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Credentialing Alliance ORGANIZATIONAL DATA FORM

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Credentialing Alliance
ORGANIZATIONAL DATA FORM
PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. New
providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider
receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing
Committee if applicable). Please Type or Print Clearly.
Please type or print this form clearly and return the completed form with attachments (attachments will need to be scanned if submitted
electronically)
Please complete a separate Organizational Data Form for entities with different AHCCCS ID #’s and/or License #’s.
Attach the following:
1. IRS 941 coupon or accurate W9
2. Liability insurance face/certificate
3. Copy of all accreditation certificates (including Medicare)
4. Medicaid required insurance certificates as applicable (see page 2 for requirements)
NON-ACCREDITED FACILITIES: 1. Copy of most recent State and/or Medicare Survey Audit
2. List of practitioners providing services at each location (See AzAHP Ancillary Provider Roster) (if applicable)
1099 Registered Name (Required):
Tax ID #:
Facility Name/DBA (if applicable):
Lines of Business: Medicaid Medicare Commercial
License #: State
: Exp. Date:
Is provider a Medicare participating provider? Yes No
AHCCCS I.D.#:
Organizational NPI#:
Facility Type (check all that apply):
Acute Rehab Family Planning O&P
Transportation
ASC
Home Health
PT/OT/ST
Urgent Care
Dialysis
Hospice
Radiology
DME/Infusion
Hospital
Sleep Center
Enteral
Lab
SNF
BILLING
SERVICE
(If applicable)
Name: Contact:
Address: Phone:
City: State: Zip Code: Fax:
PAY TO ADDRESS
(All payments sent to
this address)
Address:
City: Zip Code:
Phone: Fax: Zip Code:
PRIMARY
ADDRESS
(Physical location where
services are performed)
*Attach a sheet with
additional locations
including NPI specific
to location
Address: City: Zip Code:
Phone: Fax: County: Location NPI:
Modalities: Hours:
Is Office Accessible to Persons with Disabilities? Yes No List this Address in Directories? Yes No
FACILITY CONTACT/
MAILING ADDRESS:
Contact Name/Title: Phone: Fax:
E-mail Address: Website Address:
Address: City: Zip Code:
CREDENTIALING
CONTACT:
Name:
E-mail Address:
Address: Phone:
City: State: Zip Code: Fax:
Describe Your Medical Record Keeping System(s) (i.e. EMR, Paper, etc.):
Describe Your Cost Record Keeping System(s) (i.e. Billing or A/R system):
Electronic Claims Submission? Yes No Internet Access? Yes No Is this a minority or female owned business? Yes No
Electronic Funds Transfer? Yes No
Vision
Wound Care
Behavioral Health
Assisted Living Center
Assisted Living Home
FQHC/RHC
Outpatient Medical Rehab Center
Other
Revised 1/2020 (CYE2020)
Facility Assessment of Cognitive and Physical Disabilities Accommodations
Please identify what accommodations you provide at each of your facility locations for members with cognitive or physical disabilities.
If accommodations are the same at all locations, on Practice Location Address, please state ALL. Please, complete a separate Assessment
for each location if accommodations vary.
Facility Location Address:
________________________________________________________________________________________________
Accommodation YES
Provider/Staff trained to assist individuals with a
cognitive disability, i.e., autism or intellectual
disabilities
NO
Extended appointment times—before 8 am, after
Comments
Augmentative/Alt
Provider/Staff trained to assist individuals with a
physical disability, i.e., mobility limitations or
wheelchair bound
Flexible appointment times available—sick
appointments, same day appts—please specify
Ramps have non-slip surface material
5pm, Sat and/or Sunday—please specify
Railings between 30 & 38in high. On both sides.
Assistance available to members to fill out forms
Widened doorways (at least 32in clearance)
In-home and/or community services
Large print materials
Materials in electronic format
ernative communication devices
TDD capabilities
American Sign Language translator
Signage with Braille and raised tactile text characters
at office, elevator, stairwells and restroom doors
mounted 60in from floor
Visible & Audible alarms – emergency systems
Dimmable Lights
Paths are at least 36in wide and free of protruding
objects
Cane detectible objects on ground as a warning
barrier
Offset (swing-clear) hinges
Power assisted or automatic door openers
Door handles no higher than 48in
Lever or loop handles vs knobs
5ft circle or T-shaped space for turning a wheelchair
completely
A clear floor space, 30" X 48" minimum, adjacent to
the exam table and adjoining accessible route make it
possible to do a side transfer
Adjustable height exam table or chair (lowers to 17-
19in from floor)
Revised 1/2020 (CYE2020)
Accommodation YES
NO
Ceiling or floor-based patient lift
Comments
Positioning and support aids, such as wedges, rolled
up blankets, straps and rails
Accessible by Valley Metro Rail
Do you provide Virtual Clinic services?
