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Page 1

Please apply to the network through your local Blue Cross and Blue Shield. Lucet does not manage the provider contracts and credentialing for this Blue Plan. 
Please email Providernetwork@arkabluecross.com to join this plan. Lucet does not manage the provider contracts and credentialing for this Plan.
Medical Necessity Criteria
Please use this link to ensure your facility meets the Medical Necessity Criteria for Lucet. 

https://lucethealth.com/providers/resources/mnc/
Facility Info
Enter numbers only, no dashes
Application only accepts doc, docx, pdf, png, zip documents
Application only accepts doc, docx, pdf, png, zip documents
Person filling out this form:
Contacts
Please list all applicable
Please be sure to fill out the contact information for a contracting contact. If there is not one given it could delay contracting. 
Psychiatric Medical Director Information
Clinical Program Directors Information
Please list the name and titles for each of your Top Clinical Program Directors. You can add more than one by clicking "Add another response" at the bottom of this box. 
Accreditation
Institution Information
Program Information
Application only accepts doc, docx, pdf, png, zip documents
Application only accepts doc, docx, pdf, png, zip documents
Facilities Staffing
Number of Licensed Staff
If a license type does not pertain to your institution please enter the number zero. 
Other
If you have multiple licensed staff other than listed above please click "add another response" at the bottom of this box. 
Number of Staff with 15 hours of Supervision or Direct Patient Contact
If a license type does not pertain to your institution please enter the number zero. 
Other
If you have multiple licensed staff other than listed above please click "add another response" at the bottom of this box. 
Thank you for your interest in joining Lucet’s provider network. While we are not currently active in your state, that is subject to change. If you’d like to stay in touch, fill out the attached form for updates. A Lucet team member will reach out if we become active in your location.
Claims and Lawsuit Information
Claims and Lawsuit for Facility
For any claims or lawsuits which are pending or within the last five years have resulted in a judgement of more than $300,000 against the facility or one of the its staff or Medical Staff members or settlement of more than $300,000, please provide the following information. Please complete a separate section for each claim or lawsuit by clicking "Add another response" at the bottom corner. 

Facility Locations & Addresses

Facility Billing Address
Service Location
Practice Hours
Special Populations
Facility License(s)
Levels of Services Provided
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