Credentialing and Contracting Instructions

Transcription

1 Credentialing and Contracting Instructions What s required? All Dentists who want to enroll with DentaQuest must be credentialed AND contracted before you can begin treating members. To get credentialed you need to submit a completed credentialing application. If the office you will be participating with is not contracted, one contract for the business (i.e. Tax ID), listing all participating providers and a W-9 is required. If the office you will be participating with is already contracted with DentaQuest please simply supply a letter on company letterhead requesting the provider to be added to the existing contract. Be sure to include the business name, Tax ID, and applicable office location(s). Please note some states require additional forms that can be found on our website. All enrollment documents can be found at: Dentists [State] Dentist Page. Send enrollment documents to: initialproviderenrollment@dentaquest.com Fax: How do I get Credentialed and Contracted? There are a couple of ways to submit a credentialing application to DentaQuest. Please select one of the following options to begin the enrollment process. Option 1: Complete DentaQuest s Initial Provider Credentialing Application along with the applicable Provider Service Agreement, W-9, Disclosure of Ownership, and state required forms. Option 2: Submit your existing CAQH application. You can do this by sending us the applicable Provider Service Agreement, W-9, Disclosure of Ownership, and state required forms along with your full name and CAQH ID using the chart Option 3: Begin an online application with CAQH. To do this complete and send back the information in the below chart along with the applicable Provider Service Agreement, W-9, and Disclosure of Ownership, and state required forms. DentaQuest will then roster you with CAQH. A CAQH Quick Reference Guide is available at Important Tips and Reminders Submit your application as soon as possible. but do not submit without a Medicaid ID (if applying for a Medicaid program). Credentialing Contact Information, phone number, address. Required Documents- Check that all the information you provide is current (e.x. mal-practice insurance). Throughout the process, we will be contacting you. Please respond quickly. Submit application with all applicable sections completed. If something does not pertain, indicate N/A. Do not leave any fields blank. Questionnaire please answer each question either yes or no. N/A is not an acceptable answer on the CAQH application. For any question you answer, a detailed explanation including a summary of the situation and the resolution is required. Disclosure of Ownership is required, but is not included in the CAQH application. If you are submitting a CAQH application be sure to send us our Disclosure of Ownership. Certification, Statements and Signature Page read the statement carefully. Sign and date this page. Signature may not be older than 120 days old.

2 CAQH Enrollment Instructions What is CAQH? The CAQH (Council for Affordable Quality Healthcare) offers a single credentialing application and an online data base that contains information necessary for insurance companies to credential a provider. This allows providers to submit and maintain their credentialing information at one location rather than filing with many organizations. There is no cost to file an application with CAQH and it can be completed online. If you already have an active application with CAQH simply fill-out the below chart. DentaQuest will roster you. If you have not selected the option for all insurance companies to have access to your application you will need to give DentaQuest access to your application after we have rostered you. Remember to send the appropriate contract, W-9, and other required documents for your state. Required Fields Provider 1 Provider 2 Full Provider Individual NPI CAQH ID (if app already on file with CAQH) If you do not have an application on file with CAQH, but would like to complete an online CAQH application please fill-out the following chart. Once DentaQuest has the information we will roster you on the CAQH website. This will trigger CAQH to send you an invitation to join CAQH with instructions on how to log-in and begin your application. Once you have this you can login to using your CAQH ID Required Fields Provider 1 Provider 2 Full Provider Degree Type (DDS, DMD) License Number & Specialty Individual (Type I) NPI Date of Birth Mailing Address Phone Fax (Dentist s Personal & Credentialing Contact) All enrollment documents can be found at: Dentists [State] Dentist Page. Send enrollment documents to: initialproviderenrollment@dentaquest.com Fax: A CAQH Quick Reference Guide is available at Page 1

