HEALTHCAREDELIVERYORGANIZATION/ANCILLARY/LONG TERMCAREPROVIDERAPPLICATION **Pleasenote: Submissionofacompletedapplicationdoesnot guaranteeapprovalasaparticipatingproviderasadditionalcriteriamay berequiredascommunicatedbytheplan** Submitallapplicabledocumentsfromthelistbelowwithyourcompletedandsigned application. Failuretosubmitacompleteapplicationwithallapplicabledocumentswillresultin theapplicationbeingreturnedandwillprohibitthecompanyfromcompletingyour credentialingand/orcontractingprocess. Copyofallfederal,stateand/orlocallicensesrequiredtooperateasahealthcarefacility(bylocation) CopyofAccreditationCertificateorletter Copy of most recent CMS or state survey (with deficiencies) including your corrective action plan if deficiencies were cited AND cover letter from CMS/state agency stating facilityisinsubstantialcompliance CopyofMedicaCertification(s) W9 CurrentcopyofProfessionalLiabilityInsuranceandGeneralLiabilityInsurance(must indicatecoveragelimits/policynumber/effectivedate/expirationdate) ProofofestablishedQualityImprovementProgram Ambulance IncludecopyofcurrentAutomobileLiabilityInsurance AirAmbulance IncludecopyofFederalAviationLicense AmbulanceApplicationAddendum CardiacEventMonitoring IncludecertificationasanIndependentDiagnosticTesting Facility(IDTF) HearingAidProviders IncludecurrentcopyofHearingAidDispensingLicense Ambulatory/Home InfusionTherapy Providers Include current copy of Pharmacy Licenseinstatewherecontracting Immunization Clinics Includeaffirmation/proof of participationin VFC (vaccines for children if participating in Medicaid or Medicaid/Medicare Duals Demonstration networks) LaboratoryProviders IncludeacopyofCLIA(ClinicalLaboratoryImprovementAct)Certificate(s)foreach location(s);pathologylaboratoriespleaseprovidecollegeofamericanpathologists(cap)accreditation **PleasenotethattheremaybeadditionalpaperworkorAddendumsthatwill needtobe completedasrequestedbyournetworkprovidersolutionsdepartment** Enterprise HDO Application V1.6 05.2016 06.2016 1 WEBPUWV-0066-17 July 2017
CHECKYOURPROVIDER TYPE AND COMPLETE ALL FOLLOWINGPAGES Acupuncture DurableMedicalEquipment OccupationalTherapyServices Ambulance,Air FederallyQualifiedHealth OrganTransplantFacility Ambulance,Ground HearingAidSupplier Orthotics&Prosthetics AmbulatoryInfusionSuite HemophiliaCenter OutpatientRehab AmbulatorySurgery HomeHealthAgency PersonalAssistanceServices Center AudiologyServices HomeInfusionTherapy PhysicalTherapyServices BirthingCenter HospiceCare Outpatient PrivateDutyNursing Clinic,Immunization HospiceFacility RadiologyFacility Clinic,RetailHealth Hospital Radiology MobileUnit Clinic,RuralHealth ImagingFacility SkilledNursingFacility Clinic,UrgentCare InpatientRehabHospital SpeechTherapyServices Clinic,WalkIn IntensiveFamilyInterventions SubAcute/IntermediaryCare DialysisCenter Laboratory TraumaCenter Dietitian/Nutritional Services BEHAVIORAL HEALTH AmbulatoryDetox IntensiveOutpatientServices Substance Abuse ResidentialTxCenter Psychiatric CaseManagement,Adult Mental Health Clinic Outpatient Services ResidentialTxCenter SubstanceAbuse CaseManagement,Child MethadoneMaintenance Clinic SubstanceAbuseFacility Adult Crisis,Respite Partial Hospitalization Psychiatric SubstanceAbuseFacility Child/Adolescent Crisis,Stabilization Partial Hospitalization Substance Abuse SubstanceAbuseClinic OutpatientServices Hospital,Psychiatric PeerSupportServices SupportedEmployment Illness PsychosocialRehab SupportedHousing Management/Recovery IntensiveOutpatient Services Psychiatric LONGTERMCARE(LTSS)/HOME BASED COMMUNITY SERVICES/OTHER AdultCompanion FetalMonitoringServices NurseRegistry Services AdultDayActivity/Health FinancialAssessment/Risk NursingHome Services Services ChoreServices GeneticServices PersonalAssistanceServices CoreServices Habilitation PestControl EarlyChildhood Homemaker ResidentialServiceAgency Intervention EmergencyResponse HomeModification/Repair RespiteCare Systems EscortAttendant InterpreterServices RespiteCare InHome FamilyPlanningServices MusicTherapy RespiteCareInpatient Enterprise HDO Application V1.6 05.2016 06.2016 2
