Credentialing application

Transcription

1 Credentialing application Provider and office information Last name: First name: MI: DDS: DMD: DOB: Gender: Male Female Federal Tax ID number: Please submit W-9 Legal Business Name on W-9: Provider NPI number: Provider Social Security Number: Office Street Address: Suite: City: State: ZIP: Office website: Office phone number: Office Fax number: Office Does your office provide wheelchair accessibility? YES NO Office hours: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Minimum age of patient accepted: Maximum age of patient accepted: Languages spoken: Education Name of graduating dental school: State of graduating school: Month/Year of graduation: Board Certified: YES: NO: Name of Certifying Board: Specialists Dental specialty: Name of institution for residency or post graduate specialty training: State of graduating school or residency: Year of graduation: Professional licensure State license number: Medicaid number (If applicable): Drug Enforcement Agency (DEA) registration number: DEA is required for all applicants except orthodontist. If you do not have a DEA license, please complete the DEA form below. Five-year work history Chronologically list five-year work history, including your current employer. Include any residencies after graduation date. Recent Graduates begin with day after graduation. If there is a gap in employment greater than six months, please explain why. Start date (month/year) End date (month/year) Place of employment (including current) W-9 is required when submitting your signed application Return Address: Medversant 355 S. Grand Avenue, Suite 1700 Los Angeles, CA Fax: Humana@medversant.com GCHHKCNHH 0816 Humana Use Only PPO DHMO ADV Recruitment Code DNC 1

2 Provider name: Professional liability information Do you work exclusively as a Native American Health Care Provider? YES NO Professional liability carrier: Effective date: Expiration date: Policy No.: Occurrence/claims limit: Aggregate limit: Please answer questions 1-8 completely and accurately. If the answer to any of the questions below is yes please attach documentation explaining the response or utilize space below. Disciplinary actions 1) Has any of the following been, or is any currently in the process of being investigated, suspended, reduced, limited, placed on probation, not renewed, voluntarily relinquished, revoked, cancelled, denied or granted with stated limitations either temporarily or permanently: Dental license in any state within the past five years? YES NO DEA registration? YES NO Board certification? YES NO Clinical privileges? YES NO Participation in any Federal or State Health Program (For example: Medicare or Medicaid )? YES NO Professional liability insurance? YES NO 2) Have you been convicted of a felony or misdemeanor other than minor traffic violations? YES NO Insurance information 3) Has any professional liability suit, action or claim alleging malpractice been filed against you YES NO within the past five years? 4) Has any professional liability suit, action or claim been filed against you that is presently pending? YES NO 5) Has any judgment been made against you in professional liability cases or claims, or have you entered YES NO into any settlement within the past five years? Health status 6) Is there any reason that you are not able to perform the essential functions of your position, YES NO with or without accommodation? 7) Are you currently engaged in the unlawful use of drugs? YES NO Medicare information 8) Have you filed a valid opt-out affidavit with the Centers for Medicare & Medicaid Services (CMS) to opt out of participation with Original Medicare? YES NO GCHHKCNHH

3 HumanaDental provider additional locations form Provider name: Provider NPI #: If billing address differs from the physical office address, please list billing address below. Billing address: City: State: ZIP code: Phone number: Fax number: Federal tax ID number: (please submit a W-9) Legal Business Name on W-9 form: Please list the physical address(es) of your office location(s) in the spaces provided below. Additional office address: City: State: ZIP code: Phone number: Fax number: Federal tax ID number: Legal Business Name on W-9: Additional office address: City: State: ZIP code: Phone number: Fax number: Federal tax ID number: Legal Business Name on W-9: Additional office address: City: State: ZIP code: Phone number: Fax number: Federal tax ID number: Legal Business Name on W-9: Additional office address: City: State: ZIP code: Phone number: Fax number: Federal tax ID number: Legal Business Name on W-9: W-9 is required when submitting your signed application Return Address: Medversant Fax number: S. Grand Avenue, Suite Humana@medversant.com Los Angeles, CA GCHHKCNHH

