notification once you have been approved and credentialed as a network-participating provider with your effective date, or to notify you that you have not been approved.  If you have any additional questions, please contact the Provider Services Unit at 800.882.4462.    ConnectedCare PROVIDER OPERATIONS  Shayla Powell  Provider Service Unit | Provider Service Associate T: 1-800-882-4462', NULL, NULL, '2021-09-08 15:22:38', '2021-09-08 15:22:38'),
(11888, 11056, 19929, NULL, '2021-09-23 00:00:00.000', 'In Process', 'Email received from : 9PSSCENT@Cigna.com  Sub : RE: [External] Re: SHAMETRIA TANN NP - PARTICIPATION REQUEST  Hello,  Thank you for contacting Cigna Provider Service Unit according to our records we show that we received the application for SHAMETRIA TANN BID# 12597496 on 05/12/2021 and this closed on 06/27/2021 due to not receiving the contracts back. If you have questions or need any assistance please contact Cigna Provider Service Unit at 800-882-4462  Thank you,  Provider SOLUTIONS & OPERATIONS **Lynette W ** Provider Service Unit T: 800.882.4462', NULL, NULL, '2021-09-16 14:53:47', '2021-09-16 14:53:47'),
(11889, 11056, 19929, NULL, '2021-10-06 00:00:00.000', 'In Process', 'Rep : BIEGO V  Ref code : BIEGO9292021  Status: We have to provide an application again and they will start the credentialing process from the beginning again. It will take 90 -120 days from now.  There is no possiblity for re-opening the last application, but still trying.  medicalonboarding@cigna.com  Contact no .: 800.882.4462', NULL, NULL, '2021-09-29 09:55:05', '2021-09-29 09:55:05'),
(11890, 11056, 19929, NULL, '2021-10-12 00:00:00.000', 'On Hold', 'An email to ask for group contract at psscentral@cigna.com  Sub :  provider services & contracting  In the body : Practice name, NPI, tin, location speciality of the practice contact name, no. fax no.  & email address WIith W-9  After linking Shametria  to the tin.  Because  Cigna need atleast 2 providers.', NULL, NULL, '2021-10-05 12:23:09', '2021-10-05 12:23:09'),
(11891, 3040, 19930, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:54:21', '2021-03-11 17:54:21'),
(11892, 3040, 19930, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:16:02', '2021-03-23 09:16:02'),
(11893, 3040, 19930, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Kindly disregard the Garcia Homero form that was sent out mistakenly. Please find the attached provider contracting form for Naranjo Diego.   If you need any additional information please let me know. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 12:15:42', '2021-03-24 12:15:42'),
(11894, 3040, 19930, NULL, '2021-04-21 00:00:00.000', 'In Process', 'Email sent to: AM.Hidalgo@superiorhealthplan.com  Subject: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-14 14:56:53', '2021-04-14 14:56:53'),
(11895, 1006, 19930, NULL, '2021-04-28 00:00:00.000', 'In Process', 'We received the following update from Daniel Velez Daniel.Velez@superiorhealthplan.com:  Sub: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  \"Good Afternoon,  Diego Naranjo NPI: 1568929800 TIN 815123542 is within Credentialing.  Please allow additional time to process and feel free to proceed requesting status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA  Superior HealthPlan  3900 North 10th Street, Ste 600 McAllen, TX 78501 Direct 1-877-278-4268 Option 3 Fax: 1-866-390-1892  Daniel.Velez@superiorhealthplan.com | SuperiorHealthPlan.com\"', NULL, NULL, '2021-04-21 09:49:02', '2021-04-21 09:49:02'),
(11896, 3040, 19930, NULL, '2021-05-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Please advise me the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-05-05 08:18:32', '2021-05-05 08:18:32'),
(11897, 3040, 19930, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,   Hope you are doing well. I already sent the application for Naranjo, Diego on 03/24/2021 the same day I sent the application for Lira, Arturo A. The application was sent on SHP.NetworkDevelopment@superiorhealthplan.com.   Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you  ', NULL, NULL, '2021-05-31 10:41:06', '2021-05-31 10:41:06'),
(11898, 3040, 19930, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  Provider 1 Provider Name: Naranjo, Diego Provider NPI# 1568929800  Tax ID# 81-5123542', NULL, NULL, '2021-05-31 10:41:51', '2021-05-31 10:41:51'),
(11899, 3040, 19930, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning,  I received a notification from our contract department, “Provider needs to submit an application“.  The packet was sent on 3/24/2021, please respond to their email with the complete application.', NULL, NULL, '2021-05-31 10:42:52', '2021-05-31 10:42:52'),