Gurneys and/or stretchers
Wheelchair accessible scales
Adjustable height radiologic equipment
Handicap parking
Handicap accessible restroom
Access ramps
Accessible by bus
Provider/Staff has completed cultural competence
training
Do you provide Field Clinic services?
(A “clinic” consisting of single specialty health care
providers who travel to health care delivery settings closer
to members and their families than the Multi-Specialty
Interdisciplinary Clinics (MSICs) to provide a specific set of
services including evaluation, monitoring, and treatment for
CRS-related conditions on a periodic basis)
(Integrated services provided in community settings
through the use of innovative strategies for care
coordination such as telemedicine, integrated medical
records, and virtual interdisciplinary treatment team
meetings)
Prior to submitting your insurance information complete this checklist, use it as a tool to address everything that’s
required and send it on top of your insurance document(s).
Commercial General Liability Professional Liability
ATTACHED ATTACHED N/A
General Aggregate $2,000,000
Products Ops Aggregate $1,000,000
Personal & Adv. Injury $1,000,000
Damage to Rented Premises $50,000
Each Occurrence $1,000,000
Each Claim $1,000,000
Annual Aggregate $2,000,000
Business Automobile Liability Workers’ Compensation Liability
ATTACHED N/A ATTACHED N/A
Combined Single Limit $1,000,000
Each Accident $1,000,000
Disease – Each Employee $1,000,000
Disease – Policy Limit $1,000,000
Your Certificates of Insurance must include the minimum requirements outlined in the tables above and the
following endorsement, waiver of subrogation and/or SAM language as applicable.
Endorsement – Required for Commercial General and Business Auto Liability
This policy contains an endorsement that includes the State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability
arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor.
Waiver of Subrogation – Required for all
This policy contains a waiver of subrogation endorsement in favor of the State of Arizona, and its departments,
agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work
performed by the Subcontractor or on behalf of the Subcontractor or Contractor.
• If you are unable to obtain SAM coverage under your General Liability because the insurance market will
not support it, it should be included with the Professional Liability.
**Please check with health plan if SAM coverage is required for your specific provider type
**Sexual Abuse and Molestation (SAM) – Required for Commercial General Liability or Professional
Liability when providing services to children and/or vulnerable adults
Insurance Certificate(s) must provide the following statement “Sexual Abuse and Molestation coverage is included”
or “Sexual Abuse and Molestation coverage is not excluded”.
AHCCCS Insurance Requirements
This communication outlines the additional insurance requirements and provides examples to assist you.
AHCCCS Insurance Requirements
The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability and
Worker’s Compensation and Employers’ Liability.
Your commercial general liability policy and your business automobile policy (if applicable), need to include an
endorsement (see letter a. below under Commercial General Liability and letter a. below under Business
Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and
letter b. below under Business Automobile Liability) in the Description field of your policy.
Your worker’s compensation and employers’ liability policy requires only the waiver of subrogation language.
Outlined below are the minimum requirements. Policy examples follow.
Commercial General Liability – Occurrence Form
Policy should include bodily injury, property damage, personal and advertising injury and broad form contractual
liability coverage. The amounts below are the minimum requirements.
• General Aggregate $2,000,000
• Products – Completed Operations Aggregate $1,000,000
• Personal and Advertising Injury $1,000,000
• Damage to Rented Premises $50,000
• Each Occurrence $1,000,000
a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be named as
additional insureds with respect to liability arising out of the activities performed by or on
behalf of the Contractor." Such additional insured shall be covered to the full limits of liability
purchased by the Subcontractor, even if those limits of liability are in excess of those required by
this contract.
b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not
acceptable) in favor of the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising from work performed by
or on behalf of the Subcontractor.
c. If direct services are provided to children and/or vulnerable adults (as defined by A.R.S §46-451(A)
(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM
coverage may be sub-limited to no less than $500,000. The limits may be included within the
General Liability limit, provided by separate endorsement with its own limits. If you are unable to
obtain SAM coverage under your General Liability because the insurance market will not support
it, it should it be included with the Professional Liability.
d. The following statement must provide on their Certificate(s) of Insurance: “Sexual Abuse and
Molestation coverage is included” or “Sexual Abuse and Molestation coverage is not excluded.”
AHCCCS INSURANCE REQUIREMENTS – Required ONLY if requesting to participate in the Plan’s Medicaid Line of Business
Business Automobile Liability
Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance
of the services under contract. The amount below is the minimum required.