4 Humana Dental Plans consent and release form for: (Please print applicant s name) I hereby apply for participation in those Humana offered or administered dental benefit plans and products covered under the separate participating service agreement executed or to be executed by and between myself and identified Humana licensed dental health maintenance organization(s) and/or Humana insurance companies, included but not limited to HumanaDental Insurance Company, Humana Insurance Company, The Dental Concern, Inc., The Dental Concern, Ltd., CompBenefits Insurance Company, CompBenefits Company and their corporate affiliates and subsidiaries that underwrite or administer group dental plans (hereinafter collectively referred to as HumanaDental ). The joinder of these companies under the designation HumanaDental shall not be construed as imposing joint responsibility or cross-guarantee between or among Humana companies and their corporate affiliates who underwrite or administer group Dental plans (hereafter severally and collectively known as the Plan or the Network ) as requested in this application and I am willing to make myself available for interviews in regard to said application. I acknowledge and agree that: (a) The privilege to participate as a provider with the Plan or Network is not a right; and (b) By applying for privileges with the Plan or Network I am agreeing to comply with the terms and conditions of the Service Agreement ( Agreement ), whether signed by me or not, pursuant to which I am rendering services to Plan Members either as a direct contractor, subcontractor, independent contractor, or covering dentist or dental provider. Information given, in or attached to this application is accurate and complete to the best of my knowledge. As a condition to making this application, any misrepresentation or misstatement in, or omission from it, whether intentional or not, shall constitute cause for automatic and immediate rejection of this application, resulting in denial of request for participation. In the event that participation has been granted prior to the discovery of such misrepresentation, misstatement or omission, such discovery may result in immediate termination of participation with the Plan or Network. For the purpose of obtaining and maintaining credentialing or privileges with the Plan or Network, I agree to hold harmless and from any and all liability, the Plan or Network, its authorized representatives and any third parties, for any acts performed in good faith and without malice relating to any communications or disclosures of any kind, involving me which are performed, of any otherwise privileged or confidential information. Such information may relate to, but not be limited to information sharing on my professional qualifications, credentials, clinical competence and any other matter which might directly or indirectly impact or reflect on my competence, on patient care or on the orderly operation of a health care facility on an ongoing basis. It is understood by both parties hereto that any and all information obtained by the Plan or Network shall be confidential to the fullest extent permitted by law, regardless of whether my membership and privileges are approved or subsequently terminated, except as otherwise provided herein or in the separate participation agreement under which I will provide services to Plan or Network Members. The term Plan, Network, and its authorized representatives means the corporation(s) with which I have applied for participation, and any of the following individuals who may have any responsibility for obtaining or evaluating my credentials, or acting upon my application; the members of the Plan s or Network s Board and their appointed representatives, the Chief Executive Officer or his designees, other Plan or Network employees, consultants to the Plan, delegated credentialing entities, the Plan s or Network s legal counsel. The term third parties means all individuals, including appointees to the Plan s or Network s medical staffs, hospitals, other physicians or health practitioners, nurses, government agencies, organizations, professional liability insurance carriers, associations, partnerships, and corporations, whether hospitals, health care facilities or not, from whom information has been requested by the Plan, Network, or its authorized representatives or who have requested such information from the Plan, Network, and its authorized representatives. As a condition of the Plan s or Network s acceptance of my application for participation privileges and in support of the Plan s or Network s commitment to continuous quality improvement and peer review, I hereby authorize the Plan, Network, and its authorized representatives to disclose and communicate with my employer, partners or affiliates, as applicable in relation to my provision of dental and related health care services to Plan or Network Members, regarding actions or information relating to the Plan or Network credentialing, re-credentialing and/or quality management programs. As an applicant, I agree to produce adequate information for proper evaluation of my professional qualifications. I also agree to update the Plan or Network with current information regarding all responses and/or questions contained in this application and/or information obtained through the credentialing process as such information becomes available and any additional information as requested by the Plan, Network, or its authorized representatives. Failure to produce such information will prevent my application from being evaluated and acted upon, and may affect any existing privileges I have with the Plan or Network. I further acknowledge and agree that communications and/or documents which are required, in writing, in order to comply with applicable laws and regulations shall be considered to be in compliance with any such laws and regulations, if