(11900, 3040, 19930, NULL, '2021-06-07 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Afternoon,  Below please find status for the following providers.  Provider 1: Currently under Credentialing, please allow additional time to process. Provider Name: Naranjo, Diego Provider NPI# 1568929800 Tax ID# 81-5123542  Provider 2: Provider Effective Date 5/1/2021, displays under all three locations. Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502 Tax ID# 81-5123542  Respectfully,  Daniel Velez', NULL, NULL, '2021-05-31 10:44:15', '2021-05-31 10:44:15'),
(11901, 3040, 19930, NULL, '2021-06-24 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO  Good Morning,  Thank you for providing the information, the information was sent to our Contracting department.  Please allow time to review and feel free to continue to request for status updates.  Respectfully,  Daniel Velez Provider Account Manager, Region 4 - Provider Relations Hidalgo SDA', NULL, NULL, '2021-06-17 15:24:15', '2021-06-17 15:24:15'),
(11902, 3040, 19930, NULL, '2021-07-12 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject;Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you ', NULL, NULL, '2021-07-05 14:28:32', '2021-07-05 14:28:32'),
(11903, 3040, 19930, NULL, '2021-07-27 00:00:00.000', 'In Process', 'Email rcvd from: Daniel.Velez@superiorhealthplan.com  Subject: RE: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Good Morning Adil,  Provider Diego Naranjo NPI# 1568929800 Tax ID# 81-5123542 is currently under Credentialing.  Please allow additional time for credentialing and feel free to request status updates.', NULL, NULL, '2021-07-20 07:13:13', '2021-07-20 07:13:13'),
(11904, 3040, 19930, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Email sent to: Daniel.Velez@superiorhealthplan.com  Subject: Re: [SECURE] Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO   Hello Daniel,  Hope you are doing well. I wanted to know the enrollment status for the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.  Practice Details: Practice Name: Valley Med Urgent Care PLLC (All three locations) Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.    Thank you  ', NULL, NULL, '2021-08-27 13:16:17', '2021-08-27 13:16:17'),
(11905, 3040, 19930, NULL, '2021-09-08 00:00:00.000', 'Approved', 'Email rcvd from: ECMExecutionTeam@superiorhealthplan.com  Subject: DIEGO NARANJO WELCOME LETTER  DIEGO NARANJO  VALLEY MED URGENT CARE PLLC  VMUC@CLAIMSMEDINC.COM        Welcome to the Superior HealthPlan network. We are excited to have you as a partner of our growing network of high quality health care professionals. You play a key role as we pursue our commitment to improve the health and well-being of the members we serve.Your records were reviewed and approved by our credentialing committee. You are now able to provide covered services to Superior members.     Your effective date is: 09/01/2021                                                     C/38186   ', NULL, NULL, '2021-09-01 13:50:45', '2021-09-01 13:50:45'),
(11906, 3040, 19931, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:55:05', '2021-03-11 17:55:05'),
(11907, 3040, 19931, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Greetings,  Hope you are doing well. I wanted to enroll the below mentioned providers in the Superior Health plan for our group Valley Med Urgent Care PLLC in all three locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice NPI# 1518404631 Practice Tax ID# 81-5123542 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 101 E. Expressway 83, Suite #170 McAllen , TX 78501-1166 Tertiary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248  Provider 1: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 2: Provider Name: Lira, Arturo Alejandro Provider NPI# 1245789502  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-03-23 09:16:18', '2021-03-23 09:16:18'),
(11908, 3040, 19931, NULL, '2021-03-31 00:00:00.000', 'In Process', 'Email sent to: SHP.NetworkDevelopment@superiorhealthplan.com  Subject:  Add a provider- DIEGO NARANJO/ ARTURO ALEJANDRO  Greetings,   Hope you are doing well. Please find the attached provider contracting form as per previous email requested.   If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-03-24 12:18:12', '2021-03-24 12:18:12'),
(11909, 3040, 19931, NULL, '2021-04-19 00:00:00.000', 'Approved', 'Provider participating with Superior Healthplan. Effective Date: 05/01/2021  Please see attachment. ', NULL, NULL, '2021-04-12 14:22:44', '2021-04-12 14:22:44'),
