Provider Enrollment and Credentialing Application Form

Transcription

1 HMSA QUEST INTEGRATION PROGRAM Provider Enrollment and Credentialing Application Form Revised 10/2017 PLEASE TYPE OR PRINT USING A BALLPOINT PEN. (Mark all non applicable sections with N/A. ) Provider #: (HMSA use only) Long Term Services and Supports (LTSS) and Home and Community Based Services (HCBS) Community Care Management Agency (CCMA) Counseling & Training Environmental Accessibility Adaptation Home Delivered Meals Home Maintenance In patient Respite Care Moving Assistance Non Medical Transportation PAS 1 Companion Service PAS 1 Homemaker/Chore Service PAS 2 Care Support Services Personal Emergency Response Pest Control Private Duty Nursing I. Personal Information Legal Name 1. First 2. Middle 3. Last 4. Suffix 5. Title Other Names: Previously known as Also known as 6. First 7. Middle 8. Last 9. Suffix 10. Title 11. Social Security Number 12. Date of Birth 13. Gender Male Female 14. Home Address (street number, street name, city, state, ZIP) List if you don t have a practice location. 15. Contact Phone No. (optional) 16. Cell Phone No. (optional) 17. Address 18. Individual NPI 19. State Medicaid Number Attach documentation with your application. Page 1 of 6

2 II. Office Information/Location of Practice Main or Additional NOTE: If you have additional locations, please submit a copy of this page for each location. 1. Legal Business Name * 2. Effective Date at this Practice Location 3. Are you Owner Employed Contracted Office Address Do not list this location in HMSA s directories or on hmsa.com. 4. Street 5. City 6. State 7. ZIP Mailing Address (Check box if same as Business/Office Address) 8. Entity or DBA (doing business as) Name: 9. Street (or P.O. Box) 10. City 11. State 12. ZIP Payment Address 13. Street (or P.O. Box) Click here to enter text. 14. City 15. State 16. ZIP 17. Office Telephone (Appointments) 18. Office Manager Name 19. Office Manager Telephone 20. Office Fax 21. Referral Fax 22. Clinic or Group Name Employed 23. Group NPI 24. Federal Tax ID # Contracted 25. Payment Checks Should be Made Out to: 26. Mail Payment Check to: Provider Clinic or group Payment address Office address Provider s office practice name Other (specify): Mailing address 27. Handicap Accessibility Yes 28. Number of Office Staff (Including provider) 29. Number of office staff who speak languages other than English (Including American Sign Language) 30. Languages Spoken Check all that apply. Provider/Staff Provider/Staff Provider/Staff Provider/Staff / Cantonese / Japanese / Tagalog / Other Languages (List): / French / Korean / Thai / German / Mandarin / Tongan / Hawaiian / Samoan / Vietnamese / Ilocano / Spanish / Sign Language / Access to Interpreter Services Attach documentation with your application. * Use the name reported to the IRS; it should match your W 9 form. Page 2 of 6

3 III. Professional Education and Training (RN, HHA, PCA, CNA, and NA) ECFMG Number (if applicable) Name of Medical/Professional School Address of Medical/Professional School Degree Earned From (mm/yy) Through (mm/yy) Date of Completion Specialty Name of Medical/Professional School Address of Medical/Professional School Internship Residency Fellowship From (mm/yy) Through (mm/yy) Date of Completion Name of Medical/Professional School Address of Medical/Professional School Degree Earned From (mm/yy) Through (mm/yy) Date of Completion Specialty Name of Medical/Professional School Address of Medical/Professional School Internship Residency Fellowship From (mm/yy) Through (mm/yy) Date of Completion IV. Work History Office Practice Name or Prior Employer Name From (mm/yy) To (mm/yy) Have you had a break in service for more than six months? If yes, please explain. Office Practice Name or Prior Employer Name From (mm/yy) To (mm/yy) Have you had a break in service for more than six months? If yes, please explain. Office Practice Name or Prior Employer Name From (mm/yy) To (mm/yy) Have you had a break in service for more than six months? If yes, please explain. V. Professional Licensure/Certification List ALL active and inactive professional licenses. Number State Date Issued Expiration Number State Date Issued Expiration Number State Date Issued Expiration Number State Date Issued Expiration Page 3 of 6