transmitted, acknowledged and/or executed through the use of mail ( ), electronic data interface (EDI), Internet or other electronic transmission. I hereby acknowledge that this Consent and Release Form will be valid for a period of three years (two years in the state of Illinois) from the date I sign it, and that a photocopy or FAX will serve as an original. I attest that I currently have professional liability insurance with coverage amounts, equal to or exceeding, those mandated by state regulations. I certify that I have answered the questions truthfully and completely and I understand that, as a condition to making this application, any misrepresentations or misstatements in, or omission of any of these answers whether intentional or not, shall constitute grounds for rejection of my request for participation with the Plan or Network. I certify that this application is complete and accurate to the full extent of my knowledge, and any affirmative answers have been explained in full on an attached sheet of paper. Applicant s signature: Date: GCHHKCNHH

5 Service Agreement This agreement is made between the undersigned, an individual dentist duly licensed to engage in the practice of dentistry (hereinafter referred to as DENTIST ) and HumanaDental Insurance Company, Humana Insurance Company, The Dental Concern, Inc., Humana Dental Concern, Ltd., CompBenefits Insurance Company, CompBenefits Company and their corporate affiliates who underwrite or administer group dental plans (hereinafter collectively referred to as HumanaDental ). The joinder of these companies under the designation HumanaDental shall not be construed as imposing joint responsibility or cross-guarantee between or among Humana companies. 1. DEFINITIONS as used in this Agreement and in the attachments hereto; the following terms shall have the following meanings: A. Member Member shall mean PPO-, Access- and Medicare-covered persons or other covered persons under designated self-insured employer plans, employer trusts, insurance policies, government-sponsored programs or other third-party payors health benefits contracts (hereinafter referred to as Plan or Plans ). HumanaDental may administer the provider network for such other third-party payor(s) (hereinafter Payor or Payors ) issuing and/or administering the Plans. Members shall have an identification card or other means of identifying the Payor Plan covering the Member and other Covered Members who may be added to this Agreement from time to time by HumanaDental subject to article 2G herein. B. Covered Services shall mean those dental care services rendered to Member that are (1) included for payment under the terms of the benefit plan, subscriber agreement or certificate issued by, adopted by, or administered by HumanaDental or designated Payer or a workers compensation benefit plan administered by HumanaDental and (2) approved for payment, subject to benefit and eligibility determination. C. Effective Date of the Agreement shall be the date HumanaDental approves the application. D. Attachments shall mean all documents attached to this Agreement, which are made part of the Agreement. E. Participating DENTIST shall mean a licensed dentist who has signed an executed PPO Dentist Service Agreement with HumanaDental thereby agreeing to provide Covered Services for the Fee Schedule charges defined in this Agreement and who agrees to follow all HumanaDental payment mechanisms. F. Fee Schedule shall mean the schedule that shows the maximum allowable fee the DENTIST receives for Covered Services and is subject to plan limitations, exclusions and plan benefit certificates. G. PPO Covered Member shall mean the insured or enrolled participants and their enrolled family dependents whose plan requires them to pay deductibles and coinsurance amounts. H. Access Plan Member shall mean a plan whereby DENTIST collects the amounts listed on the Fee Schedule directly from the Member as payment in full. An Access Plan may be referred to as a Discount Plan in the Member s certificate of coverage or on the Member s identification card. I. Medicare Members are those HumanaDental participants whose Medicare product is identified by either a Humana medical ID card or a HumanaDental ID card. Reimbursement is paid according to the Fee Schedule by the member, by HumanaDental or a combination of both, depending on the benefit design. Continued on next page Page 1 of 8

6 J. Dentally Necessary shall mean the extent of care and treatment which is the generally accepted, proven and established practice by most dentists with similar experience and training where the service is provided, as determined by HumanaDental. Such care and treatment must use the least costly setting or procedure required by the patient s condition and must not be provided primarily for the convenience of the patient or the DENTIST. 