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Providers

Behavioral Health Provider Application Request

Behavioral Health

Please complete this form if you are interested in joining the Aetna network.

If you need more information about our application and credentialing process, use the link below. You will also find information on the Council for Affordable Quality Healthcare's (CAQH's) ProView® and Medversant / ProviderSource™ (for practitioners located in Washington state).

Information about application and credentialing process

As a practitioner, you have the right to correct any information obtained during the credentialing process by working directly with the reporting entities. 

All fields marked with a RED asterisk (*) are required.

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Practitioner Information

1) Practitioner Information

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Incorrect date of birth will delay the application request process.

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Please enter the email address of the individual authorized to sign the agreement.

Please enter the email address of the individual responsible for credentialing.

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2) Practitioner’s Licensure Information

If your specialty is not listed please call 1-800-353-1232.

Degree acronym definitions

*Applying as

Incorrect TIN will delay the application request process. Please do not include spaces or dashes. Some providers use the SSN instead. If joining a participating group, please use the group's tax ID to associate the request with the participating group.

*Are you applying to join an existing group that participates with Aetna?
*Are you registered with Council for Affordable Quality Healthcare (CAQH)?

This ID should be 8 numbers.

*Do you have hospital/facility admitting privileges?

If the answer to the above is Yes, please enter name and state of the hospital and/or faculties(s)s in which you have admitting privileges.

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Primary Service Location Information

3) Primary Service Location Information

*Is this location wheelchair accessible?

Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road")

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Mailing Address

4) Mailing Address

Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road")

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National Provider Identifier (NPI) information

5) National Provider Identifier (NPI) information

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A 10 digit type 1/individual NPI number must be entered if you are a physician (MD/DO).

Does NPI apply to all providers using this tax ID?
Does this NPI apply to all tax ID for this provider only?
Does this NPI apply to all service locations and billing addresses for this tax ID?
Does this NPI apply to all service locations and billing addresses for this provider only?
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Populations you work with

6) Populations you work with

Populations you work with
*Do you have accommodations for people with disabilities?
*Is the provider Medicare certified for your state?
*Is the provider Medicaid certified for your state?
*Do you wish to participate in Aetna’s employee assistance program (EAP)?
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Language spoken

Below, select up to three languages spoken other than English. Choose "Other" if the language spoken is not listed in the drop downs.

7) Languages spoken

*American sign language
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Provider Practice Focus

8) Provider Practice Focus

Please check up to (8) areas of focus

9) Acknowledgement

*Do you agree to the Email Acknowledgement?
*Do you agree to all information included in the Behavioral Health Provider Manual?

Behavioral Health Provider Manual


Please note that completing the request form does not guarantee participation in our network.

We are a participant in the Council for Affordable Quality Healthcare (CAQH) initiative. You should receive our acknowledgement to your application request within 7-10 business days.  

Providers who meet Aetna’s eligibility requirements should watch for a CAQH registration package via U.S. mail within 10-14 business days unless there is an existing CAQH record already established through past affiliation with us or through affiliation with another health plan using the CAQH application. 

Providers applying for participation may be contacted by a representative from Aetna or one of Aetna’s subsidiary companies, including Cofinity, Aetna and Coventry.

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