PROVIDER REQUEST FOR PRECERTIFICATION
Certain procedures or other services may require pre-approval depending on the specific employer precertification guidelines. Determining if pre-approval is necessary can be done when verifying the benefits of a member.
If Precertification is required, Provider will need to complete the request form below and send to Crescent Health Management Department with corresponding medical records documenting the need for such service. You will receive a response back within 24-48 hours. Approval will be provided in the form of a precertification number. If not approved, a denial letter will be provided to the insured explaining the reason for denial and including instructions for appeal.
If you are a credentialed provider and need to update your information, please supply a written explanation of any practice changes and then complete the Provider Demographic form below (#5) and a new W-9 if required (#7). This information should be submitted to the Director of Provider Relations, Deana Gardner at email@example.com or you may call (828) 670-9145 ext. 110.
If you are not yet credentialed by Crescent Health Solutions, you may follow the steps below to complete your request.
Crescent Health Solutions received URAC accreditation for Provider Credentialing in May 2015, ensuring employers and their members that we are compliant with national credentialing standards and committed to quality healthcare.
The forms below will assist new providers in applying to join the Crescent Provider Network, and existing providers to be recredentialed with the network and to add new providers to their practice.
NEW Physician Providers and NEW Allied Health Providers Application Forms – Complete and submit forms 1-7. NOTE: 2 and 3 have Physician and Allied options, complete the applicable form.
RECREDENTIALING for Existing Providers / ADDING NEW PROVIDERS to Existing Practice - Complete and submit forms 1, 4, and 7
4. NCDOI Uniform Application - PDF
NC DOI Uniform Application- Word
5. Provider Demographic Sheet - PDF
Provider Demographic Sheet - Word
7. W-9 Form
To ensure timely processing of your application:
◦ Complete the application in its entirety
◦ Remember to sign and date the application
◦ Attach copies of the following along with all other items listed on Page 2 of the NC Uniform Application:
◦ State License
◦ Face sheet of your current professional liability insurance policy
◦ Certificate from Specialty Board
◦ Curriculum Vitae or work history (account for any gaps in work history greater than 6 months)
◦ Provide an explanation for all “Yes” responses on the “Professional Information” questionnaire
Please send your completed application to:
Crescent Health Solutions
1200 Ridgefield Blvd., Ste. 215
Asheville, NC 28806
FAX: ATTN: Credentialing 828-670-9155