2. OBLIGATIONS OF THE PARTIES A. Provision of Dental Services DENTIST agrees to provide Member dental services and to provide such services in the same manner in which DENTIST provides services to other patients. DENTIST agrees to provide Member with dental services without discrimination and within the normal scope of the DENTIST S practice. Dentist agrees to provide dental services to Medicare Covered Persons pursuant to Attachment A of this agreement. B. Verification of Eligibility DENTIST shall verify the eligibility and benefit coverage of Members in accordance with Plan Policies. However, prospective verification of the Member s eligibility for coverage and whether a proposed service is a Covered Service is subject to the limitations and exclusions of the Plans and does not guarantee payment by HumanaDental for other services rendered by DENTIST. C. Claim Submission/Copayment Collection DENTIST understands and agrees to abide by the following Member/HumanaDental payment mechanisms: (1) Member pays deductibles, copayments and coinsurance amounts to DENTIST. DENTIST submits claims to HumanaDental or designated Payor for remaining amount in accordance with the Fee Schedule. (2) Access and Medicare Members pay amounts listed on the Fee Schedule to DENTIST. DENTIST does not submit claims to HumanaDental for any additional amounts. DENTIST agrees to verify the plan payment mechanism with HumanaDental or Payors designated by HumanaDental for each Member prior to rendering services. DENTIST will submit claims to HumanaDental or designated Payor for services rendered hereunder not more than 180 days from the date of service, where applicable. HumanaDental or designated Payor will pay for such claims, the lesser of billed charges or the amount as set forth in the Fee Schedule as payment in full, less all copayments, coinsurance, deductibles, and noncovered services under the respective plan of each Member. In all cases, DENTIST agrees to accept amounts listed on the attached Fee Schedule as payment in full. This provision shall apply to all employees of DENTIST, and DENTIST shall obtain from such persons specific agreement to this provision. D. Prompt Payment of Claims HumanaDental agrees to pay DENTIST for Necessary and Appropriate Covered Services rendered to Members on a timely basis using HumanaDental s normal claims processing policies, procedures and guidelines and in accordance with applicable federal and state laws, rules and regulations regarding timeliness of claims payments. E. Coordination of Benefits In cases where a Member has coverage, other than with HumanaDental, which requires or permits coordination of benefits from another party payor in addition to HumanaDental, HumanaDental will coordinate benefits with such other payor(s). Under no circumstances may DENTIST seek reimbursement from HumanaDental or Member for an amount which, when added to any other payment receivable, would exceed the total amount payable under this Agreement. HumanaDental will coordinate benefits in accordance with all applicable statutes, laws, rules and regulations. F. Offset and Adjustments DENTIST agrees that HumanaDental or designated Payer may make retroactive claims adjustments for changes in enrollment and other business reasons, including but not limited to claims payment errors, data entry errors and incorrectly submitted claims. DENTIST shall be notified in writing by HumanaDental or designated Payer of any monies DENTIST may owe HumanaDental or designated Payer and shall have thirty (30) days from receipt of such notification to refund monies owed to HumanaDental or designated Payer. DENTIST authorizes HumanaDental or Page 2 of 8

7 designated Payer to deduct monies that DENTIST owes HumanaDental or designated Payor from any outstanding monies that HumanaDental or designated Payer may owe DENTIST. G. New Plans/Payment Mechanisms* During the term of this Agreement, HumanaDental may, from time to time, develop/implement new dental plans and/or payment mechanisms. Unless specifically stated, the new plans/payment mechanisms will not increase or decrease the Fee Schedule. DENTIST shall be provided with thirty (30) days written notice prior to the implementation of such new Plan. If DENTIST does not object to the Plan within such thirty (30)-day-notice period, DENTIST shall be deemed to have accepted the new Plan. If DENTIST elects not to accept the new Plan, HumanaDental must receive written notice within said thirty (30)-day period. *In Virginia, the period of time is sixty (60) days. H. No Liability to Members (1) DENTIST agrees that in no event, including, but not limited to nonpayment by HumanaDental, HumanaDental s insolvency or breach of this Agreement, shall DENTIST bill, charge, collect a deposit from, seek compensation, renumeration or reimbursement from, or have any recourse against Members or persons other than HumanaDental acting on their behalf for dental services provided pursuant to this Agreement. This provision shall not prohibit collection for any non covered services, or collection of copayments, coinsurance, cost-share amounts, or deductibles in accordance with the terms of this agreement and the applicable Member benefit contract. (2) DENTIST agrees that in the event of HumanaDental s insolvency or other cessation of operations, benefits to Members will continue for the period for which the premium has been paid. (3) DENTIST further agrees that (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Members, (b) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between DENTIST and Member or persons acting on their behalf, and (c) this provision shall apply to all employees of DENTIST and DENTIST shall obtain from such persons specific agreement to this provision. (4) Any modification, addition or deletion to this Article I of the agreement