Standardized Practitioner Credentialing Application

Transcription

1 Standardized Practitioner Credentialing Application

2 Provider s Name Date Things to note! 1. Type or print clearly in black ink 2. If the requested Credential does not apply to the submitted provider, denote with N/A 3. A separate Organizational Credentialing Application must be completed for each NPI. 4. Cenpatico Integrated Care is the Credentialing Verification Organization (CVO) for Bridgeway Health Solutions (BW) Behavioral Health line of business only a. Contracts with both healthplans are needed to be considered in network with both Health Plan s b. Credentialing approval does not guarantee a contract approval or claims payment Please ensure the following documents are included with your application Provider Demographic Form Provide your CAQH (Council for Affordable Quality Healthcare) identifier on Demographic Form o This internal application will be phased out. Practitioners will be required to enroll with CAQH in order to be credentialed by Cenpatico Integrated Care Copy of State License(s) Copy of DEA Registration (if applicable) Copy of State Controlled Dangerous Substance Certificate (if applicable) Copy of your professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate, name of liability carrier, and insurance effective date and expiration date (Month/Day/Year). If the certificate holder is an ADDITIONAL INSURED, the policy (ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement. Copy of Board Certification Certificate, if applicable Copy of certificate or letter certifying formal post-graduate training (Initial Credentialing only) Copy of Curriculum Vita/Resume. Must include work history. All gaps in work history must be explained. (Initial Credentialing only) Copy of ECFMG Certificate (if applicable) (Initial Credentialing only) Copy of W-9 for verification of each tax identification number used (Initial Credentialing only, or if the provider is changing groups) Mail, fax or the signed application with all necessary documents to: Cenpatico Integrated Care Attention: Credentialing Department 1501 W. Fountainhead Pkwy Ste #360 Tempe, AZ FAX: CAZCREDENTIALING@cenpatico.com 1 of 15

3 For Cenpatico Integrated Care Credentialing use only Application for: Cenpatico Bridgeway Both To be completed by MDs, NPs, PhDs, LISAC s, LASAC, LCSWs, LMFTs, LPCs, and other applicable licensed providers. Name (Last, First, Middle) Provider NPI: PERSONAL INFORMATION Degree CAQH: Mailing Mailing Phone# Cellular Phone # Place of Birth: (City, State & Country) Citizenship If not an American citizen, Status & Visa Number Date of Birth Sex Male Female SSN # Beeper # Digital Answering Service # LICENSURE/CERTIFICATIONS/REGISTRATIONS License Number Expiration Date Original License Date Other State License Number/State of License (list all past and current) Expiration Date Expiration Date Expiration Date Federal DEA # Expiration Date Date DEA # Issued State Narcotics Registration # or CDS Certification/State of Registration (if applicable) Expiration Date Other professional certifications or credentials (please include description) Expiration Date 2 of 15

4 ADDITIONAL PRACTITIONER INFORMATION AND CREDENTIALING CONTACT INFORMATION Start date with practice Medicare PIN/ UPIN (Provider Identification Number) Medicaid Provider Number National Provider Identification Number Credentialing Contact (person completing application) Credentialing Contact Credentialing Phone # 3 of 15

5 BASED ON YOUR INDIVIDUAL PRACTICE, DO YOU CURRENTLY: (check appropriate box for each item) Accept new patients into your practice? If yes, how many new patients a month can you commit to accept from Cenpatico Integrated Care (CENPATICO IC)? Have evening or weekend appointments available? Provide Urgent appointments within 24 hours? Have any age restrictions? If YES, what are they? Other patient restrictions? Does the office: (check appropriate box for each item) Make 24-hour phone coverage available? Meet ADA accessibility standards? Have other services for the disabled? (TTY, American Sign Language, mental/physical impairments, etc.) Have public transportation access? 4 of 15

