Lucet Network Individual Application

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Required Documentation: 

·        W9 

·        Nurse Practitioners: Collaborative Practice Agreement with a Provider contracted with Lucet unless Licensed for autonomous practice.


This form should take approximately 10 minutes to complete. You can save your progress and return to the form using the "Save my progress and resume later” checkbox at the top right of the page. 

So let's get Started with this important question....
Not Eligible for Online Applications

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.
 
Not Eligible for Online Applications
Please email Providernetwork@arkabluecross.com to join this plan. Lucet does not manage the provider contracts and credentialing for this Plan.
Thank You for Your Interest...
Thank you for your interest in applying to the Lucet network. 

Unfortunately, you do not meet our geographical requirements. 
Alabama  Confirmation
Arkansas Confirmation
Texas Confirmation                 
Kansas City Regional Check

Missouri Counties:
Andrew, Atchison, Bates, Benton, Buchanan, Caldwell, Carroll, Cass, Clay, Clinton, Davies, Dekalb, Gentry, Grundy, Harrison, Henry, Hold, Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Platte, Ray, Saint Clair, Saline, Vernon, Worth

Kansas Counties:
Johnson; Wyandotte

Identity and Biographical Details: 
You must be at least 18 years old to apply.
9 digits only. No spaces please.

Provider Contact Information

Please provide a direct email address that you, the provider, check regularly.  Key contractual documents and credentialing notifications will be sent to this email address. The address will not be published in a directory or shared with Lucet members in any way. 


This email address should not belong to a front office staff member or 3rd party credentialing service staff member. Using a shared email address may prevent you from accessing Lucet’s Provider Portal. 

How Members Can Reach You
The email address and website provided here may be published to our provider directory and/or shared with members who are attempting to reach you to schedule care.
Your Education and Professional Experience
Please enter your degree.
Please select the appropriate Taxonomy code based on your licensure and specialty.
• A Part 2 Program is: any federally assisted individual OR entity that holds itself as providing education, treatment or prevention to individuals in need of alcohol or drug abuse treatment.
License Details
BCBA Attestation
As a Board Certified Behavior Analyst (BCBA), you must attest to meeting requirements for line therapists working under your supervision.  Please click here to get a copy of the attestation.   Once you have filled it out, please attach below.  
Physicians Assistant
CCVS Organization-Specific Authorization & Release 
To proceed with the application please click here to access the CCVS A&R Form. Please download, review and sign, and then attach to this application using the Choose File box below. 

ARNP
By selecting "yes" you attest that your office meets the required regulations for administering LAIs.
ARNPs must have certification in psychiatry.
DEA Compliance
DEA Registration Number start with two Capital letters followed by 7 Numbers.
Enter a value up to 3 years before today.
Enter a value up to 3 years from today
Texas DEA Registration Support
Missouri DEA Registration Support
Missouri Department of Health & Senior Services Bureau of Narcotics and Dangerous Drugs site. 
Arkansas DEA Registration Support
Arkansas Department of Health Pharmacy Services Controlled Substances Licensing link.
Alabama DEA Registration Support
Alabama Board of Medical Examiners & Medical Licensure Commission Controlled Substances Certificate (ACSC) Information page.
Qualified Alabama Controlled Substances Certificate (QACSC) information page for CRNP in a collaborative practice agreement.  A QACSC is specific to each collaborative practice agreement.
Residency & Board Certification for Licensed MDs and DOs
Non Board-Certified Psychiatrists
Please click here to access an attestation for non-board certified physicians who are planning on taking the boards within two testing periods of completion of their residency. Signing this attestation will allow you to proceed with applying to the Lucet network. 

Please download, review and sign, and then attach to this application using the Upload Signed Attestation feature below.
ABMS and AOA Specialist Board Certifications for MDs and DOs
Is the Physician Boad Certified in the area in which they completed their residencey by the American Board of Medical Specialties (ABMS) OR American Osteopathic Board (AOA) in one of the following areas?
  • Family Medicine
  • Internal Medicine
  • Emergency Medicine
  • Pediatrics
  • Obstetrics and Gynecology
Please note that Physician applicants in this category will require additional review

An MD Provider applicant whose residency was in a non-Psychiatry discipline may still be eligible provided that 

  • The Provider intends to treat only individuals with Substance User Disorder

    AND Furthermore...