shall not become effective until after the Commissioner of Insurance has given HumanaDental written notice of approval of such proposed changes, or such changes are deemed approved in accordance with states laws. I. Quality Assurance, Grievance and Utilization Review DENTIST agrees to participate in the quality assurance, utilization review and grievance processes developed by HumanaDental. DENTIST agrees to forward to HumanaDental within seven (7) days of receipt any complaint and/or grievance submitted by a member. DENTIST agrees to cooperate and participate with all final determinations made through the grievance procedures; however, nothing in this Article is intended to prohibit or hinder Member from using any further appeal or review in process available under applicable law. J. Malpractice Claims DENTIST shall within forty-eight (48) hours, or such lesser period of time as may be required by any applicable state statute, rule or regulation, notify HumanaDental in writing of any Member claim alleging malpractice or the occurrence of any incident involving a Member which may result in legal action. K. Dental Records (1) DENTIST shall prepare, maintain and retain records on all HumanaDental Members receiving dental services in a form and for time periods required by applicable state and federal laws and licensing, accreditation and reimbursement rules and regulations to which HumanaDental is subject, and in accordance with accepted dental practice and HumanaDental standards. HumanaDental, pursuant to authorization of Member signed at the time of enrollment during the application process, the sufficiency of which hereby is acknowledged, or any state or federal agency, as permitted by law, may obtain, copy and have access, upon reasonable request, to any dental, administrative or financial record of DENTIST related to Covered Services provided by DENTIST to any HumanaDental Member. Copies of such records shall be at no additional charge to HumanaDental. (2) DENTIST agrees to use his/her best efforts to obtain authorization, when necessary, from Members to release dental records to HumanaDental. Page 3 of 8

8 L. Transfer of Dental Records Upon request from HumanaDental or a Member, DENTIST agrees to transmit a complete acceptable copy of the dental records of any Member transferred to another dentist/facility for any reason, including termination of this Agreement. The transfer of dental records shall be provided at no charge or for a nominal copying charge to the Member and shall be made within a reasonable time frame following the request, but in no event more than five (5) business days, except in cases of emergency. DENTIST agrees that such timely transfer of dental records is necessary to ensure the continuity of care for Members. M. Dental Record Confidentiality DENTIST and HumanaDental agree to maintain the confidentiality of information contained in dental records of Members as required by law. Articles L, M and N herein shall survive the termination and/or expiration of this Agreement regardless of the cause for such termination. N. Credentialing DENTIST and all Associated DENTISTS that provide dental services to Members are required to be credentialed and shall be subject to the credentialing process prior to receiving status as a HumanaDental Participating DENTIST. Further, DENTIST shall ensure that all dental support personnel obtain and maintain for the term of this Agreement adequate professional liability insurance coverage and all applicable licensure and certification required by law. DENTIST agrees to cooperate with HumanaDental s recredentialing policies and procedures every three (3) years for the duration of this Agreement. The state of IL requires recredentialing every (2) years. O. Liability Insurance DENTIST agrees to maintain general and professional liability insurance, of which the minimum professional liability coverage shall be One Hundred Thousand Dollars ($100,000) per occurrence/three Hundred Thousand Dollars ($300,000) in the aggregate or such amount as required by state law, whichever is greater. Evidence of such coverage shall be provided to HumanaDental upon request. DENTIST shall notify HumanaDental at least ten (10) days in advance of termination of such coverage. P. Licensure DENTIST agrees to maintain, for the duration of this Agreement, accreditation and/or licensure in accordance with all applicable state and federal laws. DENTIST shall notify HumanaDental immediately of any changes in licensure or accreditation status. Q. Confidentiality DENTIST agrees to maintain in strict confidence the contents of this Agreement and information regarding any dispute arising out of this Agreement, and agrees not to disclose the contents of this Agreement nor information regarding any dispute arising out of this Agreement to any third party without the express written consent of HumanaDental, except pursuant to a valid court order, or when disclosure is required by a governmental agency. R. No Third-Party Beneficiaries With the exception of Article 2.I herein, the parties have not created and agree not to create any third-party rights or beneficiaries under this Agreement, including but not limited to Members. 