Please notify Banner Health Plans (BHP) at least 30 days before the effective date of any changes or updates.
Please use the appropriate AzAHP form as indicated in the type of request being submitted:
Adds
Add a Practitioner
- Submit AzAHP Practitioner Data Form (only after AHCCCS Registration is complete)
- Submit to: [email protected]
- Practitioner must be registered with CAQH. The primary contact information in CAQH must be current to avoid credentialing delays. Practitioners must also re-attest to the validity of their information quarterly.
Add a Location With a New Organizational NPI
Add a New TIN
- Submit a Banner Health Network Provider Interest Form
- Attach an AzAHP Organizational/Facility Application
Add a Product
Banner – University Family Care/ACC, Banner – University Family Care/ALTCS, Banner Health Network, Banner Medicare Advantage Prime HMO, Banner Medicare Advantage Dual HMO D-SNP (formerly known as Banner – University Care Advantage)
- Submit email with supporting documentation to [email protected]
- Group Name
- TIN
- Confirmation TIN holds a direct contract with the payer or are in the process of obtaining one (except for BMA, BUHP and UHC AARP Medicare Complete)
- Name of contact person & email address
- Name of signer & email address
- List of additional product(s) request
- Attach W-9
- For BUHP products, attach AzAHP Group Roster Form (AzAHP Group Roster Form)
Terminations
Include the termination effective date.
Contract/TIN
Change of Ownership
Practitioner
Location
Updates/Changes
Panel Change - Open or Close Panel
Service Address Change
No new organizational NPI or TIN.
Practitioner Name Change
Billing Contact
Billing Name or Pay-to Address
Credentialing Contact
Specialty
Practitioner Type
Other
AHCCCS Reg Number, NPI, etc.