CTR077219_A1_J.W_Builder_Inc.__Home_Modifications_25.11.12_FINAL.pdf
PDF 169 KB Posted
- Attached to
- Master Agreement AZ|CTR077219
- Contract number
- CTR077219
- Issued by
- Arizona
About this file
This document is a Contract Amendment issued by the Arizona Department of Economic Security, amending Contract Number CTR077219 with J.W. Builder Inc. The amendment is specifically related to a Home Modifications contract and focuses on updating the incident reporting requirements for the contractor.
The amendment modifies Section 1.12 of the original contract, detailing new incident reporting procedures for the contractor. The key requirements include submitting incident reports as defined in various medical policy manuals, immediately reporting sentinel events to the Division via phone (602-375-1403 or 1-855-375-1403), and submitting these reports through the AHCCCS QM Portal within one business day of occurrence. The amendment provides multiple reference links for accessing the QM Portal, user guides, and related documentation. All other contract terms and conditions remain unchanged, and the amendment will be executed through electronic approval in an application system.
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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:
CTR077219 One (1)
DESCRIPTION/ LABEL: Home Modifications
CONTRACTOR NAME: J.W Builder 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 Report 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 be 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 https://qmportal.azahcccs.gov/Account/FAQ.aspx https://qmportal.azahcccs.gov/UserGuides/QuickStart_RegistrationAccountMgmt_Provider.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Submit.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Return.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Approve.pdf
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