Fillable PRACTITIONER DATA FORM (Mercy Care)

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PRACTITIONER DATA FORM (Mercy Care)

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Revised 1/2020 (CYE2020) Page 1 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
Credentialing Alliance
PRACTITIONER DATA FORM
Directions for completion of the Practitioner Data Form (PDF)
1. Ensure your CAQH application and attestation is up to date and that each health plan you are requesting participation in is authorized to access
your data.
2. PLEASE TYPE OR PRINT CLEARLY & COMPLETE PAGES 2-6 IN ITS ENTIRETY
a. Please use a separate sheet if necessary, to include all hospital and ambulatory surgery centers where you have privileges
b. Please use a separate sheet if necessary, to include all Practitioners in Call Group—must be contracted with the plan
c. Additional Offices—Page 3 has space for one additional location. Please indicate any additional locations/offices on a separate sheet
3. Please complete the Provider Assessment of Cognitive and Physical Disabilities Accommodations assessment (Pages 4-5). A separate assessment
must be completed for each location.
4. The following ATTACHMENTS are required to be submitted with the PDF SO YOUR REQUEST MAY BE PROCESSED TIMELY
a. Copy of your Board Certification (if applicable) or CMEs in your specialty
b. Copy of W-9
c. Copy of your Certificates of Insurance information that include the minimum requirements (Commercial General Liability, Business
Automobile Liability, Workers’ Compensation Liability and Professional Liability--see pages 6-7)
d. The following endorsements, waiver of subrogation and/or SAM language as applicable must be submitted with the certificates. Use of the
Insurance Checklist to make sure all coverage levels, endorsement and waivers have been addressed.
i. Endorsement—Required for Commercial General and Business Auto Liability
a. 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 actives
performed by the Subcontractor or on behalf of the Subcontractor or Contractor
ii. Waiver of Subrogation—Required for all
a. 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.
iii. **Sexual Abuse and Molestation (SAM)--Required for Commercial General Liability or Professional Liability when providing services to
children and/or vulnerable adults
a. I
nsurance Certificate(s) must provide the follow
ing stat
ement “Sexual Abuse and Molestation coverage is included” or “Sexual
Abuse and Molestation coverage is not excluded”.
b. 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
iv. NOTE: Please see the Certificate of Liability Insurance samples at the end of this document (pages 9-10)
d.
I
f a practicing OB/GYN and you are performing Detailed Anatomic Fetal Ultrasound, provide documentation of 30 hours of CME
in fetal
anatomic ultrasound (30 hours of CMEs every 3 years)
5. 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 and signed
contract, if applicable).
Revised 1/2020 (CYE2020) Page 2 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
Credentialing Alliance
PRACTITIONER DATA FORM
PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST.
This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner.
To: Return To:
Fax: Phone: Fax: Phone:
DIRECTIONS:
Please type or print this form clearly and return the completed form with attachments
Certification in your requested specialty or documentation of your examination date is required in order to successfully complete the
contracting process
Post the following items (as applicable) to CAQH - Check box to indicate items posted:
IRS 941 coupon or accurate W9
Documentation of board certification or scheduled exam date
Medicaid required insurance certificates as applicable (see page 3 for requirements)
Fluoride Varnish Application Training Certificate (PCPs only)
Developmental Screening Tool Training Certificate-PEDS/ASQ/M-CHAT (PCPs only)
General Anesthesia Permit, Conscious
Sedation Permit and/or Oral Conscious
Sedation Permit (Dental providers only)
CAQH Registration is required (http://www.caqh.org -
for
assistance please contact CAQH HELP DESK 1-888-599-1771)
CAQH # ________ Please ensure your application and attestation is up to date and that each health plan you are requesting
participation in is authorized to access your data.
Practitioner’s Name & Degree: (Last) (First) (M.I.) (Degree)
Female Male
DOB:
1099 Registered Name (Required):
Tax ID #:
Group Practice Name (DBA) if applicable:
Are you associated with any of the following: IPA PHO N/A
If IPA or PHO marked please provide Name:
Group Type (check all that apply): FQHC RHC BH
PCP OBGYN Dentist Specialist MAT
Lines of Business: Medicaid
Medicare Commercial
Individual NPI#:
Organizational NPI#:
Malpractice Policy #:
SSN: DEA #: State
:
Exp. Date
:
License #:
State
:
Exp. Date
:
Is provider a Medicare participating provider? Yes No
AHCCCS I.D.#:
Primary Practicing Specialty:
Board Certification: Yes No
Date of Exam:
New Graduate: Yes No
Graduation/Completion Date:
Secondary Practicing Specialty:
Board Certification: Yes No
Date of Exam:
Dental Hygienist Affiliated Dentist Name:
Check any that apply to the practice/practitioner: FQHC RHC MAT prescriber
Dental Behavioral Health
If MAT Prescriber XDEA #:
State
:
Exp. Date
:
Want Contract as PCP? Yes No Accepting New Patients? Yes No
Patient Age Range:
Patient Gender: M F B
Do you provide services to individuals with special needs/chronic conditions (check all that
