What documents are required to Credential?

1) Complete the online credentialing application. Go to ActivHealthCare.com and select Credentialing then your state and then select Create an Account – if you already have an account see Re-Credentialing.

2) W-9 - This form can be downloaded from Credentialing or Forms on AHC website. Please complete the W-9 with the information that the IRS has listed with the Tax ID number you will be filing your claims under. This may be your company name and TIN or it may be your individual name and your S.S. number.

3) Release Authorization – this document is signing that everything that you stated on the online application is correct and accurate.

4) CMS Worksheet (Coventry) – this document is required by Coventry and should be completed with the proper information about your company name and shareholders.

5) Provider Agreement – this document is ActivHealthCare’s contract

6) Business Associate Agreement – this document is ActivHealthCare’s HIPAA agreement

7) Multiplan Opt In or Out – This document is required to select whether you wish to enter AHC contract with Multiplan or choose to Opt Out. AHC contract with Multiplan includes Auto at a 7% discount over the allowed amount on our Multiplan Fee schedule.

8) Auto Option (Coventry) – AHC contract with Coventry has the option of adding on Auto. If you wish to Add on Auto select yes. If not select no.

9) EFT (Electronic Funds Transfer) – This document is required to directly deposit checks from AHC to your back account.

10) Certificate of Malpractice Insurance – One page showing your Name, Coverage Amounts (minimum coverage is 1M/3M) and expiration date. Adding AHC as a certificate holder will prevent your office from having to update this annually.