3 Application and Contract Checklist Dear Provider: It is our intention to provide a streamlined credentialing process. To guide you through the process, prior to sending us your application, please use the checklist below to ensure you have sent us all the required items. Incomplete applications cannot be processed. address must be supplied to utilize DentaQuest s online credentialing and recredentialing coming soon! Date of birth required to begin the credentialing process You must supply your state issued Medicaid ID, where applicable. Specialty (i.e. General Dentist, Pediatric Dentist, Oral Surgeon, etc.) State License section must be completed or a copy of the license provided. Providing a copy of the license will speedup the credentialing process: CDS and/or BNDD enclose a copy. The state listed on the CDS and/or BNDD, must match the state where you are requested to be credentialed. Complete DEA section. A DEA is required for each state where you practice. A disclosure is required if you do not hold a DEA. Individual NPI number Group NPI if W-9 Type is Corporation, LLC, or Partnership (exception: sole proprietor s with an LLC) Location, address, city, state, zip, phone, fax, address. Office Type Federally Qualified Health Center, Local Health Department, Group Practice, etc. Credentialing correspondence contact, address, phone and address, city, state, zip. American Board Certification if you hold board certifications, you must list them. Privilege Information you must identify hospital(s) at which you have admitting privileges. Employment History section of application or curriculum vitae 5 year (10 year if providing CAQH application) history required in month and year format. An explanation of gaps within the last 5 years that are greater than 6 months is required. Start date at primary location is required. Education /Training Section list all institutions and training with the month and year of attendance. Providers treating Florida members must supply two peer reference letters Liability Insurance Binder - must not expire within 60 days and must comply with plan limits Attestation Questions (yes/no section) completed. N/A is not an allowable on the CAQH application. If to any attestation questions (1-14) please enclose a separate disclosure explanation page Signed Application - must be hand written, no stamps. Date must be less than 120 days old. Disclosure of Ownership must be completed. State required form(s) in your application packet Contract and W9 Completeness Checklist Contract signed and dated All Applicants must be listed on contract W9 signed and dated Contract Street Address, City, state, and Zip Entity on the contract must match line 1 of the W-9 and TIN on contract must match W Page 2

4 12121 rth Corporate Parkway, Mequon, WI (262) or (800) Fax (262) **INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** 1. Please print or type ALL responses. 2. If you need additional space to complete a section, please attach additional sheets. 3. If a question does not apply, please indicate N/A. 4. If you answer yes to any questions in the Questionnaire Section, you MUST attach a detailed explanation. 5. Incomplete applications will not be accepted. Every field must be completed. If an item is not applicable, please indicate N/A. 6. Please complete all sections with additional focus on those sections or questions with an *. PLEASE REMEMBER: PROVIDER CANNOT BEGIN TO TREAT MEMBERS UNTIL A WELCOME LETTER FROM DENTAQUEST IS RECEIVED DentaQuest Credentialing Process Credentialing is the process of verifying credentials (i.e. training, licensing, hospital affiliations) of potential providers by primary sources. DentaQuest takes pride in its network of providers and is proud to say that all providers are credentialed following the guidelines of the National Committee for Quality Assurance (NCQA) to ensure our members that they are receiving the best quality care possible. Using NCQA guidelines for credentialing ensures an organization that the providers affiliated with their panel are the best in the dental field. PLEASE Check One: New Provider, New Location Adding Additional Location New Provider, Existing Location Other Please add to current contract under (Provider ) (Entity ) With Tax ID#. PROVIDER APPLICATION GENERAL INFORMATION Last First Middle Initial Degree * Provider Social Security Number *Date of Birth *Provider Personal Address (MM/DD/YY) American Indian/Alaska Native Asian Male Black/African American Hispanic Female Native Hawaiian or Other Pacific Islander White Provider Gender Provider Race/Ethnicity Other Medicaid ID Specialty Please list Dental, Medical and Anesthesia licenses for all states you currently hold or previously held a license. License Type License Number License State Effective Date Expiration Date License Type License Number License State Effective Date Expiration Date License Type License Number License State Effective Date Expiration Date DEA Number Expiration Date te: A DEA license is required for each state you practice in. Please Check the Schedules that apply on your DEA certificate: 2 2N 3 3N 4 5 All Schedules If you do not hold a DEA license, please provide an explanation as to why and the name of the provider who will prescribe on your behalf, should a patient require medications Page 3

5 INDIVIDUAL NPI NUMBER NPI Number NPI Type - Individual NPI Effective Date Taxonomy Code OTHER NPI INFORMATION Please check box if Sole Proprietor is indicated on your W9. ALL providers MUST complete NPI information. GROUP /ORGANIZATION NPI INFORMATION (REQUIRED unless Sole Proprietor is indicated on your W9) NPI Number NPI Type - Group NPI Effective Date Taxonomy Code SUB-PART NPI INFORMATION (t required) NPI Number NPI Type - Subpart NPI Effective Date Taxonomy Code NPI Number NPI Type - Subpart NPI Effective Date Taxonomy Code NPI Number NPI Type - Subpart NPI Effective Date Taxonomy Code PRIMARY SERVICE OFFICE INFORMATION Primary Office Office Contact Office Phone Number Office Fax Number Primary Office Address City State Office Address Clinic FQHC Article 28 (NY) Office Type Zip Code County Secondary Office Office Contact Office Phone Number Office Fax Number Secondary Office Address City State Office Address Clinic FQHC Article 28 (NY) Office Type Zip Code County CREDENTIALING CORRESPONDENCE INFORMATION (address where credentialing information will be sent) Credentialing Correspondence Office Credentialing Contact Credentialing Telephone Number Credentialing Fax Number Correspondence Address *Credentialing Correspondence Address City State Zip Code BILLING INFORMATION Federal Tax Identification ( as it appears on Line 1 of W9) Federal Tax Identification Number Billing Office Address City State Zip Code Billing Office Contact / Title Telephone Number Fax Number Page 4

