Fillable FACILITY CREDENTIALING & Attach additional sheets when necessary. (Mercy Care)

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FACILITY CREDENTIALING & Attach additional sheets when necessary. (Mercy Care)

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Revised 1/2020 (CYE2020)
Credentialing Alliance
FACILITY CREDENTIALING &
RECREDENTIALING APPLICATION
Type of Facility (As listed on License or Accreditation)
Acute Rehab ASC
Dialysis DME/Infusion
Enteral Family Planning
Home Health Hospice
Hospital Lab
O&P PT/OT/ST
Radiology Sleep Center
Skilled Nursing Facility Transportation
Urgent Care Vision
Wound Care Behavioral Health
Assisted Living Center Assisted Living Home
FQHC/RHC Outpatient Medical Rehab Center (PT/OT/SP)
Pharmacy
Medical/Dental schools
Intensive Outpatient Treatment (BH)
Other (Please Specify):
Facility Demographics
Legal Business Name (as reported to the IRS):
Federal Tax Identification Number:
Doing Business As (dba) Name (if applicable):
Hospital or Health System Affiliation:
Mailing/Correspondence Address:
City:
State:
Zip Code:
Billing Name (if different than dba):
Billing Address:
City:
State:
Zip Code:
Phone #:
Fax #:
Credentialing Contact Name:
Phone #:
Credentialing Mailing/Correspondence Address:
City:
State:
Zip Code:
Email Address:
Fax #:
Attach additional sheets when necessary.
Revised 1/2020 (CYE2020)
Primary Location
Street Address:
City:
State:
Zip Code:
Phone #:
Fax #:
*Please provide a copy of State License and/or business license
State
License #:
Expiration
Date:
CLIA
#:
Expiration
Date:
NPI #:
(Application cannot be processed without a valid 10-digit NPI)
Medicare Certified? Yes No
*Please provide a copy of most recent (completed within the last 3 years) State Agency Site Review or CMS Certification
approval letter
Medicare #:
AHCCCS/Medicaid #:
Please indicate if this location has been reviewed by any of the accrediting authorities listed below and provide a
copy of most recent accreditation report
American Association for Accreditation of Ambulatory Surgery
Facilities
Det Norske Veritas National Integrated Accreditation for
Healthcare Organizations
American Association for Ambulatory Health Care Commission on Accreditation of Rehabilitation Facilities
American College of Radiology American Osteopathic Association
Healthcare Facilities Accreditation Program Accreditation Commission for Health Care Inc
Commission on Office Laboratory Accreditation Joint Commission
Community Health Accreditation Not Applicable
Professional Liability:
* Please provide a copy of Current Liability Declaration
Sheet
Name of Carrier:
Effective
Date:
Expiration
Date:
Per
Incident: $ _
Per
Aggregate: $
Comprehensive Liability:
* Please provide a copy of Current Liability Declaration
Sheet
Name of Carrier:
Effective Date:
Expiration Date:
Per Incident: $ _
Per Aggregate: $ _
Revised 1/2020 (CYE2020)
Supplemental Form
For each additional address copy and complete this Supplemental Form
Return all copies with the completed application
Street Address:
City:
State:
Zip Code:
Phone #:
Fax #:
*Please provide a copy of State License and/or business license
State License #:
Expiration Date:
CLIA #:
Expiration Date:
NPI #:
(Application cannot be processed without a valid 10-digit NPI)
Medicare Certified? Yes No
*Please provide a copy of most recent (completed within the last 3 years) State Agency Site Review or CMS Certification
approval letter
Medicare #:
AHCCCS/Medicaid #:
Accreditation:
Does this site have the same accrediting agency as the primary address?
Yes
No - Please specify accrediting agency or NONE: ______________________________
Revised 1/2020 (CYE2020)
Disclosure Questions
Please answer the following questions by checking the appropriate box. If the answer to any question is yes,
please provide a complete description of the facts on a separate attached sheet.
1. Has the facility license to do business in any applicable jurisdiction ever been denied,
restricted, suspended, reduced or not renewed?
Yes
No
2. Has the facility been denied participation, suspended from or denied renewal from
Medicare or Medicaid?
Yes
No
3. Has the facility ever had its professional liability coverage cancelled or not renewed?
Yes
No
4. Has the facility been denied accreditation by its selected accrediting body (e.g. TJC), or
had its accreditation status reduced, suspended, revoked, or in any way revised by
the accrediting body?
Yes
No
Facility Attestation/Consent & Release Form
Any alteration or failure to sign and date this form will result in the delay of processing this application. By
signing below, I attest that I am the duly authorized representative of the Facility, that all information on the
Application pertains to the above-named Facility, and that such information is current, complete and correct.
Your signature is required to complete this application.
Facility Name:
Name (Please Print):
Title:
Signature:
Date:
click to sign
signature
click to edit
Revised 1/2020 (CYE2020)
Facility Credentialing and Recredentialing Application Instructions
Please include with your completed/signed application the following items for each location:
□ Copy of current State License and/or business license (if a pplicable)
□ Copy of Medicare Certification letter (if applicable)
□ Copy of Certifications and/or Accreditation Certificates (e.g. TJC, CHAP, etc)
Copy of your CLIA Certificate (if applicable)
□ Copy of Declaration Sheet and/or Certificate of Insurance for BOTH Current Professional
Malpractice and Comprehensive General Liability Insurance Policies
If you have any questions, please contact our Provider Network/Operations
Please fax completed application with all required documents to our Provider Network/Operations or as
directed, to our credentialing vendor, Aperture to 866-293-0421.
Please Note:
Initial Credentialing – Failure to legibly complete all sections of this Application and submit
current copies of all required documentation will result in processing delays.
Recredentialing – Submission of recredentialing information is a contractual obligation. Failure
to complete all sections of this Application and submit current copies of all required
documentation in a timely manner will be considered a request to terminate the facility’s
participation in our network.
Revised 1/2020 (CYE2020)
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.co
m
www.azcompletehealth.com
Banner University Health
Plans
(520) 874-5290
or
(800)
5
52-5656
Email is the preferred method to submit
completed PDFs:
BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/ACC
www.BannerUFC.com/ALTCS
www.BannerUCA.com
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)
2
01-1795
(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:
contractingdepartment@mercycareaz.org
If contracted already, email completed forms
to Provider Relations at:
Providerrelations@mercycareaz.org
Or fax to: (860) 975-3201
www.mercycarez.org
Health Choice Arizona
(800) 322-8670
(options in order 4, 7)
Contracting:
hchcontracting@steward.org
If contracted already, email your provider
representative
Or fax to: (480) 760-4975
https://www.healthchoiceaz.com
United Healthcare
Community Plan
(877) 842-3210
(855)523-9998
Cred_application@uhc.com
www.uhcprovider.com
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.
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FACILITY CREDENTIALING & Attach additional sheets when necessary. (Mercy Care)

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Completed 31 July 2021

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