PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING

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.
DIRECTIONS:
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:
IRS 941 coupon or accurate W9
Liability insurance face/certificate
Copy of all accreditation certificates (including Medicare)
Medicaid required insurance certificates as applicable (see page 2 for requirements)
NON-ACCREDITED FACILITIES: Copy of most recent State and/or Medicare Survey Audit
List of practitioners providing services at each location (See AzAHP Ancillary Provider Roster) (if applicable)
Tax ID #:
1099 Registered Name (Required):
Facility Name/DBA (if applicable):
Lines of Business:
Medicaid
Medicare
Is provider a Medicare participating provider?
State:
Commercial
License #:
Yes
AHCCCS I.D.#:
No
Exp. Date:
Organizational NPI#:
Facility Type (check all that apply):
Acute Rehab
Family Planning
O&P
Transportation
Assisted Living Center
ASC
Home Health
PT/OT/ST
Urgent Care
Assisted Living Home
Dialysis
Hospice
Radiology
Vision
FQHC
DME/Infusion
Hospital
Sleep Center
Wound Care
Outpatient Medical Rehab Center
Enteral
Lab
SNF
Behavioral Health
Other
Phone #:
Billing Service Name (if applicable):
PAY TO ADDRESS
Address:
(All payments sent to
this address)
Billing Phone Number:
PRIMARY
ADDRESS
(Physical location where
services are performed)
*Attach additional
locations
MAILING
ADDRESS:
(All correspondence will
be sent to this address)
City:
State:
Billing Fax #:
Zip Code:
Address:
City:
Phone #:
Zip Code:
Fax #:
County:
Modalities:
Hours:
Address:
City:
Zip Code:
E-mail Address:
County:
E-mail Address:
Name:
CREDENTIALING
CONTACT:
Fax #:
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?
Electronic Funds Transfer?
8.2014
Yes
Yes
No
Internet Access?
Yes
No
Is this a minority or female owned business?
Yes
No
Page 1 of 4
No
AHCCCS INSURANCE REQUIREMENTS – Required ONLY if requesting to participate in the Plan’s Medicaid Line of Business
Effective October 1, 2013 AHCCCS updated its Minimum Subcontract Provisions to include additional insurance requirements. The
AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability, Worker’s Compensation and
Employers’ Liability and Professional Liability.
AHCCCS also requires your insurance policies include coverage for sexual abuse and molestation if you work with kids and/or
vulnerable adults, such as the developmentally disabled. Your insurance face sheet also has to include language in the Description
field, i.e. an endorsement, indicating you have this type of coverage.
Your commercial general liability policy and your business automobile policy (if applicable), need to include an endorsement (see
letter b. below under Commercial General Liability and letter a. below under Business Automobile Liability) and a waiver of
subrogation (see letter c. 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 require only the waiver of subrogation
language (see letter a. below under Worker’s Compensation and Employers’ Liability).
A. MINIMUM SCOPE AND LIMITS OF INSURANCE: Provider shall provide coverage with limits of liability not less than those stated
below as applicable in accordance with the services provided.
1.
2.
Commercial General Liability – Occurrence Form
Policy shall include bodily injury, property damage, personal injury and broad form contractual liability
coverage.
• General Aggregate
$2,000,000
• Products – Completed Operations Aggregate
$1,000,000
• Personal and Advertising Injury
$1,000,000
• Blanket Contractual Liability – Written and Oral
$1,000,000
• Fire Legal Liability
$ 50,000
• Each Occurrence
$1,000,000
a.
If applicable, the policy shall be endorsed to include coverage for sexual abuse and molestation.
b.
The policy shall be endorsed to include the following additional insured language: “The State of Arizona, its
departments, agencies, boards, commissions, universities and its 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".
c.
Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies, boards,
commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by
or on behalf of the Contractor.
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.
Combined Single Limit (CSL) $1,000,000
8.2014
a.
The policy shall be endorsed to include the following additional insured language: “The State of Arizona, its
departments, agencies, boards, commissions, universities and its 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".
b.
Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies, boards,
commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by
or on behalf of the Contractor.
Page 2 of 4
AHCCCS INSURANCE REQUIREMENTS – Required ONLY if requesting to participate in the Plan’s Medicaid Line of Business
3.
Worker's Compensation and Employers' Liability
Workers' Compensation Statutory
Employers' Liability
Each Accident
Disease – Each Employee
Disease – Policy Limit
a.
Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies, boards,
commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by
or on behalf of the Provider.
4. Professional Liability (Errors and Omissions Liability)
Each Claim
Annual Aggregate
a.
$ 500,000
$ 500,000
$1,000,000
$1,000,000
$3,000,000
In the event that the professional liability insurance required by contract is written on a claims-made basis, Provider
warrants that any retroactive date under the policy shall precede the effective date of the contract; and that either
continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2)
years beginning at the time work under the contract is completed.
b. The policy shall cover professional misconduct or lack of ordinary skill for those positions defined in
the Scope of Work of the contract.
B.
NOTICE OF CANCELLATION: With the exception of (10) day notice of cancellation for non-payment of premium, any changes
material to compliance with the requirements defines above shall require (30) days written notice to the State of Arizona. Such
notice shall be sent directly to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St.,
Phoenix, AZ 85034 and shall be sent by certified mail, return receipt requested.
C. ACCEPTABILITY OF INSURERS: Insurance is to be placed with duly licensed or approved non-admitted insurers in the state of
Arizona with an “A.M. Best” rating of not less than A- VII.
8.2014
Page 3 of 4
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 Bridgeway Health Solutions Care1st Health Plan Arizona Comprehensive Medical and Dental Program (CMDP) Health Choice Arizona PHONE FAX WEBSITE (866) 475‐3129
(866) 687‐0514
www.bridgewayhs.com
(602) 778‐1800
(options in order 5, 7) (602) 351‐2245 or (800) 201‐1795 (options in order 1, 2, 3) (800) 322‐8670
(options in order 4, 7) (602) 778‐1875
www.care1st.com/az
(602) 264‐3801
www.azdes.gov/cmdp
Maricopa/Pinal/Gila: (480) 760‐4975 Apache/Navajo/Mohave/Coconino: (480) 760‐4709 Yuma/LaPaz: (866) 851‐2623 Pima/Santa Cruz: (520) 322‐5784 All Dentists (Statewide): (480) 760‐4706 Apache/Coconino/Gila/LaPaz/ Maricopa/Mohave/Navajo/ Yavapai: (602) 794‐1803 Cochise/Graham/Greenlee/Pima/Pinal
Santa Cruz/Yuma: (520)258‐5172 www.healthchoiceaz.com
Health Net Access (800) 289‐2818
Mercy Care Plan (602) 263‐3000
(Express Code 631) (800) 564‐5465
(860) 975‐3201
www.mercycareplan.com
(860) 975‐0841
www.mercymaricopa.org
(602) 824‐3720
(877) 842‐3210
(602) 674‐6670
(612) 234‐0211
www.phoenixhealthplan.com
www.uhccommunityplan.com
(520) 874‐5290
or (800) 582‐8686 (520) 874‐7142
www.ufcaz.com
www.mhpaz.com Mercy Maricopa Phoenix Health Plan UnitedHealthcare Community Plan The University of Arizona Health Plans www.healthnet.com
www.universitycareadvantage.com www.universityhealthcaregroup.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 OptumInsight™ 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. 8.2014 Page 4 of 4