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Revised 2021
Page 1 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Initial Credentialing—Failure to legibly complete all sections of this application and submit current copies of all
required documentation may result in processing delays. If a question does not apply, please put N/A in that
section to ensure a complete application.
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. If a question does not apply, please
put N/A in that section to ensure a complete application.
PLEASE NOTE: FOR EVERY ORGANIZATION/FACILITY TYPE, A SEPARATE APPLICATION MUST BE COMPLETED.
• New organizational providers will receive written confirmation of their effective date with the health plan.
o Members may not be seen until written confirmation has been received and AHCCCS registration
has been completed. You cannot receive payment for services provided without AHCCCS
registration.
• Please use the Organizational/Facility Supplemental form (last page) for additional addresses. Each of the
location must have the same AHCCCS ID#, License #’s and NPI. If not, complete a new application.
INSTRUCTIONS:
PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING PROVIDING ANY ATTACHMENTS, TO
PREVENT DELAYS IN PROCESSING YOUR REQUEST.
Include the following items for each location with your completed and signed application:
Current State License and/or business license for each location (if applicable)
Medicare Certification letter (if applicable)
Certifications and/or Accreditation Certificates (e.g. TJC,CHAP, etc), if applicable
CLIA Certificate (if applicable)
Current Professional Malpractice and Comprehensive General Liability Insurance Policies
IRS form 941 voucher or accurate W9
Maintenance vehicle schedule (Transportation only)
Documentation of age-appropriate car seats (Transportation only)
Behavioral Health Facilities Only—if you employ Behavioral Health Technicians (BHTs) and/or
Paraprofessionals (BHPP), please provide your Policies and Procedures that outlines your process for
monitoring/supervision of the BHTs and BHPPs’.
If you have any questions, please contact the Provider Network/Operations Department of the Health Plan (s)
you are applying to (see page 11).
Each health plan will provide instruction as to where the completed application and required documents
should be submitted.
Revised 2021
Page 2 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
1099 Registered Name (Required):
Tax ID#:
Organizational/Facility Name/DBA (if applicable):
Lines of Business:
Medicaid Medicare Commercial
License #
Exp Date
Is Facility a Medicare
participating provider?
YES NO
AHCCCS Provider Type
AHCCCS ID#
Organization NPI#
ORGANIZATIONAL/FACILITY TYPE AS LISTED ON LICENSE OR ACCREDITATION: Check all that apply
Acute Rehab
FQHC/RHC
PT/OT/ST
Ambulatory Surgery Center
Habilitation Providers
Radiology
Attendant Care Agency
Home Health
Sleep Center
Assisted Living Center
Hospice
Skilled Nursing Facility
Assisted Living Home
Hospital
Transportation
Behavioral Health
Intensive Outpatient Treatment (BH)
Transportation—Air and Non-
Emergency
Behavioral Health Residential
Facility (BHRF)
Lab
Therapeutic Behavioral Health
Foster Home/Group Home
Dialysis
Medical/Dental Schools
Urgent Care
DME/Infusion
Orthotics & Prosthetics
Vision
Enteral
Outpatient Medical Rehab Center
Wound Care
Family Planning
Pharmacy
Other:
ORGANIZATIONAL/ FACILITY TYPE SPECIALTIES—HSD SPECIALTY CODE AND SPECIALTY NAME: Check all that apply
040 Acute Inpatient Hospitals
046 Skilled Nursing Facilities
050 Occupational Therapy
041 Cardiac Surgery Program
047 Diagnostic Radiology
051 Speech Therapy
042 Cardiac Catheterization Services
048 Mammography
052 Inpatient Psychiatric Facility
Services
043 Critical Care Services -Intensive
Care Units (ICU)
049 Physical Therapy
057 Outpatient
Infusion/Chemotherapy
045 Surgical Services (Outpatient or ASC)
ACCREDITING AUTHORITIES
:
Please indicate if this location has been reviewed by any of the accrediting authorities listed
below and provide a copy of the most recent accreditation report for each location.
Accreditation Commission for Health Care, INC.