6 Primary Secondary Standardized Practitioner Credentialing Application PROFESSIONAL/MEDICAL SPECIALTY INFORMATION Specialty Board Certified? / Name of Board Year Certified Past Re- Certified Expiration Date Professional Affiliations (e.g. AMA,AOA) *te: Submit copies of all certificates with application including copies of letters attesting to board eligibility PROFESSIONAL/POST GRADUATE EDUCATION & TRAINING/WORK HISTORY Provide history of all work for at least past five (5) years, education and training including but not limited to medical military services, public health or business training. Provide an explanation for any gaps. POST GRADUATE/MEDICAL EDUCATION University Telephone # Degree Mo/Yr Started Mo/Yr Completed University Telephone # Degree Mo/Yr Started Mo/Yr Completed INTERNSHIP RESIDENCY FELLOWSHIP TEACHING APPOINTMENT Facility Telephone # Specialty Mo/Yr Started Mo/Yr Completed Name of Department Head or Chief of Service Was this program successfully completed? INTERNSHIP RESIDENCY FELLOWSHIP TEACHING APPOINTMENT Facility Telephone # Specialty Mo/Yr Started Mo/Yr Completed Name of Department Head or Chief of Service Was this program successfully completed? 5 of 15

7 INTERNSHIP RESIDENCY FELLOWSHIP TEACHING APPOINTMENT Facility Telephone # Specialty Mo/Yr Started Mo/Yr Completed Name of Department Head or Chief of Service Was this program successfully completed? INTERNATIONAL MEDICAL GRADUATES Are you certified by the Educational Council for Foreign Medical Graduates? ECFMG # Date Issued OTHER GRADUATE LEVEL EDUCATION FOR WHICH A DEGREE WAS OBTAINED Degree(s) obtained Institution Telephone # Dates (from/to) Program Director OTHER GRADUATE LEVEL EDUCATION FOR WHICH A DEGREE WAS OBTAINED List below in chronological order, any and all additional training and places of practice, including medical military services, subspecialty training programs, or public health or business training. Include the following information: Dates of the training (from/to), program/training name, location (address), telephone number, contact person, and relevant comments 6 of 15

8 WORK HISTORY Minimum of past five years for Initial, & Recredentialing-3 years explain any gaps greater than 6 months on separate page Practice/Employer Contact Name Telephone # Fax # Dates of Employment: Mo/Yr Started Mo/Yr Ended Reason for Leaving Practice/Employer Contact Name Telephone # Fax # Dates of Employment: Mo/Yr Started Mo/Yr Ended Reason for Leaving Practice/Employer Contact Name Telephone # Fax # Dates of Employment: Mo/Yr Started Mo/Yr Ended Reason for Leaving Practice/Employer Contact Name Telephone # Fax # Dates of Employment: Mo/Yr Started Mo/Yr Ended Reason for Leaving Practice/Employer Contact Name Telephone # Fax # Dates of Employment: Mo/Yr Started Mo/Yr Ended Reason for Leaving 7 of 15

9 HEALTH CARE AFFILIATIONS STATUS OF PRIVILEGES KEY 1 Active/Admitting 4 Associate 7 Courtesy 10 Provisional 13 Pending 2 Courtesy Provisional Staff 5 Visiting 8 Admitting 11 Suspended 14 Supervisory 3 Active Provisional Staff 6 Temporary 9 Senior Staff 12 Consulting 15. Other PRIMARY FACILITY Date affiliation started Date affiliation ended (if applicable) Telephone # Fax # Website Status of privileges (indicate by using key); explain coverage arrangements. Any past or present restriction of privileges? If, explain. Attach additional pages if necessary. SECONDARY FACILITY Date affiliation started Date affiliation ended (if applicable) Telephone # Fax # Website Status of privileges (indicate by using key); explain coverage arrangements. Any past or present restriction of privileges? If, explain. Attach additional pages if necessary. OTHER FACILITY Date affiliation started Date affiliation ended (if applicable) Telephone # Fax # Website Status of privileges (indicate by using key); explain coverage arrangements. Any past or present restriction of privileges? If, explain. Attach additional pages if necessary. 8 of 15

10 PROFESSIONAL REFERENCES List three (3) professional/medical references from individuals who have worked extensively with you or who have been responsible for professional observation of your work within the past three years. Only one reference can be a current partner or associate. Do not include relatives. Name Telephone # Fax # Relationship Name Telephone # Fax # Relationship Name Telephone # Fax # Relationship 9 of 15