3. TERM/TERMINATION A. Term The Agreement shall be in effect for one (1) year, and shall be renewed automatically at the end of the first year and each year thereafter for successive one-year terms unless terminated as provided in Section 3.B. B. Termination This Agreement may be terminated, without cause, by either Party, upon advance notice to the other Party by ninety (90) days written notice. The termination shall become effective on the last day of the month following the ninety (90)-day period. DENTIST may terminate this Agreement for cause if HumanaDental fails to make payments required under this Agreement, but only after written notice providing at least sixty (60) days in which HumanaDental may avoid termination by curing the default in payment. HumanaDental may terminate this Agreement immediately upon written notice, stating the cause for such termination, in the event HumanaDental reasonably determines that (1) DENTIST S continued participation under this Agreement may adversely effect the health, safety and welfare of any Page 4 of 8

9 Member or bring HumanaDental or its dental care networks into disrepute, or (2) DENTIST engages in or acquiesces to any act of bankruptcy, receivership or reorganization, or (3) HumanaDental loses its authority to conduct business in total or as to any limited segment of business but then only as to that segment, or (4) DENTIST loses license to practice dentistry or malpractice insurance, or (5) DENTIST violates any of the provisions of applicable state and/or federal laws. DENTIST understands termination of this Agreement shall not relieve DENTIST from DENTIST S obligation to provide, arrange for and pay for Covered Services to Member through the last day of this Agreement. DENTIST agrees to complete all work in progress before the last day of this Agreement or to pay for such completion if not done so by DENTIST. HumanaDental retains the right to recover from DENTIST any costs paid on DENTIST S behalf that are obligations of DENTIST or DENTIST S employees and become necessary to be paid by HumanaDental to provide Covered Services to Members. 4. RELATIONSHIP OF PARTIES A. Patient Communications The parties acknowledge and agree that nothing contained in this Agreement is intended to interfere with or hinder communications between DENTIST and Members regarding patient treatment. DENTIST will discuss with Members their health status and all dental care and treatment options which DENTIST and/or Member deems clinically necessary and appropriate, regardless of any coverage or payment determination(s) made or to be made by HumanaDental. B. Use of DENTIST S Name DENTIST agrees HumanaDental may use its name, address, telephone number, list of dentists and a description of activities in the plan s promotional advertising. C. Independent Contractors Nothing in this Agreement shall create any relationship between HumanaDental and DENTIST other than as independent contractors. D. Severability If any part of this Agreement should be determined to be invalid, unenforceable, or contrary to law or professional ethics, that part shall be reformed, if possible, to conform to law and ethics, and if reformation is not possible, that part shall be deleted, and the other parts of this Agreement shall remain fully effective. E. DENTIST shall submit any disputes related to the Agreement in writing to HumanaDental at the address below. IN WITNESS WHEREOF, the parties have the authority necessary to bind the entities identified herein and have executed this Agreement to be effective as of the effective date established by HumanaDental. The parties agree that a facsimile signature shall have the full force and effect as a written signature. DENTIST/AUTHORIZED SIGNATORY HUMANADENTAL Signature: Signature: Printed Name: Printed Name: Kevin Regenhold Title: Title: Director of Specialty Networks Date: Date: Dentist Address for Notification: HumanaDental: N19 W24133 N. Riverwood Dr. Ste. 300 Waukesha, WI Continued on next page Page 5 of 8

10 MEDICARE ADVANTAGE PROVISIONS ATTACHMENT A The following additional provisions relate specifically to Medicare Advantage products and plans and are hereby incorporated by reference into the Agreement. a) Dentist agrees to: (i) abide by all federal and state laws regarding confidentiality, privacy and disclosure of medical records or other health and enrollment information, (ii) ensure that medical information is released only in accordance with applicable state or federal law, or pursuant to court orders or subpoenas, (iii) maintain all Member records and information in an accurate and timely manner, and (iv) allow timely access by Members to the records and information that pertain to them. b) HumanaDental and Dentist agree that HumanaDental will process all claims for Covered Services which are accurate and complete within thirty (30) days from the date of receipt. c) Dentist agrees that in no event, including, but not limited to, nonpayment by HumanaDental, HumanaDental s insolvency or breach of this Agreement, shall Dentist bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other than HumanaDental (or the payor issuing the health benefits contract administered by HumanaDental) for Covered Services provided by Dentist for which payment is the legal obligation of HumanaDental. This provision shall not prohibit collection by Dentist from Member for any noncovered service and/or copayments in accordance with the terms of this Agreement and the applicable