Fillable Credentialing Alliance ORGANIZATIONAL DATA FORM (Arizona)

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Credentialing Alliance ORGANIZATIONAL DATA FORM (Arizona)

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Credentialing Alliance
ORGANIZATIONAL DATA FORM
PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. New
providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider
receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing
Committee if applicable). Please Type or Print Clearly.
Please type or print this form clearly and return the completed form with attachments (attachments will need to be scanned if submitted
electronically)
Please complete a separate Organizational Data Form for entities with different AHCCCS ID #’s and/or License #’s.
Attach the following:
1. IRS 941 coupon or accurate W9
2. Liability insurance face/certificate
3. Copy of all accreditation certificates (including Medicare)
4. Medicaid required insurance certificates as applicable (see page 2 for requirements)
NON-ACCREDITED FACILITIES: 1. Copy of most recent State and/or Medicare Survey Audit
2. List of practitioners providing services at each location (See AzAHP Ancillary Provider Roster) (if applicable)
1099 Registered Name (Required):
Tax ID #:
Facility Name/DBA (if applicable):
Lines of Business: Medicaid Medicare Commercial
License #: State
: Exp. Date:
Is provider a Medicare participating provider? Yes No
AHCCCS I.D.#:
Organizational NPI#:
Facility Type (check all that apply):
Acute Rehab
Family Planning
O&P
Transportation
ASC
Home Health
PT/OT/ST
Urgent Care
Dialysis
Hospice
Radiology
DME/Infusion
Hospital
Sleep Center
Enteral
Lab
SNF
BILLING
SERVICE
(If applicable)
Name
:
Address:
Phone:
City:
State:
Zip Code:
Fax:
PAY TO ADDRESS
(All payments sent to
this address)
Address:
City:
Zip Code:
Phone: Fax: Zip Code:
PRIMARY
ADDRESS
(Physical location where
services are performed)
*Attach a sheet with
additional locations
including NPI specific
to location
Address:
City:
Zip Code:
Phone:
Fax:
County:
Location NPI:
Modalities:
Hours:
Is Office Accessible to Persons with Disabilities? Yes No
List this Address in Directories? Yes No
FACILITY CONTACT/
MAILING ADDRESS:
Contact Name/Title:
Phone:
Fax:
E-mail Address:
Address: City: Zip Code:
CREDENTIALING
CONTACT:
Name:
E-mail Address:
Address:
Phone:
City:
State:
Zip Code:
Fax:
Describe Your Medical Record Keeping System(s) (i.e. EMR, Paper, etc.):
Describe Your Cost Record Keeping System(s) (i.e. Billing or A/R system):
Electronic Claims Submission? Yes No
Internet Access? Yes No
Is this a minority or female owned business? Yes No
Electronic Funds Transfer? Yes No
Revised 1/2020 (CYE2020)
Vision
Wound Care
Behavioral Health
Assisted Living Center
Assisted Living Home
FQHC/RHC
Outpatient Medical Rehab Center
Other
Facility Assessment of Cognitive and Physical Disabilities Accommodations
Please identify what accommodations you provide at each of your facility locations for members with cognitive or physical disabilities.
If accommodations are the same at all locations, on Practice Location Address, please state ALL. Please, complete a separate Assessment
for each location if accommodations vary.
Facility Location Address:
_
_______________________________________________________________________________________________
Accommodation
YES
NO
Comments
Provider/Staff trained to assist individuals with a
cognitive disability, i.e., autism or intellectual
disabilities
Provider/Staff trained to assist individuals with a
physical disability, i.e., mobility limitations or
wheelchair bound
Flexible appointment times available—sick
appointments, same day appts—please specify
Extended appointment times—before 8 am, after
5pm, Sat and/or Sunday—please specify
Assistance available to members to fill out forms
In-home and/or community services
Large print materials
Materials in electronic format
Augmentative/Alternative communication devices
TDD capabilities
American Sign Language translator
Signage with Braille and raised tactile text characters
at office, elevator, stairwells and restroom doors
mounted 60in from floor
Visible & Audible alarms – emergency systems
Dimmable Lights
Ramps have non-slip surface material
Railings between 30 & 38in high. On both sides.