11 PROFESSIONAL LIABILITY INSURANCE COVERAGE (In lieu of completing this section, a copy of your insurance face sheet displaying the coverage is applicable) Malpractice Carrier Name Telephone # Fax # Website Policy # Length of time with Carrier (if less than 5 years, please list your previous carrier(s) below. ) Amount of Coverage (per claim/aggregate) Type of Coverage: Occurrence Claims made Effective Dates: From To Renewal Date Agent Name The face sheet must indicate applicant as the insured, the policy period, and the following coverage amounts; Each Occurrence - $1,000, Damage to Rented Premises - $ Personal and Advertising Injury $1,000, General Aggregate - $2,000, Products completed operations aggregates - $1,000, Sexual Abuse/Molestation - $500, Professional Liability o Each Claim $1,000, o Annual Aggregate $2,000, Additional Requirement: If the certificate holder is an additional insured, the policy (ies) must be endorsed. If Subrogation is waived, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 10 of 15 Revision8: 08/06/2015

12 MALPRACTICE CLAIMS HISTORY Provide information for all cases occurring in previous 6 years. Attach additional sheets if necessary. claims to date Date of occurrence Date claim was filed with malpractice carrier Professional liability carrier involved Address (if different from Section VII) Patient Name Age Sex Name of Plaintiff, if other than patient You were (check one): Primary Defendant CO-Defendant Other defendants (if any) Describe the alleged allegations against you Describe the alleged injury to the patient If, date filed. Claimant/Plaintiff filed suit in court? State Court Case # State County/Parish Federal Court (U.S. District Court) Case # District Present status of the Claim/Case (Include amount awarded/attributed/settlement) Pending Settled Arbitrated Award In Appeal Adjudicated Withdrawn Date Other (please specify) If pending, amount being sought? Amount of award or settlement? Amount paid on your behalf? Amount paid by all parties? Additional information/explanation (e.g. the condition/diagnosis of the patient at the time of the incident, treatment rendered, and the condition of the patient subsequent to treatment) 11 of 15

13 ATTESTATION/AFFIRMATION/RELEASE OF INFORMATION Please answer the following questions yes or no. If your answer to questions 1-19 is YES or if your answer to question 20 is NO, please provide a written explanation on a separate sheet. 1) Have any of your board certifications or equivalents ever been suspended, revoked, voluntarily surrendered or have you failed to recertify? 2) Has your professional license, in any jurisdiction, ever been voluntarily or involuntarily suspended, limited, revoked, denied, or surrendered or subjected to probationary conditions or are any such actions pending? 3) Has your DEA license or state narcotics registration ever been voluntarily or involuntarily suspended, limited, revoked, denied, or restricted for reasons other than non-completion of medical records or are any such actions pending? 4) Has your hospital or facility medical staff membership or have your hospital or facility professional privileges ever been voluntarily or involuntarily suspended, limited, revoked, denied or surrendered for reasons related to professional competence or conduct, other than non-completion of medical records or are any such actions pending? 5) Have you ever been placed on probation or asked to resign an internship or residency training program? 6) Has Medicare, Medicaid, or any other medical reimbursement plan ever voluntarily or involuntarily suspended, limited, revoked, denied, not renewed or terminated your participation for reasons related to professional competence or conduct? 7) Have you ever been or are you currently excluded from participation with Medicare or any other federally funded health care program? 8) Have your clinical privileges, membership, contractual participation or employment by any medical organization, independent practice association, health plan, health maintenance organization, preferred provider organization, private payer, medical society, professional association, medical school faculty position or other health delivery entity or system ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach of contract, or is any such action pending? 9) Has your professional liability coverage ever been restricted, limited, denied, not renewed, or special rated (for reasons other than the carrier s termination of operations in your state)? 10) Have you ever been named as a defendant in any criminal case? (excluding minor traffic infractions, but not DUIs) 11) Have you ever been convicted of a felony? 12) Have you ever been disciplined for a violation of ethical standards by a professional organization? 13) To your knowledge has information pertaining to you ever been reported to the National Practitioner Data Bank? 14) Do you have a history of engaging in the illegal use of drugs? ( Illegal use of drugs means the use of any controlled substances illegally obtained, i.e. not obtained pursuant to a valid prescription and not taken in accordance with the direction of a licensed health care practitioner.) 12 of 15