Member health benefits contract. Dentist further agrees that: (i) this provision shall survive the expiration or termination of this Agreement regardless of the cause giving rise to expiration or termination and shall be construed to be for the benefit of the Member; (ii) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Dentist and Member or persons acting on their behalf; and (iii) this provision shall apply to all employees, agents, trustees, assignees, subcontractors, and independent contractors of Dentist, and Dentist shall obtain from such persons specific agreement to this provision. d) Dentist agrees to cooperate with HumanaDental in its efforts to monitor compliance with its Medicare Advantage contract(s) and/or Medicare Advantage rules and regulations and to assist HumanaDental in complying with corrective action plans necessary for HumanaDental to comply with such rules and regulations. e) Dentist agrees that nothing in the Agreement shall be construed as relieving HumanaDental of its responsibility for performance of duties agreed to through its Medicare Advantage contracts existing now or entered into in the future with CMS. f) Dentist agrees to comply with and be subject to all applicable Medicare program laws, rules and regulations, reporting requirements, and CMS instructions as implemented and amended by CMS. This includes, without limitation, federal and state regulatory agencies including, but not limited to, HHS, the Comptroller General or their designees rights to evaluate, inspect and audit Dentist s operations, books, records, and other documentation and pertinent information related to Dentist s obligations under the Agreement, as well as all other federal and state laws, rules and regulations applicable to individuals and entities receiving federal funds. Dentist further agrees HHS, the Comptroller General s, or their designees right to inspect, evaluate and audit any pertinent information for any particular contract period will exist through ten (10) years from the final date of the contract period between HumanaDental and CMS or from the date of completion of any audit, whichever is later, and agrees to cooperate, assist and provide information as requested by such entities. g) Dentist agrees to retain all contracts, books, documents, papers and other records related to the provision of services to Medicare Advantage Members and/or as related to Dentist s obligations under the Agreement for a period of not less than ten (10) years from: (i) each successive December 31; or (ii) the end of the contract period between HumanaDental and CMS; or (iii) from the date of completion of any audit, whichever is later. Page 6 of 8

11 h) Dentist agrees in the event certain identified activity(ies) have been delegated to Dentist under the Agreement, any sub-delegation of the noted activity(ies) by Dentist requires the prior written approval of HumanaDental. Notwithstanding anything to the contrary in the Agreement, HumanaDental will monitor Dentist s performance of any delegated activity(ies) on an ongoing basis and hereby retains the right to modify, suspend or revoke such delegated activity(ies) in the event HumanaDental and/or CMS determines, in their discretion, that Dentist is not meeting or has failed to meet its obligations under the Agreement related to such delegated activity(ies). In the event that HumanaDental has delegated all or any part of the claims payment process to Dentist under the Agreement, Dentist shall comply with all prompt payment requirements to which HumanaDental is subject. HumanaDental agrees that it shall review the credentials of Dentist or, if HumanaDental has delegated the credentialing process to Dentist, HumanaDental shall review and approve Dentist s credentialing process and audit it on an ongoing basis. i) Dentist agrees to comply with HumanaDental s policies and procedures. j) Dentist agrees to maintain full participation status in the federal Medicare program. This also includes all of Dentist s employees, subcontractors, and/or independent contractors who will provide services, including, without limitation, health care, utilization review, medical social work, and/or administrative services under the Agreement. k) Dentist agrees that payment from HumanaDental for services rendered to HumanaDental s Medicare Advantage Members is derived, in whole or in part, from federal funds received by HumanaDental from CMS. l) Dentist agrees to disclose to HumanaDental, upon request and within thirty (30) days or such lesser period of time required for HumanaDental to comply with all applicable state or federal laws, all of the terms and conditions of any payment arrangement that constitutes a physician incentive plan as defined by CMS and/or any federal law or regulation. Such disclosure should identify, at a minimum, whether services not furnished by the physician/provider are included, the type of incentive plan including the amount, identified as a percentage, of any withholding or bonus, the amount and type of any stop-loss coverage provided for or required of the physician/provider, and the patient panel size broken down by total group or individual physician/provider panel size, and by the type of insurance coverage (i.e., Commercial HMO, Medicare Advantage HMO, Medicare PPO, and Medicaid HMO.) m) Dentist agrees that in the