CTR059105__Marshall_Home_for_Men_Assisted_Living__A7.pdf
PDF 164 KB Posted
- Attached to
- Master Agreement AZ|CTR059105
- Contract number
- CTR059105
- Issued by
- Arizona
About this file
This is the seventh amendment to Contract CTR059105 between the Arizona Department of Economic Security and Marshall Home for Men, Inc. for the provision of assisted living facility services. The amendment was executed electronically through the state's approval process.
The amendment modifies Section 6.3 of the Scope of Work to establish revised incident reporting requirements. The contractor must submit incident reports in accordance with the DDD's Medical Policy Manual 961, DDD Provider Manual Chapter 70, and AHCCCS Medical Policy Manual Chapter 961, as amended. Sentinel events must be reported immediately to the Division by telephone 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 contractor is provided access to the AHCCCS QM Portal through designated login pages and must utilize the available user guides for portal navigation and incident documentation. All other contract requirements, specifications, terms, and conditions remain unchanged by this amendment.
View the file
Other files
Show all 16
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR059105 Seven (7)
DESCRIPTION/ LABEL: Assisted Living Facility
CONTRACTOR NAME: Marshall Home for Men, Inc.
THE ABOVE REFERENCED CONTRACT IS HEREBY MODIFIED AS FOLLOWS:
In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, the Scope of Work, Section 6.3. Incident Reports is hereby removed in its entirety and replaced as follows:
6.3 Incident Reporting Requirements
The Contractor Shall:
6.3.1 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, as may be amended.
Division Medical Policy Manual 961 Division Provider Manual Chapter 70
AHCCCS AMPM 961
6.3.1.1 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 be submitted via the AHCCCS QM Portal within one (1) business day of the occurrence of the event.
AHCCCS QM Portal Migration User Guide
6.3.1.2 The AHCCCS QM Portal can be accessed through following links:
AHCCCS QM Portal login page AHCCCS QM Portal FAQ page
6.3.1.3 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
File details come from the government source that posted it. Updated .