AHCCCS Provider Enrollment Packets

Due to the evolving COVID-19 pandemic and Governor Ducey's directive to socially distance in order to reduce the spread of the virus, AHCCCS staff have transitioned to work alternative methods such as telework as much as possible. In order to successfully continue to meet the needs of our Provider community, we ask providers to contact us by email with any provider enrollment related questions. AHCCCS will respond within 24 hours. We also ask providers to fax or email all provider-related applications and verifications. We receive faxes electronically and can continue to distribute these documents for timely processing.

Fax (Preferred Method): 602-256-1474

Or

Email: PRNotice@azahcccs.gov

Thank you for your patience as we shift our work environments while maintaining our commitment to and standards of timely provider enrollment service.

The Provider Enrollment process is required for those who provide medical care services (including primary care doctors, transportation, etc) to AHCCCS beneficiaries.

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.

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.

  • 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  
    • 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 evolving COVID-19 pandemic and Governor Ducey's directive to socially distance in order to reduce the spread of the virus, AHCCCS staff have transitioned to work alternative methods such as telework as much as possible. In order to successfully continue to meet the needs of our Provider community, we ask providers to contact us by email with any provider enrollment related questions. AHCCCS will respond within 24 hours. We also ask providers to fax or email all provider-related applications and verifications. We receive faxes electronically and can continue to distribute these documents for timely processing.

Fax (Preferred Method): 602-256-1474

Or

Email: PRNotice@azahcccs.gov

Thank you for your patience as we shift our work environments while maintaining our commitment to and standards of timely provider enrollment service.