- BCBSAZ.ProviderCredentialing.WebUI

Becoming a BCBSAZ network provider starts with the contract request and credentialing process. In order for us to process your request, please confirm that the following steps have been completed.

Have you registered with CAQH?*

Yes, I've registered with CAQH

No, I haven't registered with CAQH

CAQH Provider ID *

Have you completed all the necessary steps below to enable BCBSAZ to access and review your universal CAQH application? *

Uploaded supporting documentation in the CAQH profile/application
Confirmed that my certificate is current and will not expire in the next 30 days
Attested to the CAQH Application
Verified that my credentialing information, including the current practice address, is current
Authorized BCBSAZ to access my CAQH application

Yes, I’ve completed all the steps listed above.

No, I haven’t completed all the steps listed above.

We are unable to process your request.

BCBSAZ requires all applicants to use the Council for Affordable Quality Healthcare (CAQH) to apply for credentialing using the CAQH universal application form. To complete this application, you must first log in and register with CAQH at ProView.CAQH.org and complete your provider profile, including the online credentialing application. Make sure to give us authorization to access your CAQH file. Once you have completed the CAQH process, and received your CAQH number, you may reapply at www.azblue.com/credentialing. If you have questions regarding CAQH or the application process, please email us at [email protected] or call 602-864-4231.

We are unable to process your request.

BCBSAZ cannot review your CAQH file until all elements above are complete. Your credentialing application is not treated as received under A.R.S. § 20-3454 until we can access your Universal CAQH file. If your CAQH ID is inactive, the contract request will be discontinued, and a new submission will be required.

Contact information for questions related to this application:

First Name*

Last Name*

Phone Number*

Ext.

Preferred way to contact

Email Address *

Preferred way to contact

BCBSAZ will notify the above contact person of any incomplete or missing information. If we do not receive the required information within 30 days, your request will be withdrawn and you will need to resubmit it for consideration.

Practice Information

* Indicates required fields

Hospital/Freestanding Surgery Facility Privileges

Facility Name

Group Information

Group's Legal Name *

Group's Doing-Business-As (DBA) Name

Group/Organization NPI *

Effective Date *

Date You Were Licensed to Practice in AZ *

Does your group have a concierge practice? *

A "concierge" medical practice is one in which the patient pays an annual fee or retainer for enhanced services not otherwise available from a provider. The concierge arrangement is typically documented in a written concierge agreement between the provider and the patient. To comply with BCBSAZ contractual obligations, providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum. For more information, please email [email protected]

Yes, it does (Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract).

No, it doesn't.

Contact person for the practice (practice administrator/office manager) for business correspondence:

Name *

Email Address *

Phone *

Fax

Contracts and correspondence must be sent to the provider, not a billing company or a consultant.

Business Website Address *

Business Email Address *

Primary Office Information

* Indicates required fields

Primary address must be a physical location in Arizona, where services are performed.

Address *

City *

State *

ZIP Code *

Phone (Patient Scheduling Number) *

Fax *

Email Address *

Office Hours

Select the days and hours that your primary office is open:

All Other Addresses

* Indicates required fields

Primary Address:

Use same for billing

Use same for mailing

Use same for medical records

Use same for credentialing

Billing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Mailing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Medical Records Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Credentialing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Note about addresses: BCBSAZ sends claims payments to the provider's billing address. Unless a separate mailing address has been specified, other correspondence (including contract updates) is also sent to the billing address. An exception is medical records requests, which are sent to the primary location address if a seperate medical records address is not specified.

Additional Office Information

* Indicates required fields

Do you have another location where you actively practice on a regular basis, under the same Tax ID?

Do not include locations where you work occasionally or cover for other providers

Yes, I've got another office.

No, I don't have another office.

Address *

City *

State *

ZIP Code *

Phone (Patient Scheduling Number) *

Fax *

Email Address *

Office Hours

Select the days and hours that your secondary office is open:

Same office hours as primary office

Additional Information/Comments

Attach Supporting Documents

(Supporting documents: Certificate of Insurance, Copy of Professional License, Curriculum Vitae and DEA Certificate
Accepted file type PDF or JPG)

Name	Close

Authorized Electronic Provider Signature

I verify that the information provided on this form is current and accurate. I agree that, by checking the box, I am verifying the information as provided. I understand my obligation to notify BCBSAZ if any of this information changes.

Signature *

Date *