• Combined Single Limit (CSL) $1,000,000
a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees shall be named as additional insureds with
respect to liability arising out of the activities performed by or on behalf of the Contractor, involving
automobiles owned, leased, hired or borrowed by the Contractor." Such additional insured shall be
covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in
excess of those required by this contract.
b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in
favor of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers,
officials, agents, and employees” for losses arising from work performed by or on behalf of the
Subcontractor.
Worker’s Compensation and Employers’ Liability
• Workers' Compensation Statutory
• Employers' Liability
Each Accident $500,000
Disease – Each Employee $500,000
Disease – Policy Limit $1,000,000
Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor
of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Subcontractor.”
Two examples for your reference are included on pages 9-10:
1. Commercial General Liability and Business Automobile Liability – includes limits, endorsement and waiver of
subrogation language
2. Worker’s Compensation and Employers’ Liability – includes limits and waiver of subrogation language
We are required to verify your adherence to these insurance requirements. We appreciate you submitting
Certificates of Liability with required coverage levels, endorsements and waivers along with the attached checklist
INSURED
Provider'
s Group Name
Address
Sui
te #
City
AZ
Zip Code
of such endorsement(s).
Insurance Company Name
License Number
Mailing Address
City, AZ
Zip Code
PRODUCER
.
DATE (MM/DD/YYYY)
1
0/01/2017
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu
AHCCCS
minimum
coverage
limits
Certificate Holder
and waiver of subrogation language
NEW – Added Sexual Abuse and
Molestation language
AHCCCS required endorsement language
Add AHCCCS as the
Contact
Name
Agent Name
Phone
(A/c,
No, Ext):
602-555-5555
Fax
(A/C, No.):
602-555-1111
E-Mail
Address:
agent@insco.com
INSURER(S)
AFFORDING COVERAGE
NAIC#
INSURER A: ABC Insurance
Company
B: DEF Insurance
Company
INSURER C:
XYZ Insurance Company
INSURER D :
INSURER E:
INSURER F:
INSURER
COVERAGES
CERTIFICATE NUMBER: 123456789
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
ADDL SUBR
POLICY EFF
POLICY EXP.
LTR
TYPE OF INSURANCE
INSD WVD
POLICY NUMBER
(MM/DD/YYYY) (MM/DD/YYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE x OCCUR
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurance)
MED EXP (Any one person)
123-ABC-456
09/01/2017 08/31/2018
PERSONAL & ADV INJURY
$ 1,000,000
$ 50,000
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
LOC
Policy
P
roject
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
2,000,000
$ 1,000,000
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
$ 1,000,000
UMBRELLA LIAB
EXCESS LIAB
DED
SCHEDULED
AUTOS
NON-OWNED
AUTOS
OCCUR
CLAIMS-MADE
RETENTIONS
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR PARTNER/EXECUTIVE
OFFICER MEMBER EXCLUDED
7
[Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
99-000-AB1111
06/01/2017
08/31/2018
BODILY INJURY (Per accident
PROPERTY DAMAGE
(Per accident
EACH OCCURRENCE
AGGREGATE
PER
STATUTE
OTHER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT
Professional Liability
12345678
$1,000,000 Per Claim/ $2,000,000 per Agg
09/01/2017 08/31/2018
X
X
XX
A
B
D
Y/N
N/A
X
$
$
$
$
$
$
$
$
$
X
$
$
DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required)
This policy contains an endorsement that includes the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials
agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor, or on behalf of the Subcontractor
or Contractor. This policy contains a waiver of subrogation endorsement in favor of the State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor, or on behalf of the Subcontractor or
Contractor. Sexual Abuse and Molestation coverage is included.
CERTIFICATE HOLDER
Arizona Health Care Cost Containment System
Attn: Contracts
700 E. Jefferson St. MD 5700
Phoenix AZ 85034
© 1988-2014 ACORD CORPORATION. All rights reserved.
AUTHORIZED REPRESENTATIVE
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
.
AHCC
minimum
coverage
limits
Certificate Holder
and waiver of subrogation language
NEW – Added Sexual Abuse and
Molestation language
AHCCCS required endorsement language
Add AHCCCS as the
CS
DATE (MM/DD/YYYY)
10/01/2017
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
Insurance Company Name
License Number
Mailing Address
City. AZ Zip Code
Provider's Group Name
Address
City.
