AHCCCS Provider Enrollment Form for Healthcare Providers

To submit the AHCCCS Provider Enrollment Form, you can use the online portal at https://www.azahcccs.gov/PlansProviders/NewProviders/APEP.html for priority processing. Alternatively, you can mail the completed and signed forms to: AHCCCS Provider Enrollment, P.O. Box 25520, Mail Drop 8100, Phoenix, AZ 85002. You can also fax the forms to 602 256-1474. Be sure to include the provider's SSN/EIN/TIN on the bottom of each page to ensure proper identification and processing. My advice is to use the online portal for faster and more efficient processing.

The form should be reviewed and updated annually. Key review dates include January 1st for 2024 and 2025 to ensure all information is current and accurate for submission.

The AHCCCS Provider Enrollment Form is designed to facilitate the enrollment of healthcare providers, medical facilities, and individual practitioners into the Arizona Health Care Cost Containment System (AHCCCS). This form helps streamline the process of registration, ensuring that all necessary information is collected and verified for compliance with state regulations. By completing the AHCCCS Provider Enrollment Form, providers can offer services under the AHCCCS program, which helps manage healthcare costs and improve access to quality care for Arizona residents. The form includes detailed sections for provider information, practice locations, billing associations, licenses, and certifications, ensuring all aspects of the provider's practice are accounted for. Submitting this form is critical for providers to participate in the AHCCCS program and receive reimbursement for services rendered. The form helps maintain an up-to-date registry of approved healthcare providers, ensuring that patients receive care from qualified professionals within the state.

• 1. Provider SSN/EIN/TIN: The provider's Social Security Number, Employer Identification Number, or Tax Identification Number must be added to each page of the form.
• 2. National Provider Identification (NPI): The provider's unique identification number assigned by the National Plan and Provider Enumeration System (NPPES).
• 3. AHCCCS ID: The provider's AHCCCS Identification number, if applicable.
• 4. Profit Type: Indicate the type of profit status for the provider, such as for-profit or non-profit.
• 5. W-9 Form: Attach a completed W-9 form, which can be found on the IRS website.
• 6. Practice Address: Details of the provider's practice address and hours of operation.
• 7. Pay To Details: Information on where payments should be sent.
• 8. Correspondence Address: Address for receiving correspondence from AHCCCS.
• 9. Provider Type and Specialty: Details about the provider's type and specialty, if applicable.
• 10. Associate Billing Provider Details: Information about any associated billing providers.
• 11. Licensing and Certifications: Copies of all relevant licenses and certifications must be included.
• 12. Bed Unit Information: Details of bed units, if applicable.
• 13. Controlling Interest/Ownership Details: Information about controlling interest, ownership, managing employees, and owner relationships.
• 14. Owners Adverse Actions: Details of any adverse actions taken against the owners.
• 15. Taxonomy: The provider's taxonomy code.
• 16. Authorized Signor: The name and details of the authorized signor for the Provider Participation/Group Biller Participation Agreement.

Failing to submit the AHCCCS Provider Enrollment Form can result in delays or denial of your enrollment in the AHCCCS program. This means you will not be able to offer services under AHCCCS or receive reimbursement.

• Service Delivery Disruption: Inability to provide services under AHCCCS due to lack of enrollment.
• Financial Loss: Potential revenue loss from delayed or denied reimbursements.
• Compliance Issues: Non-compliance with state regulations requiring timely enrollment and credentialing.

• 1. New Provider Enrollment: For new healthcare providers joining the AHCCCS program.
• 2. Revalidation: For existing providers updating or reaffirming their enrollment information.
• 3. Modification Requests: For providers making changes to their current enrollment details.
• 4. Associated Billing Providers: For adding or modifying associated billing provider information.
• 5. Licensing and Certifications: For updating licensing and certification details as required.