New PAC-IM Provider Requests

External Use Only



*Post Acute Care facilities only, this is not used for DMEPOS providers or Home Health Providers*



For additional information, please visit the link below: https://providers.carelonmedicalbenefitsmanagement.com/postacute/provider-materials/wellpoint-provider-resources-pac-im/


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*Please submit a request for each facility location*

Facility Information:

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Facility Contact Verification:

*This is separate from the location phone/fax*

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Facility Information: *Location Address*

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