First Health Network: Provider Nomination

*State
*Are you a Workers' Comp provider?

Yes
No
*This is Nomination for:

General network
New York MetraComp network
*Specialty:
- Panel Closed for Mental Health Providers
  Non Mental Health Providers call: 1-800-833-7423, Option #2
- Providers, please visit the health plan's website or Fax Request to: 1-954-858-3438
- Providers call 1-800-470-2004 ext 2501
- Providers office needs to fax request to: 1-866-341-0408.
  Only faxed nominations will be accepted.
- Providers Call: 1-630-737-7412
- Panel Closed for Mental Health Providers
  
  Non Mental Health Providers call 1-800-470-6352 and ask to be transferred to Provider Relations.
  Provider may be asked their County to assist in directing them to the appropriate contractor.
- Panel Closed for Mental Health Providers
  Non Mental Health Providers please visit the health plan website.
- Providers, please visit the health plan's website or Fax Request to: 1-866-290-0904
- Panel Closed for Mental Health Providers
  Non Mental Health Providers call: 1-800-833-7423, Option #2
- Panel Closed for Mental Health Providers
  Non Mental Health Providers call: 1-800-755-5242
- Panel Closed for Mental Health Providers
  Non Mental Health Providers call: 1-402-995-7167 or 1-800-471-0240 ext. 7167
- Provider office needs to fax request to: 1-702-515-3150 ATTN: Provider Relations
  Only faxed nominations will be accepted.
- Panel Closed for Mental Health Providers
  Non Mental Health Providers office may send request by either: Fax 1-919-337-1888 or Email to: ContractNominations@cvty.com
  
  Only faxed or emailed nominations will be accepted.
- Non Mental Health Providers call: 1-800-735-2202 if you are in the following counties:
  Ashtabula, Belmont, Columbiana, Harrison, Jefferson, Mahoning & Trumbul
- Providers office call: 1-405-945-1236
- Panel Closed for Mental Health Providers.
  
  Non Mental Health Providers call and ask to be transferred to Provider Relations:
  Western PA 1-800-735-2202
  Central PA 1-800-788-5448
  Eastern PA 1-800-788-5448
- Panel Closed for Mental Health Providers.
  Non Mental Health Providers office may send request by either: Fax 1-919-337-1888 or Email to: ContractNominations@cvty.com
  
  Only faxed or emailed nominations will be accepted.
- Panel Closed for Mental Health Providers.
  
  Non Mental Health Providers in eastern South Dakota call: 1-800-470-6352 and ask to be transferred to Provider Contracting.
- Providers call: 1-901-462-2380, Option 3 if you are in the following counties:
  Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Henry, Humphreys, Lake, Lauderdale, Madison, McNairy, Obion, Shelby, Tipton, Wayne, Weakley
  
  All other providers call: 1-800-937-6824
- Provider office needs to fax request to: 1-866-341-0408.
  Only faxed nominations will be accepted.
- Mental Health providers call: 1-800-937-6824
  
  Non Mental Health Providers call:
  Richmond area 1-800-424-0077
  Charlottesville area 1-800-975-1213
  Roanoke area 1-800-240-4345
- Providers office call: 1-888-388-1744
- Providers office needs to fax request to: 1-866-341-0408.
  Only faxed nominations will be accepted.
- Acupuncturist
- Advanced Practice Nurse
- Ambulatory Surgery Center
- Anesthesia
- Assisted Living Centers
- Audiologist
- Autism Councilors (need to be BCBA certified)
- Behavioral Analyst
- Certified Nurse Midwife
- Certified Registered Nurse Anesthetists
- Chiropractor
- Dentist
- Dialysis Clinics
- Dietician
- Durable Medical Equipment
- Emergency Room Physician
- Home Health Care
- Hospice
- Hospitalist
- Hospitals or In-patient Facilities
- Imaging Facilities / Radiological facilities (MRI, PET Scan, etc)
- Infusion Care
- Laboratory
- Licensed Professional Counselor
- Marriage and Family Counselors
- Massage Therapist
- Mobile Imaging Providers (MRI, PET Scan, etc)
- Naturopath
- Nurse Practitioner
- Occupational Therapist
- Optometrist
- Oral and Maxillofacial Surgeons
- Pathologist
- Pharmacy
- Physical Therapist
- Physician Assistant
- Physician Clinics
- Physician Specialties (MD, DO)
- Podiatry
- Psychiatrist (MD or DO)
- Psychologist (PhD)
- Radiologist
- Registered Nurse
- Skilled Nursing Facilities
- Sleep Centers / Sleep Facilities
- Social Worker
- Speech Pathology / Speech Therapist

*Physician First Name
*Physician Last Name
*Phone number
Fax number
*Email Address
*Primary Office Address Line 1
Primary Office Address Line 2
*City
County
*State
*Zip Code
*Office Contact
*Degree of Provider
Is the provider a member of a group practice? Yes No
Group Name (required if the provider is a member of a group)
*Tax ID
National Provider Identifier(NPI)
CAQH ID Number(if applicable)

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Provider Nomination

First Health

Coventry Health Care