(11910, 3046, 19932, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:55:09', '2021-03-11 17:55:09'),
(11911, 3040, 19932, NULL, '2021-04-12 00:00:00.000', 'Initiated', 'I had a word with (Crystal B) Community Health Choice representative and she send the request to the credentialing department to adding the provider on directory and it will take up to 07 to 14 days.   Ref: 2324163 Ticket: 343160   ', NULL, NULL, '2021-04-05 14:37:28', '2021-04-05 14:37:28'),
(11912, 1006, 19932, NULL, '2021-06-14 00:00:00.000', 'In Process', 'Sent f/u email @ providerrelationsinquiries@communityhealthchoice.org:  Sub: Enrollment Query - BHUCC - CHC  \"Hello,   I hope you\'re doing well, I wanted to verify if we need to separately enroll the following provider under our group, the information is as follows:  Group Name: Best Health Urgent Care & Clinic NPI# 1013540962  Provider Name: Shametria Tann NPI# 1124615612  Also, our group isn\'t showing up on the provider directory please let me know what is required to get it to show up there.   Thank you. \"', NULL, NULL, '2021-06-07 15:19:41', '2021-06-07 15:19:41'),
(11913, 1006, 19932, NULL, '2021-06-30 00:00:00.000', 'In Process', 'We received the following response from Provider Relations Inquiries ProviderRelationsInquiries@communityhealthchoice.org:  Sub: Enrollment Query - BHUCC - CHC  \"Good Afternoon,  You’re inquiry regarding adding the provider under your group has been forwarded to our Contracting Department (CHC.Contracting@CommunityHealthChoice.org).  A request has been submitted to our Provider Database Department regarding the directory. The ID of your service record is 351776, we will provide a response soon.  Thank you, Provider Relations Dept.\"  Sent f/u email:  \"Hello Kris,  I wanted to verify if both our group and the mentioned providers are now enrolled with CHC or not? Their information is as follows:  Group Name: Best Health Urgent Care & Clinic NPI# 1013540962 TIN# 84-4737737  Provider Name: Shametria Tann NPI# 1124615612  Provider Name: Stephane Cyriaque NPI# 1780192633  Please let me know if you have any questions. Thank you!\" ', NULL, NULL, '2021-06-23 10:16:44', '2021-06-23 10:16:44'),
(11914, 1006, 19932, NULL, '2021-07-15 00:00:00.000', 'Approved', 'Received update from Provider Relations Inquiries ProviderRelationsInquiries@communityhealthchoice.org:  Sub; Enrollment Query - BHUCC - CHC  \"Good Afternoon,  The issue has been resolved and the group is now showing in the directory.\"  Confirmation is attached for reference.   Eff: 2021-01-28', NULL, NULL, '2021-07-08 17:20:44', '2021-07-08 17:20:44'),
(11915, 3046, 19933, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:55:36', '2021-03-11 17:55:36'),
(11916, 1006, 19933, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:11:57', '2021-04-16 10:11:57'),
(11917, 3040, 19934, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:56:10', '2021-03-11 17:56:10'),
(11918, 3040, 19934, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Group enrolled in all three locations.    Contract attached ', NULL, NULL, '2021-03-23 09:55:16', '2021-03-23 09:55:16'),
(11919, 3046, 19935, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:56:35', '2021-03-11 17:56:35'),
(11920, 3040, 19935, NULL, '2021-04-12 00:00:00.000', 'Not Eligible', 'From: Melinda.Lopez@dchstx.org Sub: Request for Contract Stephane Cyriaque FNP  Hello Samuel, I want to acknowledge receipt of the completed request for contract form submitted for Stephane Cyriaque FNP however cannot process due to Missouri City TX is not in our service area and we do not have any members that reside in this area.  The request for contract is being withdrawn due to not in our service area. Please refer to the map below of the 24 counties within our service area.', NULL, NULL, '2021-04-05 14:41:14', '2021-04-05 14:41:14'),
(11921, 3046, 19936, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:56:37', '2021-03-11 17:56:37'),
(11922, 1006, 19936, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:03', '2021-04-16 10:12:03'),
(11923, 3040, 19937, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:57:00', '2021-03-11 17:57:00'),
(11924, 3040, 19937, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: intake_pdm@cigna.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Escobar, Angiollet Solis, Naranjo, Diego, Garcia, Homero || Cigna ||  Greetings,  Hope you are doing well. Please find the attached letter of interest for adding the provider in additional locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  Provider 1: Provider Name: Escobar, Angiollet Solis Provider NPI# 1962917997  Provider 2: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 3: Provider Name: Garcia, Homero Provider NPI# 1730564857  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you', NULL, NULL, '2021-03-23 12:33:51', '2021-03-23 12:33:51'),
