AHCCCS Provider Enrollment Packets

In reference to the COVID-19 pandemic, a public health emergency has been executed. In order to ensure Out-of-State providers are reimbursed AHCCCS is requesting a shorten Provider Enrollment form to be completed and submitted for approval. This form is only to be utilized for “temporary” enrollment of an Out-of-State provider during the public health emergency. For all other provider enrollment providers please refer to the AHCCCS Provider Enrollment Form under the “Individuals/Companies/Facilities Packet.

• Provider Enrollment Out-of-State Form
• IRS Form W-9 (required)
  (Please ensure that you enter "W-9" and not "W9" when searching for this form.)

Welcome to the Arizona Health Care Cost Containment System (AHCCCS) Provider Enrollment Form. This is a universal form and should be used for Provider enrollment, revalidation, and/or modification requests.

• Individuals/Companies/Facilities Packet

  Individuals, companies and facilities, must complete all of the following forms.

  • (AHCCCS) Provider Enrollment Form
  • IRS Form W-9 (required)
    (Please ensure that you enter "W-9" and not "W9" when searching for this form.)
• If registering as one of the following provider types listed below, complete the applicable profile, review any special registration requirements notated by the provider type, and submit with your application.
  
  
  • Attendant Care/Company  

    New - In an effort to process the submission of the Attendant Care provider type documents efficiently, AHCCCS is requiring that the list of employees requested on the second page of the Attendant Care Provider Profile form be provided in an Excel spreadsheet format. This document will substitute the second page of the Provider Type Profile. All applications submitted without the Excel spreadsheet will be pended for the Excel spreadsheet. The format of the excel spreadsheet should follow the format demonstrated in the table below:

    Provider ID	Employee Name	SSN	DOB	Employment Begin date	Employment End Date
    Must be numeric	LastName/FirstName Format	Must be numeric only E.g. 123456789	MM/DD/YY Format	MM/DD/YY Format	MM/DD/YY Format

    Note: All excel spreadsheets must be sent through email.

    PRNotice@azahcccs.gov

  • Affiliated Practice Hygienist  

  NOTE: A dental hygienist may register with AHCCCS only if the dental hygienist has an affiliated practice relationship with a dentist that complies with A.R.S. 32-1281(G) and 32-1289.01. All other dental hygienists may not register with AHCCCS or independently bill Arizona’s Medicaid system for their services.

  • Homemaker(if applying as a company)
  • Independent Testing Facility
  • Non-Emergency Transportation Provider  
    • Complete the Online training module and submit the certificate:
      Non-Emergency Medical Transportation Provider Training CBT
    • Copy of registration for each vehicle is required.
  • Nurse-Midwife
  • Physician Assistant (if a behavioral health medical practitioner)
  • School Based Bus Transportation
  • Naturopath
  • Provider Enrollment Requirements for Licensed Naturopathic Physician

  The Arizona Health Care Cost Containment System (AHCCCS) is accepting applications from licensed Naturopathic Physicians who wish to serve AHCCCS members under Early Periodic Screening Diagnostic and Treatment (EPSDT). This AHCCCS provider type is active and is designated as 17-Naturopath in the AHCCCS Provider Enrollment system.

  In order to submit claims for AHCCCS Fee for Service Programs, an active AHCCCS provider enrollment is required. In order to submit claims for AHCCCS managed care organizations (MCOs), Naturopathic physicians will need to be credentialed and contracted with the MCO(s) in addition to having an active AHCCCS provider enrollment.

  • NEMT- Transportation Network Company
  • NEMT Equine

  Note: Existing providers may use the Provider Enrollment Application to update their address on their provider enrollment file.

Mail or fax completed and signed enrollment forms.

• Mail:
  
  AHCCCS Provider Enrollment
  P.O. Box 25520, Mail Drop 8100
  Phoenix, AZ 85002
• Fax:
  Attn: AHCCCS Provider Enrollment
  602 256-1474

Note: All applicable licenses and certifications must be submitted with the enrollment forms. If you have questions regarding the types of applicable licenses or certifications, please contact Provider Enrollment at the phone numbers listed below.

For questions regarding the provider enrollment process, please contact the AHCCCS Provider Enrollment Unit.

Due to the recent COVID-19 pandemic and the need to reduce the spread of the virus, AHCCCS transitioned many staff to work alternative methods such as telework. In order to successfully continue to meet the needs of our Provider community, it is recommended to begin sending an email with provider enrollment related questions, a response will be provided within 24 hours and begin Faxing or Emailing ALL provider related applications and verifications. Our faxes are received electronically which can continue to be easily received and distributed for timely processing.

Fax (Preferred Method): 602-256-1474

Or

Email: PRNotice@azahcccs.gov