Iowa - Application Request | Providers – Amerigroup
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Providers

Provider Application Request

Thanks for your interest!

Step 1: Obtain a Iowa Medicaid ID

You must have an active Iowa Medicaid ID to complete the credentialing process. Don’t have one? Visit the Iowa Department of Human Services website and complete the documents under the Required Documents for Enrolling as an Iowa Medicaid Provider header. Follow the submission instructions contained within the forms.

Step 2:

For professional practitioners

If you have an Iowa Medicaid number and are enrolled in Council for Affordable Quality Healthcare (CAQH), please complete the online application request, the Iowa Disclosure of Ownership form and a current W-9, and fax to 1-855-832-7289 or email.

If you have not enrolled in CAQH, please complete the online application request, complete all of the documents below and fax to 1-855-832-7289 or email to email.

We cannot initiate credentialing unless all information is current. Your application for credentialing does not guarantee network participation. You cannot begin seeing Amerigroup Iowa, Inc. members until you receive notification of your effective date for participation with Amerigroup, indicated by an executed contract and completed credentialing. After submission of all documents, Provider Relations will contact you within three business days with further instructions.

For facility, ancillary, and long-term service and supports (LTSS) providers

If you are new to the Amerigroup Iowa, Inc. network, you will be required to submit both credentialing application and a signed contract. Please complete all of the documents below and fax to 1-855-832-7289 or email.

We cannot initiate credentialing unless all information is current. Your application for credentialing does not guarantee network participation. You cannot begin seeing Amerigroup members until you receive notification of your effective date for participation with Amerigroup, indicated by an executed contract and completed credentialing. After submission of all documents, Provider Relations will contact you within three business days with further instructions.

For questions, please contact Amerigroup Iowa Provider Relations at 1-855-789-7989 or via email

Iowa
Provider Application Request
Provider Application Request
Mailing Address has been validated via USPS and auto-corrected. Please review Mailing Address, City, State, Zip Code for accuracy and then click SUBMIT to continue.
Completion of this application request form indicates your interest only. You will be contacted by a Provider Relations Representative regarding next steps.
Note: Completion of this form is not part of the credentialing application for the network participation.
Fields marked with an * must be completed.
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