Paths are at least 36in wide and free of protruding
objects
Cane detectible objects on ground as a warning
barrier
Widened doorways (at least 32in clearance)
Offset (swing-clear) hinges
Power assisted or automatic door openers
Door handles no higher than 48in
Lever or loop handles vs knobs
5ft circle or T-shaped space for turning a wheelchair
completely
A clear floor space, 30" X 48" minimum, adjacent to
the exam table and adjoining accessible route make it
possible to do a side transfer
Adjustable height exam table or chair (lowers to 17-
19in from floor)
Revised 1/2020 (CYE2020)
Accommodation
YES
NO
Comments
Positioning and support aids, such as wedges, rolled
up blankets, straps and rails
Ceiling or floor-based patient lift
Gurneys and/or stretchers
Wheelchair accessible scales
Adjustable height radiologic equipment
Handicap parking
Handicap accessible restroom
Access ramps
Accessible by bus
Accessible by Valley Metro Rail
Provider/Staff has completed cultural competence
training
Do you provide Field Clinic services?
(A “clinic” consisting of single specialty health care
providers who travel to health care delivery settings closer
to members and their families than the Multi-Specialty
Interdisciplinary Clinics (MSICs) to provide a specific set of
services including evaluation, monitoring, and treatment for
CRS-related conditions on a periodic basis)
Do you provide Virtual Clinic services?
(Integrated services provided in community settings
through the use of innovative strategies for care
coordination such as telemedicine, integrated medical
records, and virtual interdisciplinary treatment team
meetings)
Prior to submitting your insurance information complete this checklist, use it as a tool to address everything that’s
required and send it on top of your insurance document(s).
Commercial General Liability
Professional Liability
ATTACHED ATTACHED N/A
General Aggregate $2,000,000
Products Ops Aggregate $1,000,000
Personal & Adv. Injury $1,000,000
Damage to Rented Premises $50,000
Each Occurrence $1,000,000
Each Claim $1,000,000
Annual Aggregate $2,000,000
Business Automobile Liability
Workers’ Compensation Liability
ATTACHED N/A
ATTACHED N/A
Combined Single Limit $1,000,000 Each Accident $1,000,000
Disease – Each Employee $1,000,000
Disease – Policy Limit $1,000,000
Your Certificates of Insurance must include the minimum requirements outlined in the tables above and the
following endorsement, waiver of subrogation and/or SAM language as applicable.
Endorsement – Required for Commercial General and Business Auto Liability
This policy contains an endorsement that includes the State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability
arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor.
Waiver of Subrogation – Required for all
This policy contains a waiver of subrogation endorsement in favor of the State of Arizona, and its departments,
agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work
performed by the Subcontractor or on behalf of the Subcontractor or Contractor.
**Sexual Abuse and Molestation (SAM) – Required for Commercial General Liability or Professional
Liability when providing services to children and/or vulnerable adults
Insurance Certificate(s) must provide the following statement “Sexual Abuse and Molestation coverage is included”
or “Sexual Abuse and Molestation coverage is not excluded”.
• If
you are unable to obtain SAM coverage under your General Liability because the insurance market will
not support it, it should be included with the Professional Liability.
**Please check with health plan if SAM coverage is required for your specific provider type
AHCCCS Insurance Requirements
Th
is communication outlines the additional insurance requirements and provides examples to assist you.
AHC
CCS Insurance Requirements
The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability and
Worker’s Compensation and Employers’ Liability.
Your commercial general liability policy and your business automobile policy (if applicable), need to include an
endorsement (see letter a. below under Commercial General Liability and letter a. below under Business
Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and
letter b. below under Business Automobile Liability) in the Description field of your policy.
Your worker’s compensation and employers’ liability policy requires only the waiver of subrogation language.
Outl
ined below are the minimum requirements. Policy examples follow.
Comm
ercial General Liability – Occurrence Form
Policy should include bodily injury, property damage, personal and advertising injury and broad form contractual
liability coverage. The amounts below are the minimum requirements.
• General Aggregate $2,000,000
• Products – Completed Operations Aggregate $1,000,000
• Personal and Advertising Injury $1,000,000
• Damage to Rented Premises $50,000
• Each Occurrence $1,000,000
a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be named as
additional insureds with respect to liability arising out of the activities performed by or on
behalf of the Contractor." Such additional insured shall be covered to the full limits of liability
purchased by the Subcontractor, even if those limits of liability are in excess of those required by
this contract.
b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not
acceptable) in favor of the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising from work performed by
or on behalf of the Subcontractor.
c. If direct services are provided to children and/or vulnerable adults (as defined by A.R.S §46-451(A)
(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM
coverage may be sub-limited to no less than $500,000. The limits may be included within the
General Liability limit, provided by separate endorsement with its own limits. If you are unable to
obtain SAM coverage under your General Liability because the insurance market will not support
it, it should it be included with the Professional Liability.
d. The following statement must provide on their Certificate(s) of Insurance: “Sexual Abuse and
Molestation coverage is included” or “Sexual Abuse and Molestation coverage is not excluded.”
