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Provider Contract

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Contract Practice Form Provider Form

In order to reduce the amount of paper in the provider contracting process, InterGroup Services provides an on-line version of our provider contract that you can download and view. The file is password protected. To review the contract please contact a Provider Relations representative at 800-537-9389. If you received a contract packet in the mail with the corresponding rate information, please go to the Signature page of the document to retrieve the password.

 

You do not need to return a copy of the contract, please keep a copy for your records.

 

You will need to return the following documents to InterGroup to complete the contract process:

 

Items 1 & 2 will be sent to you from InterGroup. Please complete these and return with the items 3.

 

  1. Exhibit III
  2. Signature Page
  3. Practice and Provider Form.

 

These may be faxed to 610-695-2531; emailed to adavis@igs-ppo.com; or mailed to InterGroup Services Provider Relations 1 S Bacton Hill Rd 2nd Floor, Malvern, PA 19355

 

Missing information may delay the processing of your contract. Retain the contract for your records. We suggested that you keep a copy of your completed Exhibit III and Signature page for your files.

 

The provider form is a general information form and is not particular to any one specialty. Complete all portions that are applicable for any individual providers that you wish to have listed in the network under this contract. If you are completing a contract for a free standing facility, acute care hospital or specialty hospital, you are not required to complete a Provider Form.

 

Reimbursement information is under Exhibit III. Please pay special attention to this section as it contains detailed information regarding network pricing. Fee schedules are based on the current year Medicare physician allowable rates as established on or about the first of the year by CMS. If your contract has a fee schedule, the rate will be listed as a multiplier of that Medicare rate. Any CPT that does not have an established rate by Medicare will have a default discount established. These discounts are indicated on Exhibit III and will be a discount from your billed charges.

 

If your contract only lists a discount and no fee schedule multiplier is listed (or NA is listed under the fee schedule), then the contracted rate will be the discount listed. The discount will apply to your billed charges.

 

Please pay special attention to all opt in/out sections of Exhibit III as there are multiple network offerings that are available through InterGroup.

 

Please make sure that all required signatures areas are signed before returning the contract.

 

If you have any questions or need any assistance, please contact the Provider Relations staff at 800-537-9389.

 

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