PROVIDERIDENTIFICATION Legalbusinessname: Doingbusinessas:(ifapplicable) PrimaryContractPerson: Title: PrimaryContactPersonAddress: State: Phone: CREDENTIALINGINFORMATION CredentialingContactName: Title: CredentialingAddress: State: Phone: Email: City: Zip: Fax: Email: City: Zip: Fax: PRIMARYOFFICE/SERVICEADDRESS (Checkbox and attach separate sheet foraddt llocations) Practicelocationname: Addressline1: Addressline2: City: State: ZIP: County: Phone: Fax: Primarycontact: PrimaryContactEmail: Phone: WebsiteURL: Administrator(fullname): Medicaid# Medicare# LongTermCareVendor#: TaxID/EIN: TaxonomyCode(s) NPI# Doesproviderbillfromthisaddress? Yes No DoesthisofficemeetADAaccessibilityrequirements? Yes No Checkallthatapply: Handicapaccessible: Building Parking RestroomServices fordisabled: Textelephone AmericanSignLanguage Mental/physicalimpairment Accessiblebypublictransportation: Bus Subway Regionaltrain Enterprise HDO Application V1.6 05.2016 06.2016 3
PRIMARYOFFICEBILLINGINFORMATION(CHECK/EOBADDRESS) ContactName(billingcontact): Title: AddressLine1: AddressLine2: City: State: ZIP: Phone: EmailAddress: WebsiteURL: Fax: Enterprise HDO Application V1.6 05.2016 06.2016 4
LICENSURE/OPERATINGCERTIFICATE(AttachacopyofcurrentlicensureandCLIAcertification,ifapplicable) State: Dateoflicense: Licensenumber: Expirationdate: State: Dateoflicense: Licensenumber: Expirationdate: CLIAcertificate#: ACCREDITATION/CERTIFICATION(Attachacopy ofcurrentaccreditationcertificate or survey) A. AAAASF AAPSF CARF CIQH COA CTEAM HQAA TJC DNV/NIAHO AAAHC ACHC CHAP CLIA COLA HFAP IMQ UCAOA FDACERT BOCINTL CABC CAP NOTACCREDITED(completesectionBbelow) Dateofinitialaccreditation: / / Dateofnextsurvey / _/ Dateoflastsurvey: / / B. HasproviderhadanonsitesurveybyCMSorstateagency? Yes No Dateoflastrecertification/annualstate survey/programreviewreport: / / Ifno,successfulcompletionofahealthplanonsitevisitwillberequiredtocompletecredentialing.Youwillbecontactedbythe healthplantoschedulethevisit. Nonaccreditedprovidersmustprovideacopyoftheirmostrecentgovernmentagencysurvey(maynotbeoldertha36months) along with your Corrective Action Plan (if deficiencies were cited), AND attach the letter from the government agencystating facilityisinsubstantialcompliancewithmostrecentsurveystandards.failuretoprovidedocumentationmaydelayyourabilityto becomeaparticipatingprovider. GENERALANDPROFESSIONALLIABILITYINSURANCE Generalliabilitycoverage(AttachcopyofCURRENT Insurance facesheet) Currentcarriername: Policynumber: Effectivedate: Perincident:$ Coveragetype: Occurrence based Expirationdate: Aggregate:$ Claimsbased Professionalliabilitycoverage(AttachcopyofCURRENT Insurance facesheet) Currentcarriername: Policynumber: EffectiveDate: Perincident:$ CoverageType: Occurrence based Expirationdate: Aggregate:$ Claimsbased ****Note ifselfinsuredcompleteallquestionsandsignonpagexandattachproofofselfinsurance Enterprise HDO Application V1.6 05.2016 06.2016 5
