1. 1. Name of member,
2. 2. Member’s Social Security Number or AHCCCS identification number,
3. 3. Insurance carrier name,
4. 4. Insurance carrier address,
5. 5. Policy number or insurance holder’s Social Security Number,
6. 6. Policy begin and end dates, and
7. 7. Insurance holder’s name.

A provider or noncontracting provider shall notify AHCCCS, in writing, of the following health insurance information within 10 days of receipt of the health insurance information:

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1146, effective May 1, 2004 (Supp. 04-1).