(11925, 3040, 19937, NULL, '2021-04-20 00:00:00.000', 'Approved', 'Location added in provider directory. ', NULL, NULL, '2021-04-13 16:35:59', '2021-04-13 16:35:59'),
(11926, 3040, 19938, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:57:43', '2021-03-11 17:57:43'),
(11927, 3040, 19938, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider added in location.   Please see attachment ', NULL, NULL, '2021-03-23 10:06:30', '2021-03-23 10:06:30'),
(11928, 3040, 19939, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:58:04', '2021-03-11 17:58:04'),
(11929, 3040, 19939, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Cigna in all three locations.   Please see attachment.', NULL, NULL, '2021-03-23 10:20:14', '2021-03-23 10:20:14'),
(11930, 3040, 19940, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:58:25', '2021-03-11 17:58:25'),
(11931, 3040, 19940, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Effective date of the requested information 01/28/2020', NULL, NULL, '2021-03-23 10:24:25', '2021-03-23 10:24:25'),
(11932, 3046, 19941, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:58:36', '2021-03-11 17:58:36'),
(11933, 3040, 19941, NULL, '2021-04-12 00:00:00.000', 'Not Eligible', 'Minimum 15 providers need to be in a facility for group contract.  Ref: 5866264', NULL, NULL, '2021-04-05 14:57:36', '2021-04-05 14:57:36'),
(11934, 3046, 19942, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:58:42', '2021-03-11 17:58:42'),
(11935, 1006, 19942, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:09', '2021-04-16 10:12:09'),
(11936, 3040, 19943, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 17:58:48', '2021-03-11 17:58:48'),
(11937, 3040, 19943, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: intake_pdm@cigna.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Escobar, Angiollet Solis, Naranjo, Diego, Garcia, Homero || Cigna ||  Greetings,  Hope you are doing well. Please find the attached letter of interest for adding the provider in additional locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  Provider 1: Provider Name: Escobar, Angiollet Solis Provider NPI# 1962917997  Provider 2: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 3: Provider Name: Garcia, Homero Provider NPI# 1730564857  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you', NULL, NULL, '2021-03-23 12:33:57', '2021-03-23 12:33:57'),
(11938, 3040, 19943, NULL, '2021-04-20 00:00:00.000', 'Approved', 'Location added in provider directory. ', NULL, NULL, '2021-04-13 16:33:18', '2021-04-13 16:33:18'),
(11939, 3046, 19944, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:00:12', '2021-03-11 18:00:12'),
(11940, 1006, 19944, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:14', '2021-04-16 10:12:14'),
(11941, 3040, 19945, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:00:26', '2021-03-11 18:00:26'),
(11942, 3040, 19945, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in McAllen Location ', NULL, NULL, '2021-03-23 10:35:53', '2021-03-23 10:35:53'),
(11943, 3046, 19946, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:01:17', '2021-03-11 18:01:17'),
(11944, 3040, 19946, NULL, '2021-04-12 00:00:00.000', 'Not Eligible', 'I had a word with (Melanie) Galaxy Health representative and she said for the group contract we need at least 02 providers in the group.   Ref: Melanie 04/05/2021', NULL, NULL, '2021-04-05 15:47:56', '2021-04-05 15:47:56'),
(11945, 11056, 19946, NULL, '2021-08-05 00:00:00.000', 'Approved', 'Approval Email received from : cguerue@ghn-mci.com  Sub : Enrollment Status || Best Health Urgent Care & Clinic || Tann, Shametria || Galaxy Health ||  Thank you Ahmed, this works perfectly and I have now marked all paperwork complete, the new group’s eff date is 7/27/21, providers Tann and Cyriaque will be linked to the group eff 7/27/21 as well.  Also, I have attached a copy of the fully executed agreement for your files.     Please feel free to contact me with any questions…  Thank you and have a good day!   The agreement has been attached. Please see the attachment.', NULL, NULL, '2021-07-28 15:57:29', '2021-07-28 15:57:29'),
(11946, 3040, 19947, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:02:18', '2021-03-11 18:02:18'),