4 VI. Professional Liability Coverage Information List all insurers. Attach additional sheets if necessary. Company Policy Number Address Issued Expiration Amount Per Incident Aggregate Amount Exclusions or Limitations Company Policy Number Address Issued Expiration Amount Per Incident Aggregate Amount Exclusions or Limitations VII. General Liability Coverage Information List all insurers. Attach additional sheets if necessary. Company Policy Number Address Issued Expiration Amount Per Incident Aggregate Amount Exclusions or Limitations Company Policy Number Address Issued Expiration Amount Per Incident Aggregate Amount Exclusions or Limitations VIII. Health Status Health status refers to your physical and mental condition as it relates to your ability to exercise the clinical privileges you re requesting. a. Can you perform the functions of the privileges that you re requesting and/or the contractual arrangement for which you re applying, with or without accommodations? If no, please explain: Yes b. Are you presently using illegal drugs? Yes c. In the past five years, have you used and/or been treated for substance abuse (i.e., drugs, prescription medications or alcohol)? If yes, please explain: Yes Page 4 of 6

5 IX. Restrictive Actions * If you answer Yes to any of the questions below, please attach an explanation of each occurrence. Be sure to include the date, parties involved, circumstances surrounding the situation, outcome, and any copies of court documents. Type A (Clinical) Community Care Management Agency (CCMA) Counseling & Training In Patient Respite Care PAS 2 Care Support Services Type A providers must answer all Restrictive Action Questions in Section IX (a n). Type B (Non clinical) Environmental Accessibility Adaptation Non Medical Transportation PAS 1 Companion Service PAS 1 Homemaker/Chore Service Personal Emergency Response Pest Control Moving Assistance Home Maintenance Home Delivered Meals Type B providers must answer the Restrictive Actions Questions in Section IX (h n) Type I Providers a. Is there any current or pending due process action relating to the denial, revocation, suspension, or restriction of any of your clinical privileges, appointments, memberships, employment, and/or contractual arrangements at any health care organization? b. Have any of your applications for clinical privileges, appointment, membership, employment, and/or contractual arrangement at any health care organization ever been denied, revoked, suspended, restricted, limited, reduced, or terminated voluntarily or involuntarily? c. Have any of your clinical privileges, appointments, memberships, employment, and/or contractual arrangement at any health care organization ever been subject to any type of monitoring that is not routinely applied to other practitioners of your specialty? d. Have any of your controlled substance certificates or federal drug enforcement agency certificate ever been challenged, denied, revoked, suspended, restricted, limited, conditioned, or voluntarily or involuntarily relinquished? e. Are you currently a named defendant in any pending malpractice claim or suit? f. Have you ever been a named defendant in any malpractice claim or suit where judgment was made against you or where you settled out of court with the plaintiff? g. Has your membership to local, state, or national medical societies ever been placed on probation, revoked, suspended, or terminated? Type II Providers h. Are you currently a named defendant in any pending civil litigation or suit? i. Have you ever been a named defendant in any civil claim or suit where judgment was made against you or where you settled out of court with the plaintiff? j. Is there any current or pending due process action relating to the denial, revocation, suspension, or restriction of any of your professional licenses or applications for professional license in any jurisdiction? k. Have any of your professional licenses or applications for professional licenses ever been challenged, denied, revoked, suspended, restricted, limited, conditioned, or voluntarily or involuntarily relinquished? l. Are there any current or pending investigations or actions being taken against you, or have there ever been any restrictive actions taken against you by the Medicare program, Medicaid program, Regulated Industries Complaints Office, Medical Complaint Conciliation Panel (MCCP), the Hawaii Department of Commerce and Consumer Affairs, and/or the Hawaii Board of Medical Examiners? m. Have you ever been convicted of a crime, pled guilty or no contest, or are you currently under indictment for an alleged crime? n. Do you currently employ anyone who has been excluded from the Medicare or Medicaid program? Page 5 of 6

