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    • Join the First Health network – Behavioral Health

    All fields marked with an asterisk (*) are required.

     

    1) Practitioner information

    Enter first and last name of requestor at provider's office
    Enter 10 digits
    Incorrect date of birth will delay the application request process.
    Please enter the email address of the individual authorized to sign the agreement.
    Enter first and last name of party responsible for credentialing
    Please enter the email address of the individual responsible for credentialing.
    Enter 10 digits
    Enter 10 digits
     

    2) Practitioner’s licensure information

    If your specialty is not listed call 1-800-353-1232 (TTY: 711)

    Degree acronym definitions (PDF)

    *Applying as

     

    *I AM INTERESTED IN JOINING THE FIRST HEALTH NETWORK AS:

    Enter the license number of practitioner
    Submit one application per state.
    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 First Health?
    *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 FACILITIES(S) IN WHICH YOU HAVE ADMITTING PRIVLEGES:

    Submit one application per state.
     
    Submit one application per state.
    Submit one application per state.
    Submit one application per state.
     
    Submit one application per state.
     

    3) Primary service location information

    *Is this location wheelchair accessible?

    Physical address

     

    Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road"). A Post Office Box is not an acceptable primary service address.

     

    FOR ALL MINNESOTA APPLICANTS:

    ARE YOU APPLOYING FOR THE ALLINA HEALTH | AETNA JOINT VENTURE NETWORK?

    e.g. Sussex County
    Enter 10 digits
    Enter 10 digits
     

    Mailing address

     

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

     

    4) National Provider Identifier (NPI) information

    Enter primary NPI contact first and last name
    Primary NPI contact's phone number (10 digits)
    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?
     

    5) Populations you work with

    *Do you have accommodations for people with disabilities?
    *Is the provider Medicare certified for your state?

     

    IF YOU ARE MEDICARE CERTIFIED, PLEASE PROVIDE YOUR MEDICARE CERTIFICATION NUMBER/PROVIDER TRANSACTION ACCESS NUMBER (PTAN).

    *Is the provider Medicaid certified for your state?

     

    IF YOU ARE MEDICAID CERTIFIED, PLEASE PROVIDE YOUR MEDICAID CERTIFICATION NUMBER.

    *Do you wish to participate in Aetna’s employee assistance program (EAP)?
     

    6) Languages spoken

    *American sign language

     

    ADDITIONAL LANGUAGES SPOKEN BY THE PROVIDER OTHER THAN ENGLISH:

     

    7) Provider practice focus

    Enter other area of focus
     

    8) Acknowledgement

    *Do you agree to the Email Acknowledgement?

    Email Acknowledgement

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

    Behavioral Health Provider Manual (PDF)
     

    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 and First Health.

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