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Home
→ Maine Carrier Credentialing Extension Application
Maine Carrier Credentialing Extension Application
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Please Note: This form has room for 10 Provider Applicant Names. As you are adding one, the fields for another will appear in case you have more than one to enter. If you are filing for more than 10 applicants, then you will need to submit another form with the remaining Provider Applicant Names.
If the delay is NOT specific to one provider, you must provide a Detailed Remediation Plan
. Field names with an * beside them are required. When information for all Provider Applicant Names is complete, press the Submit button.
Today's Date*
Insurance Carrier Name*
Licensee's NAIC, NPR, or Maine License Number*
First Name*
Last Name*
Telephone Number*
E-Mail Address*
Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI)*
Date Completed Provider Application Was Received*
60-Day Deadline Date for Application*
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days*
How Long of an Extension is Being Requested For This Applicant?*
2. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
3. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
4. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
5. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
6. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
7. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
8. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
9. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
10. Provider Applicant Name(s), Area of Practice and National Provider Identifier (NPI).
Date Completed Provider Application Was Received
60-Day Deadline Date for Application
Please explain why the insurer is unable to make a credentialing decision on the provider application(s) within 60 days.
How Long of an Extension is Being Requested For This Applicant?
Warning message
If you need to enter more than 10 applicants, please resubmit this form with the rest. Thank you.
Detailed Remediation Plan: If the delay is NOT specific to one provider application, please provide a detailed remediation plan to bring the credentialing practice in line with 24-A M.R.S. 4303(2)(D). Otherwise, enter N/A if this does not apply.*
*Signature: I hereby certify that: 1. The Licensee listed above has authorized me to execute this certification, 2. I have read and understand the statements in this certification, and 3. these statements are true and complete to the best of my knowledge and belief.
Leave this field blank