(11947, 3040, 19947, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Group enrolled in all three locations.   Contract attached ', NULL, NULL, '2021-03-23 09:55:14', '2021-03-23 09:55:14'),
(11948, 3046, 19948, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:02:37', '2021-03-11 18:02:37'),
(11949, 3040, 19948, NULL, '2021-04-12 00:00:00.000', 'Initiated', 'Email sent to: pr.south@healthsmart.com  Subject: Group Contract || Best Health Urgent Care & Clinic || Health Smart ||  Greetings,  Hope you are doing well. Can you please advise me the process for the group contract under the below mentioned practice.  Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B  MISSOURI CITY , TX 77489-5242  If you need any additional information please let me know. Waiting to hear from you soon.   Thanks ', NULL, NULL, '2021-04-05 16:50:45', '2021-04-05 16:50:45'),
(11950, 1006, 19948, NULL, '2021-06-16 00:00:00.000', 'Not Eligible', 'Healthsmart does not do group enrollment, group enrollment is done via Anci-Care for Healthsmart. ', NULL, NULL, '2021-06-09 15:30:45', '2021-06-09 15:30:45'),
(11951, 3040, 19949, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:02:39', '2021-03-11 18:02:39'),
(11952, 3040, 19949, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Cigna.   Please see attachment. ', NULL, NULL, '2021-03-23 10:02:08', '2021-03-23 10:02:08'),
(11953, 3046, 19950, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:02:40', '2021-03-11 18:02:40'),
(11954, 1006, 19950, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:20', '2021-04-16 10:12:20'),
(11955, 3040, 19951, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:03:00', '2021-03-11 18:03:00'),
(11956, 3040, 19951, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: intake_pdm@cigna.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Escobar, Angiollet Solis, Naranjo, Diego, Garcia, Homero || Cigna ||  Greetings,  Hope you are doing well. Please find the attached letter of interest for adding the provider in additional locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  Provider 1: Provider Name: Escobar, Angiollet Solis Provider NPI# 1962917997  Provider 2: Provider Name: Naranjo, Diego Provider NPI# 1568929800  Provider 3: Provider Name: Garcia, Homero Provider NPI# 1730564857  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you', NULL, NULL, '2021-03-23 12:34:03', '2021-03-23 12:34:03'),
(11957, 3040, 19951, NULL, '2021-04-20 00:00:00.000', 'Approved', 'Location added in provider directory. ', NULL, NULL, '2021-04-13 16:48:11', '2021-04-13 16:48:11'),
(11958, 3040, 19952, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:03:22', '2021-03-11 18:03:22'),
(11959, 3040, 19952, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Provider enrolled in Cigna in all three locations.   Please see attachment.  ', NULL, NULL, '2021-03-23 10:19:58', '2021-03-23 10:19:58'),
(11960, 3040, 19952, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Cigna in all three locations.   Please see attachment.', NULL, NULL, '2021-03-23 10:20:06', '2021-03-23 10:20:06'),
(11961, 3040, 19953, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:03:42', '2021-03-11 18:03:42'),
(11962, 3040, 19953, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Cigna. ', NULL, NULL, '2021-03-23 10:31:29', '2021-03-23 10:31:29'),
(11963, 3040, 19954, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:04:19', '2021-03-11 18:04:19'),
(11964, 3040, 19954, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: intake_pdm@cigna.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Rodriguez, Cynthia || Cigna ||  Greetings,  Hope you are doing well. Please find the attached letter of interest for adding the provider in additional locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  Provider 1: Provider Name: Rodriguez, Cynthia Provider NPI# 1124282553  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you', NULL, NULL, '2021-03-23 12:48:44', '2021-03-23 12:48:44'),
(11965, 3040, 19954, NULL, '2021-04-02 00:00:00.000', 'Approved', 'Location added. Please see attachment. ', NULL, NULL, '2021-03-26 08:50:38', '2021-03-26 08:50:38'),
(11966, 3040, 19955, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:05:37', '2021-03-11 18:05:37'),
(11967, 3040, 19955, NULL, '2021-03-30 00:00:00.000', 'Approved', 'ffective date of the requested information 01/28/2020', NULL, NULL, '2021-03-23 10:24:30', '2021-03-23 10:24:30'),
(11968, 3040, 19956, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:05:59', '2021-03-11 18:05:59'),
