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Internal Provider

Assistance

Please submit the form below to contact Provider Relations for assistance.  Required fields have a red line at the beginning of the field. Please fill out the form to the best of your ability with as much information as possible. Not all fields may apply to your request.

If you would like to submit a Provider Ticket Submission Form using a mobile device or tablet, please CLICK HERE for our mobile-friendly form.


Internal Ticket Submission Form
Submitter First Name  
Submitter Last Name  
Submitter Email  
Submitter Phone  
Category   
Subject  
Description of Assistance Need   
Agency Type   
Region   
Provider Specialty  
Provider Name  
Provider Phone  
Member Name  
Member ID  
Member Date of Birth   
Member Phone  
Priority   
Attachment   
Attach files
Each of your file(s) can be up to 20MB in size.
   
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Assistance Category Definitions & Notes:

  • Provider recruitment requests – Ask non-par provider to join network

  • Single case agreement requests – CM sends provider/services needed for SCA

  • Provider information update – Provider information incorrect on provider file/search tool (phone number, address, services rendered, etc.)

  • Provider needs re-education – Par provider advises member/caregiver/CM that they are non-par

  • Claim or authorization issue – NDPR should only get these from providers, but in the case where a CM is informed of an issue related to a claim or auth, they can file it here

  • Directory assistance – This should only be used after reviewing provider directory and exhausting NDPR SharePoint resources

  • General inquiry/information only – miscellaneous

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