Required documentation. Application submission
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1 Washington Organizational Credentialing Streamline Application Application to be used for location, specialty and market additions for facilities, ancillaries, and supportive housing and supported employment To begin the contracting and credentialing process, please complete this application in its entirety and submit it with all appropriate documentation. Applications that do not include all of the requested information will not be processed. Note, for multiple locations operating under separate NPI numbers or separate tax IDs, a separate application for each NPI and tax ID combination is needed. Completion and acceptance of this enrollment form by Amerigroup Washington, Inc. is not a guarantee of network participation. Amerigroup policies and procedures will govern appeals as related to network participation if available. Required documentation Copy of all federal, state and/or local licenses required to operate as a health care facility (by location) Current W-9 form completed, signed and dated Copy of accreditation certificate or letter* Copy of most recent CMS or state survey, including your corrective action plan if deficiencies were cited, or cover letter from CMS or state agency affirming facility is in substantial compliance* Copy of Clinical Laboratory Improvement Amendments (CLIA) certificate for each location as applicable Proof of general and professional liability certificate of insurance (minimum coverage of $500,000) * For urgent care centers or walk-in clinics, in lieu of accreditation or state survey, provide the medical director s name in the Accreditation/Certification section. For individual credentialing, medical directors will need to complete a Council for Affordable Quality Healthcare (CAQH) application. Application submission Submit your completed application and corresponding documentation: By fax: By FCSTPA@amerigroup.com By mail: Amerigroup TPA 705 Fifth Ave. S., Suite 300 Seattle, WA WAPEC October 2017
2 Provider information Facility name: Tax ID: NPI #: Medicaid ID: Provider ID #: Are you adding a location? Yes No Is this location replacing a previous address? Yes No Are you adding specialties and services? Yes No Are you joining the Washington market? Yes No Primary office/service address Attach a separate sheet of paper for additional practice locations. Practice location name: Address: City: State: ZIP: County: Phone: Fax: Credentialing contact: Credentialing contact phone: Licensure Attach a copy of current licensure and CLIA certification if applicable. State: License #: CLIA certificate number: Specialties and services Attach a separate sheet of paper for additional specialties and counties. Reference the attached Specialties and Services for a listing. Current specialties and services: Specialty and service additions: Current counties served: County additions: Page 2 of 5
3 Accreditation/certification A. AASM AAAHC AAAASF ABC ACHC ACR AOA ASDA BOC Int l. CABC CACH CAP CARF CCAC CHAP COA DNV HCU HFAP HQAA IAC NABP NBAOS TJC Not accredited (Complete section B.) Date of initial accreditation: Date of next survey: Date of last survey: B. Has the provider had an onsite survey by CMS or state agency? Yes If yes, date of last state survey: Liability insurance coverage General liability insurance Current carrier name: Policy number: Coverage type: Occurrence-based Claims-based No If no, successful completion of a health plan onsite visit will be required to complete credentialing. You will be contacted by the health plan to schedule a visit. Per incident: $ Aggregate: $ Professional liability insurance Current carrier name: Policy number: Coverage type: Occurrence-based Claims-based Per incident: $ Aggregate: $ Page 3 of 5
4 Attestation and information release authorization All information provided in this or in connection with this application is complete and accurate to the best of my knowledge, and I shall immediately notify Amerigroup of any changes thereto. I understand that this application does not entitle me to participation in Amerigroup. By applying for appointment as an Amerigroup participating provider, I authorize the plan, its medical director and appropriate representatives to consult with administrators and members of other institutions where I have been associated, including past and present malpractice carriers who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by Amerigroup, its medical director and appropriate representatives of all records and documents, excluding medical records of non-amerigroup plan members who may be material to an evaluation of any professional qualifications and competence to carry out the requested duties as well as my moral and ethical qualifications for participating provider status with Amerigroup. I consent and agree that Amerigroup will complete a criminal history background check to determine if I or any subcontracted providers have any history of felony convictions, including adjudication withheld on a felony, plea or nolo contendere to a felony, or entry into a pretrial for a felony. I agree to obtain any consents or approvals required for my subcontracted providers to undergo such background checks. I hereby release Amerigroup and its representatives from liability for their acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. I hereby release any individuals and organizations from any liability that provide information to Amerigroup or its staff in good faith and without malice concerning my professional competence, ethics, character and other qualifications, and I hereby consent to the release of such information. By executing this application, I confirm that I am bound by the terms of the Ancillary Agreement between Amerigroup and my group or myself as such terms may be applicable to me. I understand that as an applicant for participation in Amerigroup, I have the right to review information obtained from primary verification sources during the credentialing process. I further understand that upon notification from Amerigroup, I have the right to explain any information obtained that may vary substantially from that provided by me and correct any erroneous information submitted by another party. This shall be accomplished by my submission of a written explanation or by appearance before the Credentialing Committee if they so request. I further understand that I may appeal the committee s decision either in writing or by appearance before the Credentialing Committee if they so request. Printed name of owner/registered/authorized agent: Date: Signature of owner/registered/authorized agent: Title: Attachments Page 4 of 5
5 Specialties and Services Below is a list of all provider types, specialties and services you may apply for with Amerigroup. Facility Ambulatory surgery center (S008) Birthing center (S013) Hospital (S069) Inpatient mental health/substance abuse facility (S074) Inpatient rehabilitation hospital (S075) Nursing home (S098) Organ transplant facility (S111) Psychiatric hospital (S153) Skilled nursing facility (S173) Intensive family intervention (S819) Subacute/intermediate care facility (S180) Trauma center (S201) Ancillary Ambulance (S007) Audiology services (S012) Dialysis (S031) Dietitian/nutritional services (S033) Durable medical equipment (S036) Early childhood intervention (S037) Family planning services (S041) Federally qualified health center (S293) Fetal monitoring services (S045) Genetic services (S050) Hearing aids (S059) Hemophilia center (S062) Home health agency (S064) Home infusion therapy (S065) Hospice care outpatient (S067) Hospice facility (S068) Interpreter service (S077) Imaging facility (S071) Laboratory (S078) Lithotripsy services (S082) Occupational therapy services (S105) Orthotics and prosthetics (S112) Outpatient rehabilitation center (S116) Personal assistance services (S143) Physical therapy services (S148) Radiology facility (S165) Radiology mobile unit (S163) Rural health clinic (S172) Ongoing supports to maintain employment (H2025) Sleep disorder clinic (S175) Speech therapy/pathology (S177) Urgent care center (S202) Walk-in clinic (CCCs) (S206) Behavioral health Methadone maintenance clinic (S084) Outpatient mental health/substance abuse facility (S115) Residential treatment center (MH/SA) (S212) Long-term care Adult companion services (S214) Adult foster home (S004) Adult day activity/health services (S027) Chore services (S021) Escort attendant (S215) Financial assessment/risk education services (S046) Habilitation (1067) Home delivered meals (S063) Home health agency (S064) Home infusion therapy (S065) Homemaker (S216) Home modification/repair (S066) Hospice care outpatient (S067) Hospice facility (S068) Music therapy (S087) Nursing home (S98) Nurse registry (S213) Personal assistant services (S143) Core (S911) Pest control (S145) Residential care/assisted living facility (S168) Respite care (S169) Respite care in-home (S462) Respite care inpatient (S456) Supportive housing and employment Supportive housing services Supported housing community support services monthly (H0044) Community transition services (T2038) Supported employment services Supported employment (H2023) Page 5 of 5
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