6 Billing information for secondary location if different from Primary Location Federal Tax Identification ( as it appears on Line 1 of W9) Federal Tax Identification Number CRS-1 Identification Number (NM only) Billing Office Address City State Zip Code Billing Office Contact / Title Telephone Number Fax Number AMERICAN SPECIALTY BOARD CERTIFICATION Specialty Board(s) by which you are certified Date Certified Expiration Date Recertification Date PATIENT INFORMATION Patient Type (check one) Adults Only Children Only Adults & Children *Minimum Age Maximum Age List all Hospitals at which you have admitting privileges: HOSPITAL PRIVILEGES Hospital Address City State Hospital Address City State Hospital Address City State OFFICE INFORMATION (t Provider Specific) Office Hours Primary Location Office Hours Secondary Location Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday *In the event of an emergency, do you have coverage after normal business hours or provide emergency contact information on your office phone or have any other protocol? If yes, Please list your contact information: *Languages spoken at office (check all that apply) English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other *Does your office provide access to a skilled medical interpreter? *Are translation services available? *Is your office handicapped/wheelchair accessible? *Is your entry way handicapped/wheelchair accessible? *Is your waiting room handicapped/wheelchair accessible? *Are your bathrooms handicapped/wheelchair accessible? *Are your treatment room s handicapped/wheelchair accessible? **Do you provide sedation services for members with complex medical or behavioral conditions? *Does your office accept patient with Special Needs? If yes check all that apply: Adult Child ADHD Physically Disabled Learning Disabled HIV AIDS Paraplegic Quadriplegic Seizure Disorders Cognitive Disability Mobility Limitations Autism Communication Disorders Behavioral Disorders Hearing Impaired Visually Impaired *Is the office accessible by public transportation? Number of treatment chairs: Does your office have a computer with internet access? Page 5

7 PROFESSIONAL EMPLOYMENT HISTORY (READ CAREFULLY) Chronologically list all present and previous work history related to your professional employment within the past five (5) years (if you graduated less than five (5) years ago work history should be provided starting with your graduation date). All dates must be in Month and year format. Please provide a written explanation of any gaps greater than 6 Months. *What was your start date at your primary location? / / (month/day / year) Hire Date (MM/YY) Termination Date (MM/YY) Employer Location Address Reason for Leaving EDUCATION / TRAINING Professional School City/State Degree(s) Date Received Post Graduate Education- City / State Type (Residency, Internship, etc) Specialty Beginning / Ending Dates Post Graduate Education- City / State Type (Residency, Internship, etc) ASSOCIATES Specialty Beginning / Ending Dates If applicable, please list the name(s) of Associates at practice(s) PROFESSIONAL REFERENCES REQUIRED for New Mexico and Florida Providers Address Phone Address Phone Address Phone Page 6

8 PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE I am currently covered by the Federal Tort Claims Act? If complete the section below with current malpractice carrier information. If please complete the section below with Qualifying Entity information. of current Carrier Mailing Address Phone # Fax # Policy # Effective Date Expiration Date Amounts of Coverage: Occurrence/Claim $ Aggregate $ of Qualifying Entity (Please attach a copy of the tice of Deeming Action) Effective Date Expiration Date Coverage Limits Page 7