(11969, 3040, 19956, NULL, '2021-03-30 00:00:00.000', 'Approved', 'Provider enrolled in Cigna. ', NULL, NULL, '2021-03-23 10:31:35', '2021-03-23 10:31:35'),
(11970, 3040, 19957, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:06:21', '2021-03-11 18:06:21'),
(11971, 3040, 19957, NULL, '2021-03-30 00:00:00.000', 'Initiated', 'Email sent to: intake_pdm@cigna.com  Subject: Location Addition || Valley Med Urgent Care PLLC || Rodriguez, Cynthia || Cigna ||  Greetings,  Hope you are doing well. Please find the attached letter of interest for adding the provider in additional locations.   Practice Details: Practice Name: Valley Med Urgent Care PLLC Practice Tax ID# 81-5123542 Practice NPI# 1518404631 Primary Address: 2534 Boca Chica Blvd Brownsville , TX 78521-3496 Secondary Address: 800 E Alton Gloor Blvd Brownsville , TX 78526-4248 Tertiary Address: 101 E. Expressway 83, Suite #170  McAllen , TX 78501-1166  Provider 1: Provider Name: Rodriguez, Cynthia Provider NPI# 1124282553  If you need any additional information please feel free to call or email me. Waiting to hear from you soon.   Thank you', NULL, NULL, '2021-03-23 12:48:53', '2021-03-23 12:48:53'),
(11972, 3040, 19957, NULL, '2021-04-02 00:00:00.000', 'In Process', 'Email sent to: intake_pdm@cigna.com  Subject: Re: Location Addition || Valley Med Urgent Care PLLC || Rodriguez, Cynthia || Cigna ||  Greetings,   I received an email from PDM Cigna regarding the above email and it stated that your request has been completed, but when I checked the provider directory it showed only one address was updated which is (2534 Boca Chica Blvd Brownsville , TX 78521-3496) and the other address (800 E Alton Gloor Blvd Brownsville , TX 78526-4248) is not updated yet and I requested to add the both addresses at the same time.   Thank you ', NULL, NULL, '2021-03-26 08:49:35', '2021-03-26 08:49:35'),
(11973, 3040, 19957, NULL, '2021-04-20 00:00:00.000', 'Approved', 'Location added in provider directory. ', NULL, NULL, '2021-04-13 16:46:51', '2021-04-13 16:46:51'),
(11974, 3046, 19958, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:08:56', '2021-03-11 18:08:56'),
(11975, 3040, 19958, NULL, '2021-04-12 00:00:00.000', 'Initiated', 'Email sent to: humanahoustonPD@humana.com  Subject: Group Contract Request || Best Health Urgent Care & Clinic || Humana ||  Greetings,  Hope you are doing well. I had a word with Shane S Humana representative and she advised that you can request the copy of the group contract through email. Can you please send me the copy of the contract for the below mentioned facility.   Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B  MISSOURI CITY , TX 77489-5242  If you need any additional information please let me know. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-04-05 16:50:05', '2021-04-05 16:50:05'),
(11976, 1006, 19958, NULL, '2021-06-16 00:00:00.000', 'In Process', 'Email sent to: humanahoustonpd@humana.com  Subject: Enrollment Status || Best Health Urgent Care & Clinic || Tann, Shametria || Humana ||  Greetings,   Hope you are doing well. I wanted to know the enrollment status for the below mentioned provider in our group Best Health Urgent Care & Clinic under the below location.   Practice Details: Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242  Provider Details: Provider Name: Tann, Shametria Provider NPI# 1124615612  Please get back to me as soon as you can get a chance. Waiting to hear from you soon.   Thank you ', NULL, NULL, '2021-06-09 16:16:55', '2021-06-09 16:16:55'),
(11977, 11056, 19958, NULL, '2021-07-05 00:00:00.000', 'In Process', 'Email sent to : HumanaHoustonPD@humana.com  Sub : Enrollment Status || Best Health Urgent Care & Clinic || Tann, Shametria || Humana ||  Greetings,  Hope you are doing well. Kindly provide us the welcome letter or the contract as soon as possible. We\'ll be waiting for that eagerly.  Practice Details: Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# : 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242    Provider Details:  Provider Name: Tann, Shametria Provider NPI# 1124615612  Thank you!', NULL, NULL, '2021-06-28 12:28:57', '2021-06-28 12:28:57'),