Provider Directory The following information may be utilized in our provider directory. Please answer the following questions as accurately as possible. Whatareyourofficehours? to N/A Doyouhaveexperienceandskillsintreatingpersonswithphysicaldisabilities? Yes No N/A Doyouhaveexperienceandskillsintreatingpersonswithchronicillness? Yes No N/A DoyouhaveexperienceandskillsintreatingpersonswithHIV/AIDS? Yes No N/A Doyouhaveexperienceandskillsintreatingpersonswithseriousmentalillness? Yes No N/A Doyouhaveexperienceandskillsintreatingindividualswhoarehomeless? Yes No N/A Doyouhaveexperienceandskillsintreatingindividualswhoaredeaforhardofhearing? Yes No N/A Doyouhaveexperienceandskillsintreatingindividualswhoareblindorvisuallyimpaired?Yes No N/A Networkproviders:Whatlanguages,otherthanEnglish,arespokenbyyou, includingamericansignlanguage? WhatlanguagesotherthanEnglish,arespokenbyyourmedicalstaff and/orskilledmedical interpreter,includingamericansignlanguage? N/A N/A Doyouhavetranslationservicesavailable? Yes No N/A BehavioralHealthProviders: Whatspecialexperience,skillsand/ortraining(e.g.,trauma,childwelfare,substanceabuse) doyouhave? Enterprise HDO Application V1.6 05.2016 06.2016 6
CREDENTIALINGQUESTIONS Doesthehealthcaredeliveryorganization/ancillary/longtermcare/providerhave: 1. Evidenceofallsubcontractors professionalliabilityclaimshistory? Yes No 2. Anydisciplinaryactiontakenagainstanybusinessorprofessionallicenseheldinthisor anyotherstateorsurrenderedalicenseinthisoranystate? Yes No 3. Anyhistoryoflossorlimitationofprivilegesordisciplinaryactivity? Yes No Pleaseincludeanexplanationonaseparatesheetforanyquestions(s)answeredYES. ATTESTATIONQUESTIONS Pleaseanswerthefollowingquestions yes or no. If you answer yes, please provide full details onaseparatesheet. A. Hasyourmalpracticeinsuranceeverbeenterminatedorrevokedexceptwithyourconsentorrequest? Yes No B. Areyoucurrentlyunderinvestigationbyanygovernmentagency? Yes No C. HaveyoubeenexpelledorsuspendedfromreceivingpaymentunderMedicareorMedicaid? Yes No D. Hasyouraccreditationstatuseverbeenreduced,terminated,suspendedorrevoked? Yes No E. Isyourmalpracticeinsuranceprovidedthroughaselfinsurancetrustorprogram? Yes No Ifyes,anofficerofthecompany(i.e.President,VicePresident,ChiefFinancialOfficerorChiefOperatingOfficer)mustsign thefollowingattestation. OnbehalfoftheapplicantI representandwarrantthefollowing withrespecttotheselfinsurance programmaintainedbytheapplicant,orwhichprovidesprofessionalliabilityinsurancefortheapplicant: 1. Theselfinsuranceprogram isadequatelyfundedtoprovidetheminimumrequiredlimitsofliabilityasrequiredbyplan, and; 2. Theselfinsuranceprogramhasanactuariallyvalidatedreserveadequateforincurredclaims,forincurredbutnot reportedclaims,andfutureclaimsbasedonpastexperience,and; 3. Theselfinsuranceprogramhasadesignatedthirdpartyadministratororotherappropriatelylicensedclaimsprofessional orattorneyservingtheprogram,and; 4. Theselfinsuranceprogramhasadesignatedmedicalmalpracticedefensefirm,ormorethanonedesignatedmedical malpracticedefensefirm,and; 5. Theselfinsurancemaintainsexcessinsurance/reinsuranceabovetheselffundedlevel,iftheselfinsuredlevelaloneis insufficienttomeetplan srequiredlimits,and; 6. Theselfinsuranceprogrammaintainsevidenceofasuretybondorletterofcreditascollateraltotheselfinsuredlimit, oracaptive,selfmanagementofalargeretentionthroughatrust,and; 7. Theselfinsurancemaintainsatotalvalueoftheprogramthatataminimummeetstherequiredlimitofliabilityasset forthbyplan? 8. Ihaveconfirmedtheforegoingwithmyauditorortheactuaryfortheselfinsurancefund. Attest: Name: Title: NOTE: ThePlanreservestherighttorequestdocumentationfromtheapplicanttoconfirmtheinformationmaintainedinthis attestation Enterprise HDO Application V1.6 05.2016 06.2016 7
ATTESTATION Iherebyaffirmthattheinformationsubmittedinthisapplicationistruetothebestofmyknowledgeandbeliefandis furnished in good faith. I understand that significant omissions or misrepresentations may result in denial of applicationorterminationofprivileges,employmentorparticipatingpractitioneragreement. Aphotocopyofthisdocumentshallbeaseffectiveastheoriginal. Preparer snamehere Signature (StampedSignatureIsNotAcceptable) Title Date Enterprise HDO Application V1.6 05.2016 06.2016 8