Commission on Office Laboratory Accreditation
American Association for Accreditation of Ambulatory
Surgery Facilities
Community Health Accreditation
American Association for Ambulatory Health Care
Det Norske Veritas National Integrated Accreditation for
Healthcare Organizations
American College of Radiology
Healthcare Facilities Accreditation Program
American Osteopathic Association
Joint Commission
Commission on Accreditation of Rehabilitation Facilities
Other:
Revised 2021
Page 3 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
PRIMARY ADDRESS: Physical location where services are performed. Complete a supplemental form for each additional location
Address
City
State:
Zip Code
Phone
Fax
County
Location NPI(
can’t be processed
without a valid 10 digit NPI) if applicable
Modalities
Hours
List Address in Directories YES NO
ORGANIZATIONAL/FACILITY CONTACT
Contact Name/Title:
Phone:
Fax:
Email:
Organizational/Facility Website Address:
Mailing Address:
City:
State:
Zip Code:
BILLING SERVICE
Name of Service:
Contact Name:
Address:
Phone:
City:
State:
Zip Code:
PAY TO ADDRESS
Name:
Contact:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Revised 2021
Page 4 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
CREDENTIALING CONTACT
Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
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
Electronic Funds Transfer?
YES NO
Internet Access: YES NO
Is this a minority or female owned business: YES NO
If appropriate, has EVV training been completed through Sandata YES NO
(See pages 12-13 for more information. List of facilities required to
complete this information is on page 13)
EVV Office Contact (Primary contact for EVV. This
person will receive primary communications and notices
from Sandata and AHCCCS:
Phone:
Email
Revised 2021
Page 5 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Organizational/Facility Assessment of Cognitive and Physical Disabilities Accommodations
Please identify what accommodations you provide at each of your organizational 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.
Organizational/Facility Location Address:
_______________________________________________________________________________________
Accommodation YES NO Comments
Provider/Staff trained to assist individuals with a
cognitive disability, i.e., autism or intellectual
disabilities
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
Extended appointment times—before 8 am, after
5pm, Sat and/or Sunday—please specify
Assistance available to members to fill out forms
In-home and/or community services
Large print materials
Materials in electronic format
Augmentative/Alternative 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
Ramps have non-slip surface material
Railings between 30 & 38in high. On both sides.
Paths are at least 36in wide and free of protruding
objects
Cane detectible objects on ground as a warning
barrier
Widened doorways (at least 32in clearance)
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
Revised 2021
Page 6 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Accommodation YES NO Comments
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)
Positioning and support aids, such as wedges, rolled
up blankets, straps and rails
Ceiling or floor based patient lift
Gurneys and/or stretchers
Wheelchair accessible scales
Adjustable height radiologic equipment
Handicap parking
Handicap accessible restroom
Access ramps
Accessible by bus
Accessible by Valley Metro Rail
Accessible by Taxi or similar options i.e., Uber/Lyft
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)
Do you provide Virtual Clinic services?
(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)
Revised 2021
Page 7 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
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 sheet to be attached to application.
1. Has the Organizational/Facility license to do business in any applicable jurisdiction ever been
denied, restricted, suspended, reduced or not renewed?
Yes
No
2. Has the Organizational/Facility been denied participation, suspended from or denied renewal
from Medicare or Medicaid?
Yes
No
3. Has the Organizational/Facility ever had its professional liability coverage cancelled or not
renewed?
Yes
No
4. Has the Organizational/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
Organizational/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 Organizational/Facility, that all information on the Application pertains to the
above-named Organizational/Facility, and that such information is current, complete and correct.
ORGANIZATIONAL/FACILITY NAME:
REPRESENTATIVE NAME:
TITLE:
SIGNATURE:
DATE:
Revised 2021
Page 8 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
AHCCCS INSURANCE CHECKLIST
AHCCCS INSURANCE REQUIREMENTS – Required ONLY if requesting to participate in the Plan’s Medicaid Line of Business
Use this checklist as a tool to address all insurance requirements
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.
Commercial General Liability
—policy should include bodily injury, property damage, personal and advertising injury,
and broad form contractual liability coverage.
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
Policy Number:
Attached NA
Requirements:
Endorsement—The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the
following insure 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.