apply)? Physical Developmental Behavioral Emotional None
Physician Assistant Supervising Physician Name:
Do you provide services/accommodations to individuals who have difficulty communicating
or cooperating (i.e. those with autism or intellectual disabilities)? Yes No
Do you provide services to individuals with mobility
limitations (i.e. wheelchair bound)? Yes No
Do you treat any of the following diagnoses (check all that apply)? Anxiety ADHD Depression HIV Substance Use None
PCPs & OBs ONLY: Do you provide any of the following services (check all that apply)? EPSDT OB None
OBs ONLY: Do you perform Detailed Anatomic Fetal Ultrasound? Yes No - if yes, please provide documentation of 30 hours of Fetal anatomic
u/s CMEs
Do you participate in VFC (Vaccines for Children)? Yes No (PCPs seeing AHCCCS members 18 & < must participate)
VFC PIN Code:
Names of Practitioners in Call Group (Must be contracted with plan): Do you E-Prescribe? Yes No
Hospitals & Ambulatory Surgery Center(s) where practitioner has
privileges:
1
licensed to practice medicine or dentistry for the first time in your career and or completed post-graduate training for the first time within the last 6 months
Revised 1/2020 (CYE2020) Page 3 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST.
This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner.
New providers will 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).
B
ILLING
SERVICE
(If applicable)
Name
: Contact:
Address: Phone:
City: State: Zip Code: Fax:
PAY TO ADDRESS
(All payments sent to
this address)
Address:
City:
State:
Phone:
Fax:
Zip Code:
PRIMARY
ADDRESS
(Physical location
where services are
performed)
Address:
City:
Zip Code:
Phone:
Fax:
County:
Office Hours:
Is Office Accessible to Persons with Disabilities? Yes No
List Practitioner in Directories at this Address? Yes No
ADDITIONAL
OFFICE:
(Indicate other
additional offices on
a separate sheet)
Address:
City:
Zip Code:
Phone:
Fax:
County:
Office Hours:
Is Office Accessible to Persons with Disabilities? Yes No
List Practitioner in Directories at this Address? Yes No
PRACTICE CONTACT/
MAILING ADDRESS:
Contact Name/Title:
Phone:
Fax:
E-mail Address:
Website Address:
Address:
City:
Zip Code:
CREDENTIALING
CONTACT:
Name:
E-mail Address:
Address:
City:
State:
Zip Code:
Fax:
Languages other than English spoken by PRACTITIONER: N/A
Languages other than English spoken by OFFICE STAFF: N/A
Any other Name(s) Possible in Records? N/A
Describe Your Medical Record Keeping System(s) (i.e. EMR system, 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) Page 4 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
Provider Assessment of Cognitive and Physical Disabilities Accommodations
P
lease identify what accommodations you provide at each of your practice 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.
Practice 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)
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
Revised 1/2020 (CYE2020) Page 5 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
Accommodation
YES
NO
Comments
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.
Revised 1/2020 (CYE2020) Page 7 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
AHCCCS Insurance Requirements
Thi
s communication outlines the additional insurance requirements and provides examples to assist you.
AHCCCS
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.
Out
lined below are the minimum requirements. Policy examples follow.
Comme
rcial 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.”
Revised 1/2020 (CYE2020) Page 8 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
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.”
Two 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
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.
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
Revised 1/2020 (CYE2020) Page 11 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
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 practitioner under an existing Health Plan contract, please only send to the Plan(s) you are
contracted with.
HEALTH PLAN
PHONE
FAX/EMAIL
Arizona Complete
Health – Complete Care
Plan
(888)788-4408
(866)687-0514
AzCHProviderData@azcompletehealth.c
om
Banner University
Health Plans
(520) 874-5290
or
(800) 582-8686
Email is preferred method to send
completed PDFs:
BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/ALTCS
www.BannerUCF.com
www.BannerUHP.com
Care1st Health Plan
Arizona – A WellCare
Company
(602) 778-1800
(options in order 5, 7)
(602) 778-1875
SM_AZ_PNO@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
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
Mercy Care
(602) 263-3000
Contracting:
contractingdepartment@mercycareaz.org
If contracted already, email completed
forms to Provider Relations at:
Providerrelations@mercycareaz.org
Or fax to: (860) 975-3201
Health Choice Arizona
(800) 322-8670
(options in order 4, 7)
Contracting:
hchcontracting@steward.org
If contracted already, email your
provider representative
(480) 760-4975
https://www.healthchoiceaz .com
United Healthcare
Community Plan
(877) 842-3210
(855) 523-9998
Cred_applications@uhc.com
Each plan retains the right to make their own contracting decisions (whether or not to add practitioners 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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Completed 31 July 2021

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