Enrollments

What do you want to do? * Enroll a new provider to a contracted group Enroll multiple providers to a contracted group

Choose all applicable networks * Ambetter (Exchange) SilverSummit (Medicaid) Wellcare by Allwell (Medicare)

Enroll a New Provider to a Contracted Group

Practitioner First Name *

Practitioner NPI # *

Group/Facility Name *

Practitioner Last Name *

TIN (last four digits only) *

Group/Facility NPI # *

SSHP Provider Data Form (PDF)

(Template revised in 12/2024)

Please ensure that CAQH is current and accessible to the health plan for all practitioners

NV Standard Credentialing Application (PDF)

(Template revised in 12/2016)

If you do not have CAQH, we will need a completed NV Standard Credentialing Application

Behavioral Health Addendum NV (PDF)

(Template revised in 12/2016)

Behavioral Health Addendum must be completed in its entirety for any Behavioral Health enrollment.

Hospital – Facility Provider Application (PDF)

(Template revised in 01/2017)

If submitting a new facility or clinic, a credentialing application will be required along with the documents refer

New Provider Data Form Upload *

NV Standard Credentialing Application (required if the practitioner does not have CAQH) *

Behavioral Health Addendum (required for Behavioral Health enrollments) *

Hospital – Facility Provider Application (required if submitting a new facility or clinic) *

W-9 Upload (required if Billing Information on the Provider Data Form is not filled out) *

Update Requested By

Requestor *

Requestor's Email Address *

Comments

Enroll Multiple Providers to a Contracted Group

TIN (last four digits only) *

Group/Facility NPI # *

Group/Facility Name *

SSHP NEW Practitioner Data Form NV (PDF)

SSHP Roster Template (Excel)

(Template revised in 12/2024)

Please ensure that CAQH is current and accessible to the health plan for all practitioners

NV Standard Credentialing Application (PDF)

(Template revised in 12/2016)

If you do not have CAQH, we will need a completed NV Standard Credentialing Application

Behavioral Health Addendum NV (PDF)

(Template revised in 12/2016)

Behavioral Health Addendum must be completed in its entirety for any Behavioral Health enrollment.

Hospital – Facility Provider Application (PDF)

(Template revised in 01/2017)

If submitting a new facility or clinic, a credentialing application will be required along with the documents referenced on the last page of the applicationenced on the last page of the application

New Provider Roster Upload *

NV Standard Credentialing Application (required if the practitioner does not have CAQH)

Behavioral Health Addendum (required for Behavioral Health enrollments)

Hospital – Facility Provider Application (required if submitting a new facility or clinic)

W-9 Upload *

Update Requested By

Requestor *

Requestor's Email Address *

Comments