Waiver of Subrogation—The 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.
Sexual Abuse and Molestation coverage (SAM)—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 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.
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.”
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
Revised 2021
Page 9 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
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.
(required only if you provide transportation to members)
Combined Single Limit $1,000,000
Policy Number:
Attached NA
Endorsement—The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the
following 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.
Waiver of Subrogation—The 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.
Workers’ Compensation Liability
Each Accident $1,000,000
Disease—Each Employee $1,000,000
Disease—Policy Limit $1,000,000
Policy Number:
Attached
NA
Waiver of Subrogation—The 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.
Professional Liability
(if applicable)
Each Claim $1,000,000
Annual Aggregate $2,000,000
Policy Number:
Attached NA
Sexual Abuse and Molestation coverage (SAM)—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
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
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.”
Revised 2021
Page 10 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
SUPPLEMENTAL FORM FOR ADDITIONAL ADDRESSES/LOCATIONS
For each additional address that has the same AHCCCS ID and license, copy and complete this Supplemental form. A Provider
Assessment of Cognitive and Physical
Disabilities Accommodations must be completed for each location unless
accommodations are the same at each location.
(Please note: if a different AHCCCS ID and license the entire application
must be completed)
Location Name:
Street Address:
City:
State:
Zip Code:
Location NPI:
Phone #:
Fax #:
Accreditation:
Does this site have the same accrediting agency as the primary address? (as listed on page 3)
Yes
No - Please specify accrediting agency or NONE:
For each additional address that has the same AHCCCS ID and license, copy and complete this Supplemental form. A Provider
Assessment of Cognitive and Physical Disabilities Accommodations must be completed for
each location unless
accommodations are the same at each location.
(Please note: if a different AHCCCS ID and license the entire application
must be completed)
Location Name:
Street Address:
City:
State:
Zip Code:
Location NPI:
Phone #:
Fax #:
Accreditation:
Does this site have the same accrediting agency as the primary address? (as listed on page 3)
Yes
No - Please specify accrediting agency or NONE:
Revised 2021
Page 11 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
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 practitioner 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) 582-8686
Email is preferred method to send completed
PDFs:
BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/ACC
www.BannerUFC.com/ALTCS
www.BannerUCF.com
www.BannerUHP.com
Care1st Health
Plan Arizona
(602) 778-1800
(options in order 5, 7)
(602) 778-1875
SM_AZ_PNO@care1stAZ.com
www.care1staz.com
DentaQuest
(800) 233-1468
(262)241-7401
initialproviderenrollment@dentaquest.com
http://www.dentaquest.com/sta
te-
plans/regions/arizona/az-
dentist- page
Health Choice
(800) 322-8670
(options in order 4, 7)
If not yet contracted: Email form to
HCHContracting@healthchoiceaz.com
If contracted: Email form to your Provider
Representative or
HCHCredentialing@healthchoiceaz.com
(480) 760-4975
www.healthchoiceaz .com
Molina Complete
Care of Arizona
(800) 424-5891
(888)656-0369
MCCAZ-Provider@molinahealthcare.com
www.mccofaz.com
Mercy Care
(602) 263-3000
Network Management (Provider Relations
and Contracting)
MercyCareNetworkManagement@MercyCareAz.org
Fax: (860)975-3201
www.mercycareaz.org
UnitedHealthcare
Community Plan
For questions please
Email:
networkhelp@uhc.com
Submission to the RFP Portal is the preferred
method for accepting the pdf UHC RFP Portal
(855) 523-9998
Cred_applications@uhc.com
www.uhcprovider.com
Revised 2021
Page 12 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Sandata—Electronic Visit Verification
As of January 1, 2021 and in response to a federal mandate known as the 21
st
Century Cures Act, the AHCCCS program
will begin using an Electronic Visit Verification (EVV) system for selected home and community-based services. The
legislation outlines key data points that must be collected and electronically verified, but states create their own systems
and decide how to gather and report data, as well as whether to include additional compliance rules.
