PROVIDER ACCESS CORRECTIVE ACTION PLAN (CAP) ONLINE SUBMISSION FORM

STEP 1: Complete the practice site detail fields below

(*Must be completed)

Note: Choose Medicaid and Medicare only if your practice site was audited for both Medicaid and Medicare and the corrective action plan (CAP) covers all failed standards.

STEP 2: Please check the box below that identifies your practice site's action plan status

Corrective Action Plan Status

STEP 3: Please identify your site's barrier(s) to meeting the provider access standards

Barrier(s)

STEP 4: Please identify the corrective action(s) your site has taken to ensure the access standards are met

Corrective action(s)

STEP 5: By entering your name and title below you are attesting that your practice site has completed staff training and a practice self-assessment to ensure that you meet Highmark Health Options access standards

Attestation* (Should be completed by an Office Administrator or Corporate compliance)
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