How Providers Can Participate in an Aetna Network

Physicians and other providers can participate in the Aetna health care network to provide medical services to its growing number of members. Once accepted as part of the network, a doctor is an in-network provider and people with the Aetna plan will use their services on a preferential basis. This is a great advantage if Aetna has a lot of subscribers in your area.

Aetna is recognized as one of the nation’s leaders in health insurance. With millions of members in its health plan, Aetna continues to have a strong presence in most states. Use the following steps as a guide to becoming a participant in an Aetna network.

Step 1: Obtain a National Provider Identifier (NPI)

Before applying to participate in the Aetna network, providers, including physicians, other clinicians, physician’s offices, and certain providers, must obtain an NPI.

The National Provider Identifier or NPI is a 10-digit unique identification number that is used to replace provider identifiers, such as the Unique Provider Identification Number (UPIN) in standard HIPAA transactions. Healthcare providers are required by HIPAA regulation to obtain an NPI.

If you don’t already have an NPI, apply for one at  nppes.cms.hhs.gov  or call the NPI Enumerator at 1-800-465-3203.

Step 2: Submit a request to participate

Aetna requires that any provider interested in participating in an Aetna network submit a request for participation before submitting a request. The request for participation is evaluated to determine the need for a participating provider within the geographic location of your medical office. Contact one of the following to submit your request for a physician and other clinical professionals:

  1. Complete the online health plan application request form  on the Aetna website
  2. Contact a representative at 1-800-353-1232
  3. The medical center should contact the Aetna Provider Service Center at 1-888-632-3862.

Make sure you have your doctor’s office tax ID and medical license number handy. If your request is accepted, Aetna will email your provider agreement for your review. A signature is required.

Step 3: Join the CAQH Universal Provider Data Source (UPD)

CAQH UPD is an online tool designed to simplify the information gathering process required by health plans for provider accreditation and much more. This process prevents providers from having to send the same information to multiple health insurance plans. Members can fill out and submit their information to all health plans for free.

  • Obtain a CAQH Vendor ID by calling the CAQH Support Desk at (888) 599-1771 or email [email protected]
  • Login to upd.caqh.org/oas/
  • Follow the instructions to complete and activate the registration.

Step 4: Complete the application

Any applicable supporting documentation should be faxed to CAQH at (866) 293-0414. Will need:

  • Curriculum vitae
  • Medical license
  • DEA certified
  • CDS Certificate
  • IRS Form W-9
  • Malpractice insurance face sheet
  • Summary of any pending or resolved negligence case

Aetna has a unique accreditation process. The Aetna CVO (Credential Verification Organization) evaluates the qualifications of each applicant before a provider can be accepted to participate in an Aetna network. In addition to the information requested by CAQH, Aetna will also review professional competence and conduct.

Other relevant information

The application process can be completed completely online. Once the application is complete and certified, you will need to authorize Aetna to access your enrollment application and other information. The whole process shouldn’t take more than two hours to complete. The module is also designed to save your information if you need to complete the application in multiple sessions.

The CAQH support desk is available to assist you if you need assistance during the process.

Step 5: Gather All Supporting Documentation

  • The whole process can take three to six months.
  • Written notification will be sent to the provider once a decision has been made.
  • For more information on how your medical office becomes an Aetna participating provider, visit  www.aetna.com  and  www.caqh.org.

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