AHCCCS is using EVV to help ensure, track and monitor timely service delivery and access to care for members. AHCCCS
is also using EVV to help reduce provider administrative burden associated with scheduling and hard coy timesheet
processing. This means AHCCCS wants to use EVV to make sure members get the service that they need when they need
them. AHCCCS’ contracted vendor, Sandata Technologies LLC, will deliver the EVV system and associated devices, as
well as provide system orientation and training to providers.
Many agency providers will use the EVV system provided by Sandata. However, some agency providers may choose to
use an alternate EVV system, which is permissible if they meet the business requirements as an alternate data collection
specifications found on the AHCCCS webpage.
Next page includes a list of the Provider types, services and places of service subject to EVV.
Resource:
Electronic Visit Verification (EVV) Website (azahcccs.gov)
Reference Materials and Technical Assistance
• AHCCCS EVV Webpage (www.azahcccs.gov/EVV
)
o Session PowerPoint and Recording
o Link to the companion guide
• General EVV Questions (EVV@azahcccs.gov)
NOTE:
• Please identify who will serve as the primary EVV Office Contact on page 4 of this application. This person will
be responsible for receiving communications and notices from AHCCCS and Sandata.
• The Electronic Visit Verification (EVV) Compliance Attestation on page 14, MUST be signed by the
Organizational/Facility Chief Executive.
Revised 2021
Page 13 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Provider types, services, and places of service subject to EVV:
Provider Description
Provider Type
Provider Description
Provider Type
Attendant Care Agency
PT 40
Home Health Agency
PT 23
Behavioral Outpatient Clinic
PT 77
Integrated Clinic
PT IC
Community Service Agency
PT A3
Non-Medicare Certified Home
Health Agency
PT 95
Fiscal Intermediary
PT F1
Habilitation Provider
PT 39
Private Nurse
PT 46
Service
HCPCS Service
Code
DDD Focus Codes
Attendant Care
S5125
ATC
Companion Care
S5135
Habilitation
T2017
HAH, HAI
Home Health Services (aide, therapy, and part-time/intermittent nursing services
Nursing
G0299 and G0300
Home Health Aide
T1021
Physical Therapy
G1051 and S9131
Occupational Therapy
G0152 and S9129
Respiratory Therapy
S5181
Speech Therapy
G0153 and S9128
Private Duty Nursing (continuous nursing services)
S9123 and S9124
HN1, HNR
Homemaker
S5130
HSK
Personal Care
T1019
Respite
S5150 and S5151
RSP, RSD
Skills Training and Development
H2014
Place of Service Description
POS Code
Home
12
Assisted Living
13
Other
99
Revised 2021
Page 14 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
Electronic Visit Verification (EVV) Compliance Attestation
As the Chief Executive of a provider agency that provides services to AHCCCS members subject to Electronic Visit Verification
(EVV), I attest to the following:
1. My agency will utilize an EVV system for all EVV applicable services as outlined on the AHCCCS website. I understand that my
agency can choose to use the AHCCCS supplied state-wide system with Sandata Technologies or an alternate EVV system that my
agency procures.
2. I understand my agency cannot onboard with EVV until we have an AHCCCS Provider ID number. We will not be able to bill for
services until after we have completed credentialing and have our EVV system in place (i.e. access to the system, people trained,
devices deployed, etc.) and record visits.
3. For EVV services that don’t require prior authorization, my agency will input/upload required information including updates and
changes into the AHCCCS Service Confirmation Portal to inform AHCCCS and Managed Care Organizations (MCOs) of the following
information to support monitoring access to care through the EVV system
● Service codes, units and modifiers
● Beginning and end date of the services
● Medical necessity determination date
4. I understand and will adhere to the AHCCCS Medical Policy Manual (AMPM) Electronic Visit Verification policy (540).
Please verify the name and contact information (page 4 of application) for the administrative representative within your organization
who will be responsible for serving as the primary contact for EVV. This person will receive primary communications and notices from
Sandata and AHCCCS.
Chief Executive Name:
Title:
Direct email
Signature
Revised 2021
Page 15 of 15
Credentialing Alliance
ORGANIZATIONAL/FACILITY APPLICATION
If
the organization has multiple AHCCCS Provider Registration IDs that may be subject to EVV, please list all relevant
Provider IDs.
AHCCCS Provider IDs
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