Form Mo-15-04-69 - Credentialing Application Request Form
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1
2Aetna Better Health® of Missouri
10 South Broadway, Suite 1200
St. Louis, MO 63102
Aetna Better Health® of Missouri
Practitioner credentialing requirements checklist and request form
To prevent delays in the credentialing process, please complete and submit the following information:
A. Please submit this checklist to Aetna Better Health of Missouri and attach all documents listed
below:
Aetna Better Health of Missouri Practitioner Credentialing Request Form
Aetna Ownership & Controlling Interest Worksheet - one worksheet for each Tax ID request
Attach additional sheets if needed and signature is required by any individual with signature authority
for the practice.
Collaborative Practice Agreement - with an Aetna Better Health of Missouri participating practitioner
(Nurse Practitioners only)
Signed by both supervising physician and nurse practitioner
W-9 (for each Tax ID request)
B. Please complete/update the following, but do not submit with request form:
CAQH Online Application is current and complete, including:
Application Attestation - less than 30 days old at the time request is submitted
Section 2 - Education and Training (all training must be completed prior to submitting request)
Section 3 - Professional / Medical Specialty Information
Section 4 - Practice Location Information (must include Tax ID)
Current Licensure* - including medical, DEA and BNDD (Missouri providers only), upload licensure in
CAQH and update application
*providers with temporary or provisional licensure can not be credentialed
Current Malpractice Insurance - upload current certificate in CAQH and update application
C. Please submit all credentialing information to Aetna Better Health of Missouri-Provider
Relations/Credentialing by email, fax or mail:
Email:
Fax: 1-866-278-9981
Mail: Attn: Provider Relations/Credentialing, 10 S. Broadway, Suite 1200, St. Louis, MO 63102
Note: The credentialing process can take 90-120 days.
Complete the information below and return both pages to Aetna Better Health of Missouri
Practitioner’s Name (please print):
Last
First
Title
Practitioner’s NPI:
Page 1 of 2
Aetna Better Health of Missouri Public Domain Use
MO-15-04-69
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