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Get Nc Amerihealth Caritas Facility Data Intake Form
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How to fill out the NC AmeriHealth Caritas Facility Data Intake Form online
This guide provides detailed instructions on how to effectively complete the NC AmeriHealth Caritas Facility Data Intake Form online. Follow these steps to ensure that all required information is accurately submitted, facilitating a smooth intake process.
Follow the steps to successfully complete the online form.
- Use the ‘Get Form’ button to access the NC AmeriHealth Caritas Facility Data Intake Form and open it in your chosen editor.
- Begin by filling out Section 1, which includes the provider's entity name as it appears on the W9 form, the IPA name if applicable, billing type, and the name doing business as, if relevant. Ensure that you complete all required fields.
- Enter the W-9 Tax Identification Number (TIN)/Employer Identification Number (EIN) accurately, followed by the primary contact name and email address. Include the address details explicitly, comprising Address Line 1, Address Line 2, city, state, and ZIP + 4 digits.
- Input the primary contact phone number including area code and the recovery address, if necessary. Fill in the organization website if available.
- In Section 2, provide information for all practice locations, listing each location number followed by the facility name, address details, county, and facility NPI or Atypical ID as appropriate.
- Detail the office hours for each practice location. Indicate whether each day is open or closed, and the specific opening and closing times if applicable.
- For Section 3, assess and indicate the ADA compliance for each listed location. Use checkboxes to represent whether the building is compliant in areas like accessible medical equipment and restroom access.
- Move to Section 4 where you will specify the services provided at each location, as well as the age groups served. Mark each service provided appropriately for each practice location.
- After thoroughly completing the form, review all entries for accuracy. When satisfied, save your changes. You can then download, print, or share the completed form as required.
Complete your NC AmeriHealth Caritas Facility Data Intake Form online today to ensure a smooth processing experience.
In North Carolina, the timely filing limit for Medicaid claims is generally 12 months from the date of service. Understanding this timeline helps you prepare and submit claims effectively. For precise guidance and processing, the NC AmeriHealth Caritas Facility Data Intake Form may be beneficial.
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