Central Northeast Southeast West What is the provider organization's Reviewers will enter the contact information for Question: contact information (for Provider the primary contact person for the organization Qualification)? who is responsible for Provider Qualifications. This should be the person who is responsible for 6) qualifications for the provider. Contact Name (first and last name): _________________________________ Contact Phone Number: _________________________________ Contact E-mail Address: _________________________________ Does the provider intend to operate Please choose if the Question: Source Document(s): “Yes” “AWC” as an Agency With Choice (AWC) or an organization intends to operate as an Agency Organized Health Care Delivery System with Choice provider and if they do not. “No” (OHCDS)? Please choose under if the “YES” “OHCDS” organization intends to operate as an Organized Healthcare Delivery System and if they do “No” not. AWC: Agencies that are qualified as a waiver provider, Yes 7) and render at least one direct waiver service and No are enrolled in HCSIS and PROMISeTM as a OHCDS: Provider Type 55, may function as an Yes Organized Health Care Delivery System No (OHCDS). Remediation: If the provider selects but is not on “Yes” the list, the reviewer should notify the provider and provide assistance as needed.
Central Northeast Southeast West 6) Question: What is the provider organization's contact information (for Provider Qualification)? Contact Name (first and last name): _________________________________ Contact Phone Number: _________________________________ Contact E-mail Address: _________________________________ Reviewers will enter the contact information for the primary contact person for the organization who is responsible for Provider Qualifications. This should be the person who is responsible for qualifications for the provider. 7) Question: Does the provider intend to operate as an Agency With Choice (AWC) or an Organized Health Care Delivery System (OHCDS)? AWC: Yes No OHCDS: Yes No Source Document(s): Please choose “Yes” “AWC” if the organization intends to operate as an Agency with Choice provider and “No” if they do not. Please choose “YES” under “OHCDS” if the organization intends to operate as an Organized Healthcare Delivery System and “No” if they do not. Agencies that are qualified as a waiver provider, and render at least one direct waiver service and are enrolled in HCSIS and PROMISeTM as a Provider Type 55, may function as an Organized Health Care Delivery System (OHCDS). Remediation: If the provider selects “Yes” but is not on the list, the reviewer should notify the provider and provide assistance as needed.
New+Provider+Self-Assessment+and+Guidelines+2017.docx