event of HumanaDental s insolvency or termination of HumanaDental s contract with CMS, benefits to Members will continue through the period for which premium has been paid and benefits to Members confined in an inpatient facility will continue until their discharge. Note: The provision cited below is applicable predominantly to medical providers and may not apply to dental procedures. This provision will only be invoked should the Dentist, for any reason, perform services that fall under the scope of the provision as this is required by CMS. n) Dentist agrees to provide or arrange for continued treatment, including, but not limited to, medication therapy, to Medicare Advantage Members upon expiration or termination of the Agreement. In accordance with all applicable state and federal laws, rules and/or regulations, treatment must continue until the Member: (i) has been evaluated by a new participating provider who has had a reasonable opportunity to review or modify the Medicare Advantage Member s course of treatment, or until HumanaDental has made arrangements for substitute care for the Medicare Advantage Member; and (ii) until the date of discharge for Medicare Advantage Members hospitalized on the effective date of termination or expiration of the Agreement. Dentist agrees to accept as payment in full from HumanaDental for Covered Services rendered to HumanaDental s Medicare Advantage Members, the rates set forth in the payment attachment which are applicable to such Member. o) Dentist agrees to cooperate with the activities and/or requests of any independent quality review and improvement organization utilized by and/or under contract with HumanaDental as related to the provision of services to Medicare Advantage Members. Page 7 of 8

12 Note: The provision cited below is applicable predominantly to medical providers and may not apply to dental procedures. This provision will only be invoked should the Dentist, for any reason, perform services that fall under the scope of the provision as this is required by CMS. p) Dentist agrees to cooperate with Humana s health risk-assessment program. q) Dentist agrees to provide to HumanaDental accurate and complete information regarding the provision of Covered Services by Dentist to Members ( Data ) on a complete CMS 1500 or UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by law when submitting claims and encounters in an electronic format, or such other format as is mutually agreed upon by both parties. The Data shall be provided to HumanaDental on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be required in the Agreement, or as is otherwise agreed upon by the parties in writing. The submission of the Data to HumanaDental and/or CMS shall include a certification from Dentist that the Data is accurate, complete and truthful. In the event the Data is not submitted to HumanaDental by the date and in the form specified above, HumanaDental may, in its sole option, withhold payment otherwise required to be made under the terms of the Agreement until the Data is submitted to HumanaDental. r) Dentist agrees not to collect or attempt to collect copayments, coinsurance, deductibles or other cost-share amounts from any HumanaDental Medicare Advantage Member who has been designated as a Qualified Medicare Beneficiary ( QMB ) by CMS. s) Dentist agrees to maintain written agreements with employed and contracted health care providers and health care professionals providing services under the Agreement in a form comparable to, and consistent with, the terms and conditions of the Agreement. Dentist s downstream provider agreements shall include terms and conditions which comply with all applicable requirements for provider agreements under state and federal laws, rules and regulations including, without limitation, the Medicare Advantage rules and regulations to which HumanaDental is subject. In the event of a conflict between the language of the downstream provider agreements and the Agreement, the language in the Agreement shall control. Note: The provision cited below is applicable predominantly to medical providers and may not apply to dental procedures. This provision will only be invoked should the Dentist, for any reason, perform services that fall under the scope of the provision as this is required by CMS. t) With respect to any Members who are eligible for both Medicare and Medicaid, Dentist agrees that such Members will not be held liable for Medicare Part A and Medicare Part B cost sharing when the State is responsible for paying such amounts. Further, with respect to such Members, Dentist agrees to: (i) accept the payment amount from HumanaDental as payment in full, or (ii) bill the appropriate State source. Humana.com Page 8 of 8

13 Dental Provider DEA Exception Form Please respond to the following questions: Provider Name: Do you have a DEA license? If you answered no, please explain why you do not have a DEA license: Yes No Are you eligible to obtain a DEA license? If you answered no, please explain why you are not eligible to obtain a DEA license: Yes No If you do not have a DEA license, please provide an alternate plan for prescribing controlled substances for Humana patients if the need arises (be specific): Note: Failure to provide this information will prevent your credentialing application from being approved.