6 X. Attestation I hereby affirm that the information in this application is complete, accurate, true, and to the best of my information, knowledge, and belief. Signature Date Printed or Stamped Name Please return application and attachments to: Hawai i Medical Service Association Attn: Data Administration KLCR PDA P.O. Box 860 Honolulu, HI Fax on Oahu QUESTdata@hmsa.com Page 6 of 6

7 Disclosure of Ownership (Required to participate in the HMSA QUEST Integration Program) Med-QUEST Hawaii requires disclosure information (as identified in 42 CFR 455 Subpart B) before a provider agreement can be made. List each individual or corporation with a 5 percent or more ownership or controlling interest in the provider business entity. Also, provide the requested information for all of the applicant s managing employees. Attach additional pages as needed. Section I Owner (Individual) Name (individual): Start Date of Ownership: End Date: Title: Has this individual been: convicted, debarred, suspended, or none of the above? Date of Birth: Social Security Number: Address: Are you the spouse, parent, child, or sibling of another person with an ownership or controlling interest in the provider? Yes or No Do you have an ownership or controlling interest in a subcontractor of the provider? Yes or No If yes, does the provider have a 5 percent or more interest in that subcontractor? Yes or No Name any other providers (individual or group practices) in which you have an ownership or controlling interest: Section II Owner (Corporate) Name (corporation): Primary Business Address: Mailing Address (P.O. Box): Other Business Location Address(es): Tax Identification Number: a. Please provide the tax identification number of any entity with an ownership or controlling interest in any subcontractor of the provider if the provider has a 5 percent or more interest in that subcontractor: b. Is the corporation the spouse, parent, child, or sibling of another person with an ownership or controlling interest in the provider? Yes c. Does the corporation have an ownership or controlling interest in a subcontractor of the provider? Yes If yes, does the provider have a 5 percent or more interest in that subcontractor? Yes d. Other providers (individual or group practices) over which the corporation has an ownership or controlling interest: No No No e. Has this corporation been: convicted, debarred, suspended, or none of the above? Section III: Managing Employee Information A managing employee is a 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 operations of an institution, organization, or agency. (42 CFR section ) Managing employees are in a position to exert influence over the conduct of the provider s operations. Name: Start Date: End Date: Title: Date of Birth: Has this individual been: convicted, debarred, suspended, or none of the above? Social Security Number: Address: Section IV: Additional Information a. List the names and addresses of all other Hawaii Medicaid providers with which your health service and/or facility engages in a significant business transaction and/or a series of transactions that during any one fiscal year exceed the lesser of $25,000 or 5 percent of your total operating expense. (Attach extra page if necessary.) Check here for N/A Name: Address: City: State: ZIP: b. List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5 percent or more, who have been convicted of a criminal offense related to the involvement of such persons or organizations in any program established under Title XVIII (Medicare), or Title XIX (Medicaid), or Title XX (Social Services Block Grants) of the Social Security Act or any criminal offense in this state or any other state since the inception of those programs. (Attach extra page if necessary.) If individual or organization is associated with a Hawaii Medicaid provider number(s), please indicate below. (Attach extra page if necessary.) Check here for N/A Name(a)/Hawaii Medicaid Provider Number (s), if applicable: Name(b)/Hawaii Medicaid Provider Number (s), if applicable: Rev. 10/2017 QI 1 of 2

8 I don t have any managing employees, owners, or other Medicaid providers to report in Sections I, II, III or IV. I hereby affirm that the above information is complete, accurate, and true to the best of my information, knowledge, and belief. If I have signed this form electronically, it means I acknowledge and agree to the terms of this form and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this form just as a handwritten signature would on a traditional paper form. Signature Date Printed or Stamped Name Social Security Number (last four digits only) If the provider, any owner, or managing employee is found to be on the List of Excluded Individuals and Entities (LEIE) maintained by the OIG, HMSA will deny the application for participation in the HMSA QUEST Integration Program and Medicare programs. To see the list go to the Department of Health and Human Services Office of Inspector General (HHS-OIG) online exclusion database at Rev. 10/2017 QI 2 of 2