105 Application Fees

Policy

An application fee is collected for events such as:

Initial Enrollments and Revalidations;
New practice locations; and
Change of owners.

Application fees are collected by AHCCCS before completing a provider agreement. An institutional provider will pay one fee per application, regardless of how many physicians are with the institution. The following table is the current application fees for the provider. These Federal standards generally change every year on January 1st.

2024	2025
$709.00	$730.00

Exceptions to the application fee include the following:

Individual physicians, non-physician practitioners, or other non-institutional providers.
Providers that are enrolled in Medicare or in another State’s Medicaid Plan
Providers that have paid the application fee within the last four years. AHCCCS reserves the right to request an application fee, if needed, even if the fee has been paid within the last four years.
Simple changes to provider enrollment information such as:
- New phone numbers;
- New bank account information;
- New billing address;
- Change in the name of the provider.
If the fee would cause an Undue Hardship for the provider. When a provider claims undue hardship, it is reviewed by AHCCCS. If AHCCCS supports the claim of undue hardship, it is forwarded to the CMS for approval. CMS will respond to the claim within 60 days of receiving the request.

A refund of the application fee may be issued for any of the following reasons:

The application was denied or withdrawn before AHCCCS completed screening activities;
The application fee was already paid to a Medicare contractor or another state;
AHCCCS could not approve the application because of a temporary moratorium on the applicant’s provider type; or
Applicant is approved for a hardship exception.

Definitions

Term	Definition
Applications	For the purposes of this section, refers to the following application types: Initial Provider Enrollment Applications; Modification Requests; Revalidations; and Reenrollment Applications
Institutional Providers	Any providers who are considered institutional in Medicare are also considered institutional in Medicaid. Medicare defines the following provider types as “institutional” for purposes of the application fee: Ambulatory surgical centers Ambulance service suppliers Community mental health centers (CMHCs) Comprehensive outpatient rehabilitation facilities (CORFs) Competitive Acquisition Program/Part B Vendors DMEPOS suppliers End-stage renal disease facilities Federally qualified health centers Health programs operated by an Indian health program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian health service pursuant to Title V of the Indian Health Care Improvement Act Histocompatibility laboratories Home health agencies Hospices Hospitals Independent clinical laboratories Independent diagnostic testing facilities Mammography screening centers Mass immunization roster billers Nursing Facility (other) Outpatient physical therapy/outpatient speech pathology providers enrolling via the Form CMS-855A Organ procurement organization (OPO) Pharmacies that are newly enrolling or revalidating via the Form CMS-855B application Portable x-ray suppliers (PXRS) Radiation therapy centers Religious non-medical health care institutions (RNHCI) Rural health clinics Skilled nursing facilities
Non-institutional Provider	Individual practitioners, group practices and entities that do not meet the definition of institutional provider.

Proof

AHCCCS checks Medicare’s enrollment system, Medicare Provider Enrollment, Chain, and Ownership System (PECOS), to see if an application fee has been paid. When a provider states they are enrolled with another State Medicaid system, AHCCCS will contact the other state to verify.

Claims of Undue Hardship

When a provider claims undue hardship, a written statement explaining the hardship and supporting documentation is required. Supporting documentation must be provided along with the written statement. If supporting documentation is not provided, the undue hardship request may be denied. Examples of supporting documents includes historical cost reports, balance sheets and income statements, cash flow statements, and tax returns.

Legal Authority

42 CFR 424.514(d)(2)(v)
42 CFR 455.460