Contractor: Date Received: Contractor contact: Phone #: Lines of Business: AHCCCS Approved Date: AHCCCS Reviewer: AHCCCS Reviewed Date: The Contractor must complete a separate checklist for each line of business. As indicated in the table, the Contractor must complete column ‘C’ and may complete column AHCCCS and ‘F’ if applicable. completes columns ‘D’ or ‘E’ ‘G’ Contractor AHCCCS Contractor AHCCCS (a) (B) (C) (D) (E) (F) (G) Network Development and Requirements apply to Found Yes No Contractor Comments AHCCCS Comments Management Plan; Periodic Lines of Business as on Page: Network Reporting indicated below Requirements Contract Section D Care ACOM Policy 415 The submission includes all of the following: ACUTE CMDP ALTCS/EPD DDD CRS RBHA Attachment A Network – X X X X X X Attestation Statement Attachment C ALTCS/EPD – X Contractor Supplement. ACOM 417 Attachment A (One for each quarter of the previous X X X X X X year).
Contractor: Date Received: Contractor contact: Phone #: Lines of Business: AHCCCS Approved Date: AHCCCS Reviewer: AHCCCS Reviewed Date: The Contractor must complete a separate checklist for each line of business. As indicated in the table, the Contractor must complete column ‘C’ and may complete column ‘F’ if applicable. AHCCCS completes columns ‘D’ or ‘E’ and ‘G’ Contractor AHCCCS Contractor AHCCCS (a) Network Development and Management Plan; Periodic Network Reporting Requirements Contract Section D ACOM Policy 415 The submission includes all of the following: (B) Requirements apply to Lines of Business as indicated below (C) Found on Page: (D) Yes (E) No (F) Contractor Comments (G) AHCCCS Comments ACUTE Care CMDP ALTCS/EPD DDD CRS RBHA Attachment A – Network Attestation Statement X X X X X X Attachment C – ALTCS/EPD Contractor Supplement. X ACOM 417 Attachment A (One for each quarter of the previous year). X X X X X X
415-Attachment-B-Network-Development-and-Management-Plan-Checklist.docx