AETNA BETTER HEALTH®

Practitioner application
Aetna Better Health of Pennsylvania is committed to the quality of health care services delivered to our members. In support of this commitment, we have structured provider credentialing and contracting processes in place.

Practitioners joining an existing, participating Aetna Better Health of Pennsylvania provider practice should complete, sign, and submit the Practitioner Application. Practitioners may not treat members until they become credentialed.

As a participant with the Council for Affordable Quality Healthcare (CAQH), Aetna Better Health utilizes the CAQH uniform provider application.
If you have a current CAQH application on file, be sure to include your CAQH ID # on the Application. If you do not currently have a MEDICAID/PROMISe ID you must complete the Disclosure Of Ownership Form (OIG Form), in addition to this application. Effective July 1, 2019, all providers must be enrolled and have a valid PROMISe Identification Number (PROMISe ID) for each location where services are rendered.

Practitioners may not treat members until they become credentialed.

You will be notified of your participation effective date with ABH when the full credentialing and contracting process is complete.

Please contact your PR representative or call 1-866-638-1232.

Have MedicaidID/PromiseID : Existing Group :
Provider Info: Last Name * First Name * MI Degree *
Please enter last name
Please enter first name
Please enter degree
Gender * DOB * Group Name
Male  Female
Please choose an option
Please enter DOB
Joining as :      Individual      Group A New Provider :     Yes     No
FQHC/RHC:
FQHC  RHC
Are you : * Practicing as : *
DBA Name : *
Please enter DBA Name.
Employment Start Date : Does your Office utilize Physician extenders? *
 Yes   No
Please choose an option
If     Yes, how many?
Please enter physician count
EDI and Internet Electronic Claim Submissions: *
Yes  No
Please choose an option
Practicing Specialties Primary: *
Please enter Primary speciality.
Secondary:
Board Certified       Yes       No Board Certified       Yes      No
If not Board Certified, are actively pursuing Board Certification:      Yes      No
Malpractice Coverage:     Yes     No Limits: FTCA     Yes     No
Is provider accepting new members?       Yes       No Gender Restriction *
Maximum number of new members accepted:
Please enter number of maximum members
Do you have age limits for practice? *
Yes No  
Please choose an option
If Yes, what are the limits?
Administrative Contact (Health Plan's Contact) Contact Name: *
Please enter Contact Name
Email: *
Please enter valid email
Phone Number: *
Please enter valid phone number
Fax Number: *
Please enter Fax
Admin Street: *
Please enter Street
Admin Suite:
Admin City: *
Please enter City
Admin State: *
Please enter State
Admin ZIP: *
Please enter ZipCode
NPI: Pay To NPI that a Group own this number: *
Please enter GroupNPI
Individual NPI: Only one person can own this number*
Please enter Individual NPI
Other IDs Medicaid # (PROMISe ID): *
Please enter MedicaidID
CAQH#: *
Please enter CAQH#
Eff. Date:
Primary Taxonomies: *
Please enter primary taxanomy code
Secondary Taxonomies:
DEA #: Exp. Date:
340B     Yes     No
State License: State License#: *
Please enter license ID
Date First Issued: Exp.date: *
Please enter expiry date
State Of issue: *
Please enter state of issue
Hospital/Free Standing Surgery Facilities
   
     Active      Courtesy        Delivery        Provisional
   

Language and Culture Primary: Language(s) spoken other than English
Please enter language
Cultural Heritage: Completed Cultural Competence Training     Yes     No Secondary:
Ethnicity *
Group : *
Please select group
Primary Service Location
(Main location where
provider offers services) 		Primary Service Location Name: *
Please enter location name
PROMISE ID : * SiteCode : *
Please enter Site Code
street:*
Please enter street name
Suite:
City:*
Please enter city
State:*
Please enter state
ZipCode:*
Please enter Zipcode
County:
Phone:*
Please enter valid phone number
Fax:*
Please enter Fax number
Toll Free Phone:
Email Address:*
Please enter valid email
Handicap Accessible : *
Yes  No
Please choose an option
Office Hours:(list)*
Please enter office hours
Experience treating:     AIDS/HIV     Mental Illness     ESRD     Co-occurring disorders     Visual Impairment Evening hours:*
Yes  No
Please choose an option
 Weekend hours:*
Yes  No
Please choose an option
Accommodate special needs patients: Developmentally Disabled *
Yes  No
Please choose an option
 Physically Disabled *
Yes  No
Please choose an option
Services offered to the deaf / hearing impaired (circle): *
sign language TTD/TTY None available
Please choose an option
 Adjustable exam table:*
Yes  No
Please choose an option
Is Office Located on public transportation route (bus/rail/ferry): *
Yes  No
Please choose an option
    Bus     Rail     Ferry/Boat
Language Interpreters: *
Please enter language
Payment Info
(This information must
be the same as the W-9
information provided) 		Pay To Information Address: Contract and remits will be mailed to this address unless otherwise specified
Tax ID: *
Please enter TAX ID Number
line Of Business: *
Please select line Of Business
Street: *
Please enter Payment Street
Suite:
City: *
Please enter Payment City
State: *
Please enter Payment State
ZipCode: *
Please enter Zip code
County:
Phone: *
Please enter Payment Phone
Fax: *
Please enter Payment Fax
Toll Free Phone:
Billing contact Name: Billing Email:
(All correspondence,checks,remittance advices,contracts will be sent to this address)

I affirm that all of the information on this form is accurate and complete to the best of my knowledge, information, and belief. I Promise to keep confidential any information that Aetna Better Health shares with me during this process.
You must agree before submitting.
   
Provider Information
FirstName : LastName : Gender : DOB :
Physician Type : Practitioner Type : New Members Accepted : PhysicianExtenders :
EDI Submissions: Primary Speciality: Board Certified : Age Limits :
Adminstrative Contact Information
Contact: Email: Phone : Fax :
Street: City : State: Zip :
NPI and other Details
Group NPI: Individual NPI : Medicaid ID : CAQH# :
Primary Taxonomy: DEA #: State License : IssuedState :
Language Information
Primary Language: Language: Ethnicity : Group :
Primary Service Location Information
Location: PromiseID: SiteCode :
Street: City : State: Zip :
County: Email: Phone : Fax :
Handicap: Weekendhours: EveningHours : DisabledAccommodation :
Disabled?: Services Offered: Transportation : LanguageInterpreters :
Payment Information
TAX ID: LOB: County :
Street: City : State: Zip :
     

Please verify all data entered in the form before submitting the form

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