AHCCCS Provider Enrollment Applications and Revalidations

To prepare for the AHCCCS Provider Enrollment application, have the following documentation available when you apply:

• National Provider Identifier (NPI) – The federal government requires that providers who administer “medical and other health services” should obtain an NPI number – a unique 10-digit identification number for covered health care providers. For more information visit the National Plan and Provider Enumeration System (NPPES) webpage at https://nppes.cms.hhs.gov or contact the NPI Enumerator at 1-800-465-3203 or TTY 1-800-692-2326.
• Atypical providers are not required to have an NPI in the AHCCCS Provider Enrollment Portal (APEP). An NPI can be added to the profile after approval upon request by submitting a ticket.
  
  Submit a ticket by email to APEPTrainingQuestions@azahcccs.gov with the subject “Add NPI to Profile” The body of the email must include:
  • Provider’s Name,
  • Provider’s AHCCCS ID,
  • Provider’s Tax ID, and
  • Provider’s NPI to be added.
  If you do not include all the information listed above, the ticket will be closed, and you will need to submit a new, complete ticket.
• Completed W9 Tax Form - Request for Taxpayer Identification Number and Certification – Any provider who will be receiving state/federal funds for services rendered or provided to Medicaid recipients must provide completed W9 tax form as part of the application process. The W9 form can be found on the IRS website.
• Current Professional Certifications or Licensures – Providers must maintain current and ongoing certification or licensure when enrolling and participating in the Medicaid Program with an active status of the provider enrollment AHCCCS ID.
• If enrolling as a behavioral health provider, Arizona Department of Health Services will issue a Certificate & Transmittal (C&T) upon request along with the state license. The C&T is required for behavioral health providers issued a license in Arizona, as it identifies the provider type the applicant should enroll under. The Behavioral Health Provider Types pdf identifies which provider types require the C&T. For additional questions about the C&T, visit Arizona Department of Health Services or contact the Office of Medical Facilities at 602-364-3030.
• If enrolling as one of the following provider types listed below, the additional documentation is required as part of the enrollment process. Review the instructions section outlined in each form, download the form, complete, and upload it in the AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type-License” under “Document Name-AHCCCS Provider Registration.”
• (PT-01) Group Biller - Group Biller Roster Disclosure Form
• Affiliated Practice Hygienist Link
• Attendant Care (PT-40)
• Employee information is uploaded in APEP under Employee Details. Template instructions are outlined in the Employee Details step.
• Community Health Worker Organization (PT-CH)
• Homemaker (applying as a company)
• Independent Testing Facility
• (PT-28) Non-Emergency Transportation Company
• Employee/Driver information is uploaded in APEP under Employee Details. Template instructions are outlined in the Employee Details step.
• Non-Emergency Transportation Network Company (PT-NT)
• NEMT Equine (PT-NE)
• Physician Assistant (behavioral health medical practitioner)
• School Based Bus Transportation
• Any other supporting documentation associated with your provider type. Review the Provider Enrollment Screening Glossary (PEP-903) to help determine the screening requirements for your provider type.

Each applying provider must be screened based on their assigned risk level. The general screening requirements for each risk level are outlined below.

Limited	Moderate	High
Verify that a provider meets any applicable Federal regulations or State requirements for the provider type prior to making an enrollment determination, License verifications, Conduct Database Checks.	Verify that a provider meets any applicable Federal regulations or State requirements for the provider type prior to making an enrollment determination, License verifications, Conduct Database Checks, Site Visit.	Verify that a provider meets any applicable Federal regulations or State requirements for the provider type prior to making an enrollment determination, License verifications, Conduct Database Checks, Site Visit, Fingerprint-Based Criminal Background Check (FCBC) (PEP-902).

EFT is required for all Group Billers, FAOs, Atypical FAOs, and Individual Sole Proprietors who are NOT rendering providers.

To enroll in EFT, follow the steps below:

1. Create and submit an application in the AHCCCS Provider Enrollment Portal (APEP). For new enrollments, you will need the APEP application ID for the EFT form.
2. Complete the EFT form. Make sure the application ID is entered in the correct field.
3. Email the completed form to AHCCCS_EFT_Enrollment@azahcccs.gov with either a copy of a blank check or a verification letter from the bank confirming your account details. Please use the words "New Enrollment EFT" in the subject line of the email.
4. Respond to any subsequent requests from AHCCCS regarding your application or EFT enrollment. Failure to complete the EFT requirement will result in the application being denied.

Section 6401(a) of the Affordable Care Act (ACA) requires the State Medicaid Agency to impose a fee on each “institutional provider of medical or other items, services, and suppliers.” The application enrollment fee amount is the same fee that applies to Medicare enrollment. The enrollment fee does not include non-institutional providers (e.g., Practitioners, Dentist, Group Billers). The purpose of the enrollment fee collected by the State Medicaid Agency is to offset the cost of conducting the required screening for the provider application. The enrollment fee is collected during the new enrollment, revalidation, and reactivation of a disenrolled provider.

The fee amount increases each calendar year and is issued by the Centers for Medicare and Medicaid Services (CMS). The enrollment fee for calendar year 2025 is $730, effective January 1, 2025 through December 31, 2025.

