New Provider Setup Packet

New Provider Setup Packet

Need help? Email NetworkRelations@AllianceHealthPlan.org.
All new providers enrolling in the Alliance Health Provider Network should complete the full Practice Setup Packet, to ensure accurate set up for payment and authorization submissions, which includes:
1. Practice Profile
2. Vendor Setup Packet
3. Trading Partner Agreement and Connectivity Form
4. ACS Portal Access Request
For our purposes, "practice" refers to the operating entity and not individual service locations.
Practice Profile
I. General practice information
Legal name of practice*
Doing business as (DBA)
Clinically Integrated Network name (if applicable)
Website address (URL)
Main phone*
Please enter a valid phone number.
Has your practice completed a cultural competency training?

YesNo
Practice business address*

Street address

Street address line 2

City

Postal code
State*
Postal code*
Full address (calculated field)
II. Practice contact information
Contact information is required for the practice administrator, but is requested for each of the roles listed.

Practice contact information*

	Name	Phone	Email
Practice administrator *
Office manager
Contracting contact
Referral contact
Quality Management (QM) contact
QM

III. Panel size information for physical health Primary Care Providers (PCPs)
For each location in your practice offering Primary Care services (PCP) please list the full address and PCP panel size. Non-PCP locations should not be included.

If you have 5 or fewer PCP locations, you may enter the required information in the table below.

If you have more than 5 PCP locations, please complete the Excel template here and upload via the file upload box instead.

Five (5) or fewer PCP locations? Please enter that below:

	Address (street, city, state, postal code)	PCP panel size
1. Primary
2.
3.
4.
5.

More than five (5) PCP locations?

Attach a document to this form listing each location. Include Name, Address, PCP (y/n), and PCP panel size if applicable.
Cancelof
Table with data?
PDF Upload Notification 1
PDF Upload Notification 2
IV. Provider training information and registration

END
Please designate up to three staff that will be invited to take the trainings through the Alliance Learning Management System (LMS) or submit reciprocal certificates through that system:

Staff designated for training

Trading Partner Agreement

All entities wishing to submit claims trough 837 HIPAA files must be connected to the Alliance Claim System. If the entity is using a clearinghouse, billing service or third-party biller, please fill out the applicable box.
Please select:

This is a new trading partner agreementThis is an update to an existing trading partner agreement
I. Provider information

(required)
NPI*
Provider contact name*
Title*
Contact email*
example@example.com
Phone*
Please enter a valid phone number.
Does your entity use either or both of the following partners:

ClearinghouseBilling Service/Third-party Biller
II. Clearinghouse information

(if applicable)
Clearinghouse name
Contact name
Title
Contact email
example@example.com
Phone
Please enter a valid phone number.
Tax ID
Address (street, city, state, postal code)
III. Billing service/Third-party biller

(if applicable)
Company name
Contact name
Title
Contact email
example@example.com
Phone
Please enter a valid phone number.
Tax ID
Address (street, city, state, postal code)
Authorization
Signature

Clear
Please select:

Send 835 to ProviderSend 835 to Clearinghouse/Biller

Practice Profile