(11978, 11056, 19958, NULL, '2021-07-20 00:00:00.000', 'In Process', 'Email received from : HumanaHoustonPD@humana.com  Sub : Enrollment Status || Best Health Urgent Care & Clinic || Tann, Shametria || Humana ||  Please read the following instructions carefully:  For the following requests (fee schedules, copies of contracts, network participation, credentialing status, or effective dates) call provider relations at 800-448-6262 or 800-626-2741. All maintenance requests (provider adds, terms and changes)  need to be sent through Humanahoustonpd@humana.com.  Note:  This mailbox is only for these intents (adds, terms, changes). Requests for fee schedules, copies of contracts, network participation, credentialing status, or effective dates will not be processed through this mailbox.  Allow 60 days for processing of new applicants submission. Allow 30 days for processing of terminations and demographic updates. Status requests should be sent on your original email submission for tracking purposes. Please do not send direct emails to associates as there may not be a response to your request, and the request will not be processed.  In addition, please do not cc a Humana associate on your email requests to the above mailbox or this may delay the processing of your request. Disputing a claim paid/denied and appeals: contact humanaproviderservices@humana.com Log on to Humana.com or Availity.com for Provider updates, claim inquiries, eligibility/benefits information, fee schedule inquiries and more! For Humana.com issues and password resets, please call a Humana Web Specialist at 877-845-3480.    Thank you,  HumanaHoustonPD', NULL, NULL, '2021-07-13 14:07:04', '2021-07-13 14:07:04'),
(11979, 11056, 19958, NULL, '2021-07-29 00:00:00.000', 'In Process', 'I had words with Aya A for the practice and provider\'s approval letter. She informed me by their policy that they don\'t provide the approval letter to the Specialty of Nurse Practitioner or not to the practice either for this specialty. But they are in network with Humana and par in Humana as HMO & PPO . The eff. date is  : 04/01/2021. Ref code : 2000193367970', NULL, NULL, '2021-07-22 13:09:30', '2021-07-22 13:09:30'),
(11980, 11056, 19958, NULL, '2021-08-03 00:00:00.000', 'In Process', 'I have words with Jayson about the approval again But she said the same as Aya A. There is no credentialing of NP. But she informed me the procedure related to showing up of the provider in the directory. The provider is linked with the Tax ID of practice and participating with Humana. Plans :     1. Humana HMO       2. Humana PPO      3. Medicare PPO     4.Choice care PPO Ref no. : 2000193784179  We have to sent a LOI with provider roster and W-9 at npxnm@humana.com', NULL, NULL, '2021-07-26 14:31:08', '2021-07-26 14:31:08'),
(11981, 11056, 19958, NULL, '2021-08-11 00:00:00.000', 'In Process', 'Email sent to : HumanaHoustonPD@humana.com  Sub : Enrollment Documents - BHUCC - Humana  Good evening!  Hope you are doing well. Here are the documents W-9 attached with LOI and providers rosters you requested for the practice / group enrollment mentioned below:  Practice Details: Practice Name: Best Health Urgent Care & Clinic Practice Tax ID# 84-4737737 Practice NPI# 1013540962 Practice Address: 3003 TEXAS PKWY UNIT B MISSOURI CITY , TX 77489-5242  Provider Details: Provider Name : Tann, Shametria Provider NPI # : 1124615612  Provider Name : Cyriaque, Stephane Provider NPI # : 1780192633  Furthermore, If you need any documents or information feel free to contact me. Waiting for your response, eagerly.  Thank you! Have a Great Day!', NULL, NULL, '2021-08-03 16:29:43', '2021-08-03 16:29:43'),
(11982, 11056, 19958, NULL, '2021-08-17 00:00:00.000', 'In Process', 'Email received from : HumanaHoustonPD@humana.com  Sub : Enrollment Documents - BHUCC - Humana  Please advise who you spoke with.  You indicate this information was requested by this mailbox, yet I find no record of this request.  Both of these practitioners are already in the Humana system and linked to this TIN.', NULL, NULL, '2021-08-10 11:39:59', '2021-08-10 11:39:59'),
(11983, 11056, 19958, NULL, '2021-08-24 00:00:00.000', 'In Process', 'Email sent to :   HumanaHoustonPD@humana.com  Sub : Enrollment Documents - BHUCC - Humana  Good morning!  Hope you are doing well. I had spoken to one of your representatives and She had advised me to send both providers\' roster and LOI for the facility approval  If both providers are in the Humana system and linked to the TIN, please provide us the approval letter for both providers with the effective date soon.  If you need any information or documents please feel free to reach out to me. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-16 14:50:04', '2021-08-16 14:50:04'),
