By notifying CenCal Health with any practice changes, you are not only complying with your Provider Agreement, but you ensure that CenCal Health is in compliance with the Department of Health Care Services provider data regulations.
The following are changes that require attention:
- Change "Mail-To" and "Pay-To" addresses
- Adding additional rendering physicians
- Add business owners,officers, and managers
- Change in member age range/quantity of members you are willing to accept
- Change to office hours
- Change to languages capabilities provided at your office
Downloadable CenCal Health Provider Roster Template
Please submit changes related to your practice, and/or if you have more than one provider within your practice, via our new downloadable CenCal Health Roster. As a Managed Care Plan, CenCal Health is required to submit a comprehensive roster, which includes all contracted providers, on a monthly basis to the State of California. By using this helpful tool, we are asking for you to partner with us to ensure accurate reporting to the State.
Provider Information Form
Please submit changes on this form if your practice, and/or provider have individual updates. Rosters are highly recommended if you have more than one change within your practice.
W-9 Taxpayer Information Form
If you are a Contracted Provider and have changes to your Tax ID Number, DBA, or legal business name, please submit a new W-9 to CenCal Health. Please submit this document to CenCal Health's Provider Services Department via fax at (805) 681-3019 or email firstname.lastname@example.org.
If you are a Non-Contracted Provider and have changes to your Tax ID Number, DBA, or legal business name, please submit a new W-9 to CenCal Health. Please submit this document to CenCal Health's Provider Services Department via fax at (805) 681-3015 or email email@example.com.
Signing up for EFT or changing EFT information
Please visit our Provider Portal to create a new EFT account. To make changes, please download the Electronic Funds Transfer (EFT) Enrollment Form and email us the completed form to firstname.lastname@example.org or contact our Finance Department at (805) 562-1081.
Moving or Retiring?
If you decide to leave CenCal Health, please submit a notification letter via email to CenCal Health. Sixty (60) day advance notification is required for address changes, retirement, or resignation from CenCal Health.
All of these forms can be emailed to email@example.com. For questions, please contact your Provider Services Representative or contact the Provider Service's main line at (805) 562-1676.