14 ATTESTATION/AFFIRMATION/RELEASE OF INFORMATION Please answer the following questions yes or no. If your answer to questions 1-19 is YES or if your answer to question 20 is NO, please provide a written explanation on a separate sheet. 15) Are you currently engaged in the illegal use of drugs? ( Currently does not mean on the day of or even the weeks preceding the completion of this application. Rather, it means recently enough so that the illegal use may have an impact on one s ability to practice.) 16) Are you currently in treatment for addiction to drugs or alcohol? 17) Within the last five years, have you been reprimanded or disciplined in any manner by any state licensing authority or other professional board for conduct related to the use of alcohol or the use of any drug? 18) Do you or a member of your family own, have an investment in, or otherwise have a business interest in any clinical laboratory, diagnostic testing center, hospital, ambulatory surgery center, or other business dealing with the provision of ancillary health services, equipment, or supplies? 19) Do you have any mental, emotional or physical disabilities that may limit your ability to practice? 20) Are you able to perform the procedures and the essential functions of the position for which you have applied or requested privileges, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to patients? 13 of 15

15 This credentialing information and the attached documents contain detailed and specific information relating to my character and professional competence. I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that willful falsification or willful omission of this information will be grounds for rejection or termination. I understand that this application does not entitle me to participation in the Cenpatico Integrated Care (CENPATICO IC) I release CENPATICO IC, its representatives, and any individuals or entities providing information to CENPATICO IC from liability for any act or omission related to the evaluation or verification contained in this application provided CENPATICO IC, its representatives and individuals providing information to CENPATICO IC act in good faith and without malice. I further agree to notify CENPATICO IC of any change to the information provided in this application within 30 days of any such change. I understand that any information provided in this application that is not publicly available will be treated as confidential by CENPATICO IC. In addition to any notice required by any contract with a Healthcare Organization, I agree to notify CENPATICO IC immediately in writing of the occurrence of any of the following: (i) the unstayed suspension, revocation, limitation, restriction or nonrenewal of my license to practice in any state; (ii) any suspension, revocation, limitation, restriction or nonrenewal of my DEA or other controlled substances registration; or (iii) any cancellation, limitation, restriction or nonrenewal of my professional liability insurance coverage. I further agree to notify CENPATICO IC in writing, promptly and no later than fourteen (14) calendar days from the occurrence of any of the following: (i) receipt of written notice of any adverse action against me by the applicable State Regulation and Licensing or the applicable State Medical Examining Board taken or pending, including but not limited to, any accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to practice medicine; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a report with the applicable State Regulation and Licensing or the applicable State Medical Examining Board, or a report with the National Practitioner Data Bank; or (iii) the denial, revocation, suspension, reduction, restriction, limitation, nonrenewal or voluntary relinquishment by resignation of my medical staff membership or clinical privileges at any Healthcare Organization; or (iv) any material reduction in my professional liability insurance coverage; or (v) my receipt of written notice of any legal action against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including, but not limited to, fraud and abuse proceedings or convictions. I authorize CENPATICO IC and its agents and any individual or entity providing information to CENPATICO IC to investigate and evaluate my provider application, and consult with any person, organization, or entity that has, or could have any information, data, or documents regarding my background, competence, and credentials. Practitioner s Right to Review Information: As an applicant to CENPATICO IC network, you have the right to review information obtained to evaluate your application, and to correct incomplete, inaccurate or conflicting credentialing information. Information obtained from outside primary sources; such as malpractice insurance carriers or state-licensing boards will be available for your review upon written request. You may also request to be informed of the status of your credentialing or recredentialing application, and supply additional information if there is a problem identified. Applicant Signature Print Name Degree or Certification Date 14 of 15

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