AZ Zip Code
INSURED
Producer
CONTACT
NAME:
Agent Name
PHONE
(A/C, No, Ext):
602-555-5555
FAX
(A/C, No):
602-555-1111
Address: agent@insco.com
INSURER(S) AFFORDING COVERAGE NAIC#
A: SCF Casualty Insurance 13210
INSURER B :
INSURER C:
INSURER D :
INSURER E:
INSURER F:
E-Mail
INSURER
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
ADDL
SUBR
POLICY EFF
POLICY EXP
LTR
TYPE OF INSURANCE
INSD WVD
POLICY NUMBER
(MM/DD/YYYY) (MM/DD/YYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
SCHEDULED
AUTOS
A
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY
PROJECT
LOC
OTHER:
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
Ea accident)
BODILY INJURY (Per person)
(Per accident)
BO
DI
LY
IN
JU
RY
$
$
$
$
$
$
$
$
$
$
or Contractor.
AHCCCS
minimum
coverage limits
Only Waiver of Subrogation
language is required for Worker’s
Comp policy
UPDATED – limits to
$1,000,000
Add AHCCCS as the
Certificate Holder
HIRED AUTOS
NON-OWNED
AUTOS
UMBRELLA LIAB
EXCESS LIAB
DED RETENTIONS
OCCUR
CLAIMS-MADE
WORKERS COMPENSATION
AND EMPLOYERS’ LIABUTY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/ MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
C12345
N/A
PROPERTY DAMAGE
(Per accident)
EACH OCCURRENCE
$
$
$
$
$
E L. EACH ACCIDENT $ 1,000,000
E
L. DISEASE - EA EMPLOYEE $
1,000,000
E.L. DISEASE-POLICY LIMIT 5
1,000,000.
AGGREGATE
PER STATUTE OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
This policy contains a waiver of subrogation endorsement in favor of the State of Arizona, and its departments, agencies, boards, commissions
universities, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor
CERTIFICATE HOLDER CANCELLATION
Arizona Hearth Care Cost Containment System
Attn: Contracts
700 E. Jefferson St. MD 5700
Phoenix, AZ 85034
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
AHCCCS
minimum
coverage limits
Only Waiver of Subrogation
language is required for Worker’s
Comp policy
UPDATED – limits to
$1,000,000
Add AHCCCS as the
Certificate Holder
The fax number and phone number for each participating plan is listed in the table below.
If your intent is to apply for participation in a Health Plan network, please send only to the Plan(s) you are
interested in joining. NOT ALL Plans provide services in every county. Please contact the Plan directly to verify that
they provide services in your county and that they are accepting new providers.
If you are adding a location/facility under an existing Health Plan contract, please only send to the Plan(s) you are
contracted with.
HEALTH PLAN PHONE FAX/EMAIL WEBSITE
Arizona Complete Health
-Complete Care Plan
(888) 788-4408 (866)687-0514
AzCHProviderData@azcompletehealth.com
www.azcompletehealth.com
Banner University
Health Plans
(520) 874-5290
or
(800) 552-5656
Email is preferred method to submit
completed PDFs:
BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/ACC
www.BannerUHP.com
Care1st Health Plan
Arizona—A WellCare
Company
(602) 778-1800
(options in order 5,
7)
(602) 778-1875
SM_AZ_PNO@care1stAZ.com
www.care1staz.com
Comprehensive Medical
and Dental Program
(CMDP)
(602) 351-2245
or
(800) 201-1795
(options in order 1, 2,
3)
(602) 264-3801
CMDPProviderServices@azdcs.gov
https://dcs.az.gov.cmdp
DentaQuest (800) 233-1468 initialproviderenrollment@dentaquest.com
262-241-7401
http://www.dentaquest.com
/state-
plans/regions/arizona/az-
dentist-page
Magellan Complete Care
Arizona
800-424-5891
888-656-0369
MCCAZProvider@MagellanHealth.com
www.mccofaz.com
Mercy Care (602) 263-3000 Contracting:
If contracted already, email completed forms to
Provider Relations at:
Providerrelations@mercycareaz.org
Or fax form to (860) 975-3201
www.mercycareaz.org
(800) 322-8670
(options in order 4,
7)
Contracting:
hchcontracting@steward.org
If contracted, email your provider
representative
(480) 760-4975
United Healthcare
Community Plan
(877) 842-3210
Each plan retains the right to make their own contracting decisions (whether or not to add organizations to their network)
and also will make their own credentialing committee decisions (review of the primary source verification information
obtained by Aperture Credentialing, LLC resulting in approval/denial by the plan’s committee). You will receive separate
communication from each plan regarding the effective date of your credentialing and the effective date of your contract.
www.BannerUFC.com/
ALTCS www.BannerUCA.com
contractingdepartment@mercycareaz.org
Health Choice Arizona www.healthchoiceaz.com
(612) 234-0211
www.uhccommunityplan.com
Revised 1/2020 (CYE2020)
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Credentialing Alliance ORGANIZATIONAL DATA FORM

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Completed 11 March 2022

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