AHCCCS INSURANCE REQUIREMENTS – Required ONLY if requesting to participate in the Plan’s Medicaid Line of Business
Business Automobile Liability
Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance
of the services under contract. The amount below is the minimum required.
• Combined Single Limit (CSL) $1,000,000
a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees shall be named as additional insureds with
respect to liability arising out of the activities performed by or on behalf of the Contractor, involving
automobiles owned, leased, hired or borrowed by the Contractor." Such additional insured shall be
covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in
excess of those required by this contract.
b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in
favor of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers,
officials, agents, and employees” for losses arising from work performed by or on behalf of the
Subcontractor.
Worker’s Compensation and Employers’ Liability
• Workers' Compensation Statutory
• Employers' Liability
Each Accident $500,000
Disease – Each Employee $500,000
Disease – Policy Limit $1,000,000
Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor
of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Subcontractor.”
Tw
o examples for your reference are included on pages 9-10:
1. Commercial General Liability and Business Automobile Liability – includes limits, endorsement and waiver of
subrogation language
2. Worker’s Compensation and Employers’ Liability – includes limits and waiver of subrogation language
We
are required to verify your adherence to these insurance requirements. We appreciate you submitting
Certificates of Liability with required coverage levels, endorsements and waivers along with the attached checklist
AHCCCS
minimum
coverage
limits
Add AHCCCS as the
Certificate Holder
AHCCCS required endorsement language
and waiver of subrogation language.
NEW – Added Sexual Abuse and
Molestation language
AHCCCS
minimum
coverage limits
Only Waiver of Subrogation
language is required for Worker’s
Comp policy
Add AHCCCS as the
Certificate Holder
UPDATED – limits to
$1,000,000
The fax number and phone number for each participating plan is listed in the table below.
If your intent is to apply for participation in a Health Plan network, please send only to the Plan(s) you are
interested in joining. NOT ALL Plans provide services in every county. Please contact the Plan directly to verify that
they provide services in your county and that they are accepting new providers.
If you are adding a location/facility under an existing Health Plan contract, please only send to the Plan(s) you are
contracted with.
HEALTH PLAN
PHONE
FAX/EMAIL
WEBSITE
Arizona Complete Health
-Complete Care Plan
(888) 788-4408
(866)687-0514
AzCHProviderData@azcompletehealth.com
www.azcompletehealth.com
Banner University
Health Plans
(520) 874-5290
or
(800) 552-5656
Email is preferred method to submit completed
PDFs: BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/ACC
www.BannerUFC.com/ALTCS
www.BannerUCA.com
www.BannerUHP.com
Care1st Health Plan
Arizona
(602) 778-1800
(options in order 5,
7)
(602) 778-1875
SM_AZ_PNO@care1stAZ.com
www.care1staz.com
Comprehensive Medical
and Dental Program
(CMDP)
(602) 351-2245
or
(800) 201-1795
(options in order 1, 2,
3)
(602) 264-3801
CMDPProviderServices@azdcs.gov
https://dcs.az.gov.cmdp
DentaQuest
(800) 233-1468
initialproviderenrollment@dentaquest.com
262-241-7401
http://www.dentaquest.com
/state-
plans/regions/arizona/az-
dentist-page
Magellan Complete Care
Arizona
800-424-5891
888-656-0369
MCCAZProvider@MagellanHealth.com
www.mccofaz.com
Mercy Care
(602) 263-3000 Contracting:
contractingdepartment@mercycareaz.org
If contracted already, email completed forms to
Provider Relations at:
Providerrelations@mercycareaz.org
Or fax form to (860) 975-3201
www.mercycareaz.org
Health Choice Arizona
(800) 322-8670
(options in order 4,
7)
Contracting:
hchcontracting@healthchoiceaz.com
If contracted, email your provider
representative
(480) 760-4975
www.healthchoiceaz.com
UnitedHealthcare
Community Plan
(877) 842-3210
(612) 234-0211 www.uhccommunityplan.com
Revised 1/2020 (CYE2020)
Each plan retains the right to make their own contracting decisions (whether or not to add organizations to their network)
and also will make their own credentialing committee decisions (review of the primary source verification information
obtained by Aperture Credentialing, LLC resulting in approval/denial by the plan’s committee). You will receive separate
communication from each plan regarding the effective date of your credentialing and the effective date of your contract.
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Credentialing Alliance ORGANIZATIONAL DATA FORM (Arizona)

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Completed 20 July 2020

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