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Facility Network Request Form (FNRF) - Provider Express 2025

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The document is a Facility Network Request Form and Credentialing Application for Optum/OptumHealth Behavioral Solutions of California. It outlines the application process for facilities seeking to join the Optum provider network, detailing required information, documentation, and compliance standards necessary for credentialing. The form includes sections for organizational information, levels of care desired, accreditation, licensure, insurance requirements, and legal status. It emphasizes the importance of thorough completion to avoid delays in the credentialing process.

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Click ‘Get Form’ to open the Facility Network Request Form in the editor.
Begin by filling out the Organizational Facility Identifying Information section. Ensure you provide the legal name, administrative address, and contact details accurately.
Identify the levels of care your facility desires to contract. Check all applicable boxes for services such as Substance Abuse, Psychiatric/Mental Health, and others.
Complete the Organizational Provider Contact Information section. Include names and roles of key contacts within your organization.
Fill in the Accreditation and Licensure/Certification sections with relevant details about your facility's credentials.
Review all entries for accuracy before signing on Page 6. Ensure that the authorized individual’s name and date are included.

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Versions	Form popularity	Fillable & printable
2017	4.7 Satisfied (61 Votes)
2015	4.3 Satisfied (54 Votes)
2014	4.1 Satisfied (71 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long does it take to be credentialed with UHC?

How long does the UnitedHealthcare credentialing process take? The entire credentialing process generally takes up to 45 calendar days or more to complete once we have a completed application and all required information. After receiving a completed application, we perform primary source verification.

What is the PDR form for Optum?

This form is designed for providers to submit disputes related to claims. It provides necessary instructions and requirements for successful submission. Fill out the requested fields accurately to ensure a smooth resolution process.

How long does it take to credential with Optum?

OptumHealth strives to process complete credentialing applications in 60 days or less. It may take longer if you submit an incomplete application or if requested attachments are not submitted with the application.

How long does it take to get credentialed with Optum?

This will take 3-6 months depending on the facility(s), health plans, and State of practice involved. Many OptumCare business entities utilize CAQH as their repository.

How do I contact provider express?

For additional assistance, you may also call the Provider Express Support Center at 1 866-209-9320 (toll-free) from 8 a.m. to 8 p.m. Eastern time.

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How long does it take to get credentialed with insurance?

After you submit an application on your own, you can expect to wait 90 to 120 days before your credential is awarded.

How long does each credentialing application take?

The general timeframe for healthcare providers to complete credentialing is between 90 to 120 days. However, this is an average estimate. Some payors may complete the process quicker, while others might take longer, especially for certain specialties.

What is an express access network provider?

What is Express Access? Express Access is a network of behavioral health professionals, credentialed through Optum Behavioral Health, who agree to offer initial appointments within five business days of a new clients request. Express Access members include both solo and group practices.