(11984, 11056, 19958, NULL, '2021-08-31 00:00:00.000', 'In Process', 'Email received from : HumanaHoustonPD@humana.com  Sub : Enrollment Documents - BHUCC - Humana  Did you ask customer service for the approval letter?  We do not have access to them.   Replied :   Good morning!  Hope all is well. Yeah I asked about the approval letter because she informed me that credentialing of the provider is in the last stages. Please provide me with the latest updates soon.  If you need any information from me please let me know. Waiting to hear from you soon.  Thank you! Have a great day!', NULL, NULL, '2021-08-23 14:46:05', '2021-08-23 14:46:05'),
(11985, 11056, 19958, NULL, '2021-09-08 00:00:00.000', 'Approved', 'I have words with Marjorie. She informed me that the group is active  eff date is : 6/1/2020  Humana HMO Humana PPO Humana Medicare Choice care PPO & HMO Medicare private C  Call interaction code : 2000198840082  Please see the attachment.', NULL, NULL, '2021-08-31 14:47:47', '2021-08-31 14:47:47'),
(11986, 11056, 19958, NULL, '2021-09-08 00:00:00.000', 'Approved', 'Email received from : mnario@humana.com  Sub : Humana Partipation_Best Health Urgent Care and Clinic  Hello Ahmed,     Good afternoon!     As requested, sending the items discussed over the phone earlier under Interaction# 2000198840082.     ·         The practice is participating with Humana HMO, Medicare PPO, Medicare PFFS, Humana PPO and ChoiceCare PPO effective 6/1/2021.  ·         Shametria Tann FNP eff 4/1/2021  ·         Stephane Cyriaque MSN eff 6/1/2020     Thank you,       Marjorie Mae Nario  Frontline Leader | Provider Relations     Humana  HGS Manila     T 800 626 2741  F 888 274 1963  mnario@humana.com     Humana.com  ', NULL, NULL, '2021-08-31 14:49:58', '2021-08-31 14:49:58'),
(11987, 3046, 19959, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:09:12', '2021-03-11 18:09:12'),
(11988, 1006, 19959, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:26', '2021-04-16 10:12:26'),
(11989, 3046, 19960, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-11 18:10:44', '2021-03-11 18:10:44'),
(11990, 1006, 19960, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:31', '2021-04-16 10:12:31'),
(11991, 3046, 19961, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-12 12:09:02', '2021-03-12 12:09:02'),
(11992, 3040, 19961, NULL, '2021-04-13 00:00:00.000', 'Approved', 'Medicaid No: 409228001 Effective Date: 02/25/2020', NULL, NULL, '2021-04-06 10:10:13', '2021-04-06 10:10:13'),
(11993, 3046, 19962, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-12 12:09:44', '2021-03-12 12:09:44'),
(11994, 1006, 19962, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:37', '2021-04-16 10:12:37'),
(11995, 11056, 19962, NULL, '2021-08-28 00:00:00.000', 'Initiated', 'adeoye-bhucc Application Status : Submitted PEP Ticket Number : 18024430', NULL, NULL, '2021-08-20 16:42:32', '2021-08-20 16:42:32'),
(11996, 11056, 19962, NULL, '2021-09-03 00:00:00.000', 'In Process', 'Deficiency issue resolved of Medicare ID  Enrollment Application Status   Application Status :  In Progress	 PEP Ticket Number  :    18024430 ', NULL, NULL, '2021-08-27 10:22:04', '2021-08-27 10:22:04'),
(11997, 11056, 19962, NULL, '2021-09-21 00:00:00.000', 'Approved', 'Portal Ticket #     Application Nam     NPI	            Status Update Date   	     Transction Type	                       Status	   18024430	     adeoye-bhucc	   1629418025	        9/3/2021     Enrollment - First Time Applicant	    Closed Approved   Eff date is :  07/15/2021', NULL, NULL, '2021-09-14 10:41:08', '2021-09-14 10:41:08'),
(11998, 3046, 19963, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-12 12:14:09', '2021-03-12 12:14:09'),
(11999, 3040, 19963, NULL, '2021-04-13 00:00:00.000', 'Approved', 'Medicare ID	        1A1121  Practice Location Name	 BEST HEALTH URGENT CARE & CLINIC	  Practice Location Address	 3003 TEXAS PKWY UNIT B MISSOURI CITY TX 77489	  Effective Date	 02/25/2020	 ', NULL, NULL, '2021-04-06 10:32:19', '2021-04-06 10:32:19'),
(12000, 3046, 19964, NULL, NULL, 'New/Not Initiated', NULL, NULL, NULL, '2021-03-12 12:15:05', '2021-03-12 12:15:05'),
(12001, 1006, 19964, NULL, '2021-04-23 00:00:00.000', 'Not Eligible', 'Segun is a supervising physician for Stephane, we only enrolled him under Cigna for billing purposes. We can\'t enroll him in any other insurances unless required and given a go-ahead from both Stephane & Segun. ', NULL, NULL, '2021-04-16 10:12:43', '2021-04-16 10:12:43'),
(12002, 11056, 19964, NULL, '2021-07-22 00:00:00.000', 'Initiated', 'Received Permission from the Provider.  Applicant Name: BEST HEALTH URGENT CARE & CLINIC  Tracking ID: T071420210004817  Submitted Date: WED - JULY 14 2021 06:20:32 PM EST  Submitted By: Stephane Cyriaque  Contact Email(s): FANFAN0503@HOTMAIL.COM BHUCC@CLAIMSMEDINC.COM', NULL, NULL, '2021-07-14 17:25:55', '2021-07-14 17:25:55');