You can review the Provider Enrollment Screening Glossary (PEP-903) to identify which providers require the enrollment fee.

To pay the enrollment fee, please visit the following webpage: Make an online payment

Requesting a Refund of the Application Fee

A refund of the application fee may be issued for any of the following reasons:

• The application was denied or withdrawn before AHCCCS conducted screening activities;
• The application fee was already paid to a Medicare contractor or another state;
• AHCCCS could not approve the application because of a temporary moratorium on the applicant’s provider type; or
• Applicant is approved for a hardship exception.

To request a refund of the application fee, submit a ticket by email to apeptrainingquestions@azahcccs.gov with the subject “Application Fee Refund.” The request must include all the following information:

• Provider name
• NPI, if applicable
• Application ID associated with the request
• The qualifying reason for the requested refund
• Documentation to support the refund request. For example, if the fee was paid to Medicare or to another state Medicaid, you must provide the payment receipt as proof.

If you do not include all the information listed above, the ticket will be closed. You will need to complete and submit a new ticket to request the refund of the application fee.

You will receive a response once your request has been processed. When approved, a paper check is issued by AHCCCS. The refund process may take 30 to 60 days.

Processing Timeframes

AHCCCS generally processes Provider Enrollment applications within 60 days of submission. An expedited application process may be requested. Some examples of what may justify an expedite includes (but is not limited to):

• An emergent medical need of an AHCCCS member such as a transplant or and out-of-state emergency service,
• An AHCCCS member needs placement or relocation,
• The provider is a Department of Child Safety Foster Parent.

Follow the steps below to request an expedited application:

1. Complete a Provider Enrollment Application in the AHCCCS Provider Enrollment Portal (APEP).
2. Email your request to expedite. The following information is required and must be included in the email:
• Provider Name,
• Provider National Provider Identification Number (NPI),
• Provider Taxpayer Identification Number (TIN),
• Application number located in APEP,
• The reason for the expedited request.

Any requests missing the required information will not be processed. The email request should be sent to APEPTrainingQuestions@azahcccs.gov Once your email has been submitted, you will receive a ticket number confirmation. It’s important that you do not resubmit an email for the same reason, as this will impact the timeliness of your request

3. Provide any additional information or supporting documentation that may be needed to complete the expedite request.
4. Complete all required screening and enrollment steps required for AHCCCS Provider Enrollment process.

Enrollment Effective Dates

In general, the effective date of AHCCCS enrollment is the date the application is approved. In some instances, a retroactive enrollment date may be requested. All requests are reviewed on a case-by-case basis. Some examples of what may justify a retroactive enrollment include (but are not limited to):

• An emergent Medical need of an AHCCCS member such as a transplant or an out-of-state emergency service,
• A change in provider type, licensure, ownership or service location which required a new application in APEP,
• A physician began providing Medicaid covered services at the request of a Managed Care Organization,
• The provider was previously terminated for failure to complete revalidation.

This list is not all available reasons why a retroactive enrollment date may be considered. These are examples and not a guarantee of a retroactive enrollment.

Before requesting a retroactive enrollment date, there must be a completed Provider Enrollment Application in the AHCCCS Provider Enrollment Portal (APEP) and all required screening and enrollment steps for the AHCCCS Provider Enrollment process must be completed.

To request a retroactive enrollment date, send an email to APEPTrainingQuestions@azahcccs.gov with “Retroactive Enrollment Date” as the subject line. The email must include all the following information:

• Provider Name
• Provider National Provider Identification Number (NPI)
• Provider Taxpayer Identification Number (TIN)
• Application number located in APEP
• The reason for the retroactive enrollment request.

Provide any additional information or supporting documentation that may be needed to complete the retroactive enrollment request. Failure to submit supporting documentation with the request will result in the request being denied.

Reporting Changes and Maintaining Current License and Certifications

After being approved as an AHCCCS registered provider, you are required to:

• Report any changes to your information using APEP. Changes may include, but are not limited to:
• Change in service address,
• Changes in ownership or managing employees,
• Adding a New Behavioral Health Professional In the AHCCCS Provider Enrollment Portal (APEP)
• Maintain current license and certifications,
• Respond to any requests from AHCCCS about your enrollment information.

Revalidation

A provider must revalidate their enrollment every four years to maintain Medicaid billing privileges. AHCCCS reserves the right to request off-cycle revalidations.

During revalidation, screening is based on the current risk level for the provider type. Based on provider type the screening requirements may include an enrollment fee, site visit, and fingerprint criminal background check. Revalidations also require the provider to review all information on file and confirm the information is correct. Providers may log into the AHCCCS Provider Enrollment Portal (APEP) to view revalidation dates.

APEP will not be available during the following planned maintenance times:

Maintenance Type	Date	Time (MST +1 day)
Regular maintenance	Saturday, February 1, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, March 15, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, April 26, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, June 7, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, July 19, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, August 30, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, October 11, 2025	3:00 PM to 11:00 AM
Regular maintenance	Saturday, November 22, 2025	3:00 PM to 11:00 AM