9 QUESTIONNAIRE Please mark with an X under the yes/no columns for each question. If you answer YES to any of the following questions with the exception of 16, please provide us with a detailed explanation and attach to the application. YES NO 1. Has your Professional License been limited, suspended, denied, revoked, restricted, subject to probationary conditions, or have proceedings been instituted against you? 2. Have you allowed your Professional License to expire in a state you no longer practice in? If yes, what state? 3. Other than allowing a license to expire because you no longer practice in a state, have you voluntarily relinquished, reduced, restricted, or otherwise limited your Professional License in any jurisdiction?. 4. Have you been reprimanded or disciplined by any State or Commonwealth Department of Regulation and Licensure of any Professional Examining Board? 5. Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been suspended or limited or have you voluntarily terminated your participation? 6. Has your participation with a managed care organization, other health care organization, or hospital privileges been suspended, limited, or terminated? 7. Have you had a judgment made against you for alleged malpractice, negligence, or related matters? Are any cases pending? 8. Have you had any judgments made against you in a professional liability case or has your liability insurer placed any conditions or restrictions on your coverage or ability to attain coverage? 9. Have any litigation settlements been made on your behalf? 10. Are you currently using illegal drugs? 11. Are you, or have you been, under the treatment for the use of narcotics, barbiturates, alcohol, or other drugs? 12. Do you presently have any physical or mental conditions that would adversely affect your ability to provide high quality professional services? Are there any accommodations that need to be considered? Please list accommodations below. 13. Has your Drug Enforcement Agency (DEA) registration been denied, revoked, suspended, or not renewed? 14. Have you been convicted of any criminal offenses, pending or otherwise, other than a minor traffic violation? 15. Do you use any form of protective stabilization without having completed a residency program, a graduate program, or a Continuing Medical Education (CME) certified course in protective stabilization? 16. (NJ provider only are required to complete this question) Are accommodations made for the patient s cultural and linguistic needs and are they noted in the patient s dental record? 17. (Florida Medicaid Providers only) I attest and affirm that this office maintains a ratio of one FTE per 1,500 active patients and 500 additional active patients for each FTE licensed dental hygienist up to a maximum of two hygienists per FTE dentist. The active patient load is a complete count of all the office s active patients for all lines of business and plans (including Medicaid, Medicare and commercial) An active patient is defines by AHCA as any patient who has been seen by the office two times in the last year For example, if a patient was seen only one time in the last year they would not be considered and active patient. FTE stands for full time equivalent. Dentist : (Please Print) Page 8

10 CERTIFICATION, STATEMENTS, AND SIGNATURE I hereby acknowledge that the information provided in this application is material to the determination by DentaQuest whether or not to execute an agreement with me. I hereby represent and warrant that all information provided herein is true, correct and complete to the best of my knowledge, and I agree to notify DentaQuest in the event an error is discovered or when new events occur which alter the validity of any response herein. I hereby authorize DentaQuest to consult with individuals or institutions with which I have been associated and with others, including but not limited to past and present malpractice carriers, educational institutions, and state licensing boards, who may have information bearing on my professional competence, character and ethical qualifications and authorize the release of any such written or oral verification as needed by DentaQuest. I hereby release from liability for any such entity, institution, or organization that provides information as part of the application process. I certify that: * All parties of material interest have been identified and include no persons or entities with a potential for profit from selfreferral, * All services are provided by and under the on Premise supervision of a licensed dentist, * The above information is complete, correct and true to the best of my knowledge, * My malpractice information is current at the time of application and the limits are at or exceed the minimum amounts required by the Plan and DentaQuest. Individual Provider Participation Attestation Attestation to confirm that you have agreed to become a Participation Provider/ Provider Dentist in the DentaQuest provider network, by means of your or your office s Provider Agreement with DentaQuest to render services to Members pursuant to the Agreement with DentaQuest. Power of Attorney The undersigned does hereby constitute and appoint each owner, member and partner of the entity set forth in the space designated for Entity on Page 3 of this document ( Entity ), its true and lawful attorney-in-fact, in undersigned s name, place, and stead, to execute, acknowledge, sign and deliver any and all contracts, documents, and writings on undersigned s behalf in connection with arrangements with DentaQuest for the provision of dental services. And the undersigned grants said agent full power and authority to do, take, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said agent, or his/her/its substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. Signed by: Principal Date: Please print name: All applications are subject to review and approval by DENTAQUEST. All information contained in a credentialing file will be held in strict confidence, and available for review by only duly authorized employees of DentaQuest Dental USA, Inc., the Plan, and/or third party review organizations (i.e. NCQA, etc.). Practitioner has the right to obtain a copy of their credentialing file, by submitting a written, signed request to the Supervisor of Credentialing at the corporate headquarters for. Any corrections, additions, or clarifications to these files must be submitted in writing to the Supervisor of Credentialing within 30 days of the original submission. This information will be added to the provider application and considered in the credentialing decision. The practitioner has the right, upon request, to be informed of the status of their credentialing or recredentialing application via phone, fax, or mail. If the Credentialing Committee recommends the acceptance of an application with restrictions, denial of an application, or discipline or termination of a practitioner, written notification will be issued within 30 days of that decision. The practitioner then has 30 days from the date of the notice to submit a written appeal of that decision. Appeals should be addressed to the Credentialing Committee, sent to DentaQuest s corporate address. In the event that a dentist s application for participation is rejected or limited for reasons pertaining to the applicant s professional conduct or competence, DentaQuest is required to submit a report to the Plan. The Plan will submit a report to the National Practitioner Data Bank and the state licensing board as required by law Page 9

