A1_CTR077218_Independence_Home_Remodeling_Inc_2025.10.29.pdf
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- Attached to
- Master Agreement AZ|CTR077218
- Contract number
- CTR077218
- Issued by
- Arizona
About this file
This is a Contract Amendment (Amendment One) issued by the Arizona Department of Economic Security to Independence Home Remodeling Inc. under Contract Number CTR077218. The amendment modifies the existing Home Modifications contract and is executed through electronic approval in the state's APP system.
The amendment removes and replaces Section 1.12 (Incident Reporting Requirements) in its entirety. Under the revised requirements, the contractor must submit incident reports as defined in the DDD's Medical Policy Manual 961, DDD Provider Manual Chapter 70, and AHCCCS Medical Policy Manual Chapter 961. Sentinel events must be reported immediately to the Division at 602-375-1403 or 1-855-375-1403 (available 24 hours daily, including weekends and holidays) and subsequently submitted via the AHCCCS QM Portal within one business day of occurrence. The amendment provides access information and user guides for the AHCCCS QM Portal, including login pages, FAQ resources, and four provider user guides covering provider access, IAD submission, return, and approval procedures. All other contract requirements, specifications, and terms and conditions remain unchanged.
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Text version
CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR077218 One (1)
DESCRIPTION/ LABEL: Home Modifications
CONTRACTOR NAME: Independence Home Remodeling Inc.
THE ABOVE REFERENCED CONTRACT IS HEREBY MODIFIED AS FOLLOWS:
In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, Exhibit A, Section 1.12. Incident Reporting Requirements are being removed in their entirety and replaced as follows:
1.12. Incident Reporting Requirements
The Contractor Shall:
1.12.1 Submit Incident Reports as defined in the DDD’s Medical Policy Manual 961, DDD Provider Manual Chapter70 and AHCCCS Medical Policy Manual -Chapter 961 as may be amended.
Division Medical Policy Manual 961 Division Provider Manual Chapter 70
AHCCCS AMPM 961
1.12.1.1 Sentinel events shall be reported to the Division immediately at 602-375-1403 or 1-855-375- 1403 (phone lines are available 24 hours a day, weekdays, weekends and holidays) and must then submitted via the AHCCCS QM Portal within one (1) business day of the occurrence of the event.
AHCCCS QM Portal Migration User Guide
1.12.1.2 The AHCCCS QM Portal can be accessed through following links:
AHCCCS QM Portal login page
AHCCCS QM Portal FAQ page
1.12.1.3 The AHCCCS QM Portal User Guides can be found at the links below:
AHCCCS PROVIDER USER GUIDE
AHCCCS IAD Submit User Guide AHCCCS Return IAD User Guide AHCCCS Approve IAD User Guide
ALL OTHER REQUIREMENTS, SPECIFICATIONS, AND TERMS AND CONDITIONS REMAIN UNCHANGED
ACKNOWLEDGEMENT AND AUTHORIZATION
This Amendment shall be fully executed by means of electronic approval in APP.
https://des.az.gov/sites/default/files/media/Division_Medical_Policy_Manual_961_Incident_Accident_and_Death_Reporting.pdf?time=1761096186787 https://des.az.gov/sites/default/files/media/DDD_Provider_Policy_Manual_Chapter_70_Qualified_Vendor_Incident_Reporting.pdf?time=1717792726488 https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/900/961.pdf https://docs.google.com/document/d/17V9leTt-Mf9lPUSaOFTqQRz_7jGNutPfKi4m9WcQ6IA/edit?tab=t.0%23heading=h.arsfm1vhtwua https://qmportal.azahcccs.gov/Account/Login.aspx about:blank https://qmportal.azahcccs.gov/UserGuides/QuickStart_RegistrationAccountMgmt_Provider.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_RegistrationAccountMgmt_Provider.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Return.pdfhttps:/qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Approve.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Approve.pdf
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