  • Has obtained Board Certification for Addiction Medicine from one of the following boards:
    • American Board of Medical Specialities (ABMS) Preventive Medicine with sub-specialty Addiction Medicine
    • American Osteopathic Board (AOA) Addiction Medicine
    • American Board of Addiction Medicine (ABAM)
Such physicians will be designated Addiction Medicine Specialsts in the Lucet network. 
Thank you for your interest in applying to the network, however you do not meet the requirements to join the Lucet network. You may discontinue finishing and submitting this application.  
Service Specialties
Please identify any areas of practice where you specialize.  
Race/Ethnicity Self-Identification
In accordance with the provisions of Title VI of the Civil Rights Act of 1964, Lucet does not discriminate on the basis of race, color, or national origin.  Please be aware that this information is beneficial to our members as some members may feel more comfortable with a provider of a particular ethnicity.

If you choose to provide this information, you may add more than one response by clicking the Add Another Entry link at the lower right.
Age Groups
Special Populations Served
Languages
What languages other than English do you speak with clinical fluency?
You may add multiple entries.
Provider Availability
Please indicate the timeframe between when you receive a referral and when the first appointment is scheduled. 
Scheduling Tool & EHR
Scheduling Platform

A Benefit For You...

As an in-network provider, you will have access to our free direct scheduling platform. This software will allow you to open your appointment availability to Lucet members seeking behavioral health services. The program offers many benefits to providers, allowing you to optimize your day and track availability and patient progress. 

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.
We recognize that often Individual Provider applicants have a business associate who is actually using this form to start the application.  Please identify yourself as either the Provider or an Associate.  

Page 2: About Your Practice & Platforms

Practice Bundle: Tax ID, Billing Address and Service Location Address
Please note the difference between a Legal Name and a DBA (or Trade Name).

Your organization's Legal Name is the official name which has been registered with the IRS.  It is entered on Line 1 of the W-9.

A DBA (standing for Doing Business As) or your trade name is how people refer to your organization in everyday speech.  It is entered on Line 2 of the W-9.
Financial Reporting Information
For IRS reporting purposes, we need to know how the practice bills.  You determined this on your W-9, which either uses the Provider's SSN or an Employer Identification Number (EIN).

Upload your W-9 and use it to answer the next few prompts.  If you need a new form, it can be downloaded from the IRS at https://irs.gov/pub/irs-pdf/fw9.pdf 

Upload proof of Professional Liability Insurance for this Practice.
Please make sure this is your professional liability insurance and not general business or auto insurance.
When entering addresses below, kindly recall that address validation is enabled.
And don't forget to add a suite number if applicable.
Billing Address
Service Address
Practice Hours
About Practice Hours for this Location
Please add the standard hours where you see patients for this practice.  Note: At the bottom of the list of half-hour intervals is a value "Closed" that can be used to indicate you are generally not open at all on a specific date.
Practice Bundle: Tax ID, Billing Address and Service Location Address
Please note the difference between a Legal Name and a DBA (or Trade Name).

Your organization's Legal Name is the official name which has been registered with the IRS.  It is entered on Line 1 of the W-9.

A DBA (standing for Doing Business As) or your trade name is how people refer to your organization in everyday speech.  It is entered on Line 2 of the W-9.

Here's a useful example from real life.  In corporate documents, Starbucks' Legal Name is Starbucks Corporation. Whereas its DBA or trade name is simply Starbucks —the name it uses on its advertising and website,and how it is generally known.
Financial Reporting Information
For IRS reporting purposes, we need to know how the practice bills.  You determined this on your W-9, which either uses the Provider's SSN or an Employer Identification Number (EIN).

Upload your W-9 and use it to answer the next few prompts.  If you need a new form, it can be downloaded from the IRS at https://irs.gov/pub/irs-pdf/fw9.pdf 
When entering addresses below, kindly recall that address validation is enabled.
And don't forget to add a suite number if applicable.
Billing Address
Service Address
Practice Hours
About Practice Hours for this Location
Please add the standard hours where you see patients for this practice.  Note: At the bottom of the list of half-hour intervals is a value "Closed" that can be used to indicate you are generally not open at all on a specific date.
Certification & Acknowledgement

I hereby certify that I have reviewed all the information above and attest that it is true and accurate. 

I understand that any provider data subsequently found to be untrue and/or materially incorrect can result in my termination from the Lucet network.
Provider or Duly Authorized Representative
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