11 Page 1 Disclosure of Ownership and Control Interest Statement Completion and submission of this form is a condition of participation in any program established by Medicaid or Medicare only. One full and accurate disclosure of ownership is required for each Business Entity. Failure to submit the requested information will result in refusal to participate in the DentaQuest Network or in termination of an existing agreement. If there are any changes in the ownership an updated form must be submitted. 1. Identifying Information of Entity DBA Tax ID Telephone Number Street Address City, County, State Zip Code 2. Answer the following questions by checking "" or "". If any of the questions are answered "", list names and addresses of individuals or corporations under Remarks on page 4. Identify each item number to be continued. a. Are there any individuals or organizations that have a direct or indirect ownership or control interest of 5% or more in the Business Entity that have been convicted of a criminal offense related to the involvement of such persons in any of the programs under Medicaid and Medicare Programs? b. Have any directors, officers, agents, or managing employees of the Business Entity that ever been convicted of a criminal offense related to their involvement in such programs established by Medicaid and Medicare? c. Are there any individuals currently employed by the Business Entity in a managerial, accounting, auditing, or similar capacity who were employed by the entity's fiscal intermediary or carrier within the previous 12 months? d. Have you verified through the System for Award Management (SAM.gov) that none of the employees and none of your Board of Directors or Governing Board and Managing Employees (General Manager, Business Manager, Administrator, Director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation) working in you practice(s) are excluded from participating in Medicaid or Medicare programs? te: remarks are needed if the answer to this question is "". 9/6/2014

12 of Entity: Page 2 Disclosure of Ownership and Control Interest Statement Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the Business Entity. A Business Entity is defined as a Medicare and/or Medicaid provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid and/or Medicare Program. Indirect ownership interest is defined as ownership interest in a Business Entity that has direct or indirect ownership interest in the disclosing entity with ownership of 5 percent or more. Controlling interest is defined as the operational direction or management of this Business Entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of this Business Entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of this Business Entity; the ability or authority, expressed or reserved, to amend or change the by laws, constitution, or other operating or management direction of this Business Entity; the right to control any or all of the assets or other property of this Business Entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of this Business Entity to new ownership or control. 3a. List names, addresses, and EIN for individuals or organizations having direct or indirect ownership or a controlling interest in this Business Entity. (List each member of the Board of Directors or Governing Board and Managing Employees also including General Manager, Business Manager, Administrator, Director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation.) List any additional names and addresses under "Remarks" on page 4. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks. Address EIN b. Type of Entity Sole Proprietorship Partnership Corporation Unincorporated Associations Other c. If this Business Entity is a corporation, list names, addresses of the Directors, and EINs for entities under Remarks. 9/6/2014

13 of Entity: Page 3 Disclosure of Ownership and Control Interest Statement Check appropriate box for each of the following questions: d. Are any owners of the Business Entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. Address Provider Number 4a. Has there been a change in ownership or control within the last year? If yes, give date b. Do you anticipate any change of ownership or control within the year? If yes, when? c. Do you anticipate filing for bankruptcy within the year? If yes, when? 5. Is this entity operated by a management company, or leased in whole or part by another organization? If yes, give date of change in operations 6. Has there been a change in management (such as: change in Director, a new Administartor, contracting operations of facility to a management coproration, hiring or dismissing employees with 5% or more interest, or similar change) within the last year? 7a. Is this entity chain affiliated? (If yes, list name, address of Corporation, and EIN) EIN# Address 9/6/2014

14 of Entity: Page 4 Disclosure of Ownership and Control Interest Statement 7b. If the answer to Question 7a. is, was the entity ever affiliated with a chain? (If yes, list, Address of Corporation, and EIN) EIN# Address WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. of Authorized Representative (Typed) Title Signature Date Remarks if applicable 9/6/2014