Provider Facility Credentialing Application INSTRUCTIONS: All sections must be completed. Incomplete applications will result in a delay in processing. 2. Attach copies of the following: Current facility license(s) Current certificate of insurance for professional liability Current certificate of workers compensation insurance Medicare participation agreement, if applying for Medicare Advantage contract Accreditation survey, if applicable (required for Ambulatory Surgery Centers) List of practitioners who own or have ownership interest in and who provide services at the facility, if applicable (required for Ambulatory Surgery Centers) General Information Organization Name: Primary Address: Fax: Secondary Address: (If applicable. If necessary use separate sheet for other locations) Fax: Mailing Address: (If different than above) Credentialing Address: (if different than above) Contact Person Name: (for all information contained on this application) Administrator/Chief Executive Officer Name: Medical Staff/Credentialing Coordinator Licensing Information Tax Identification Number: Medicaid Provider Number: Medicare Provider Number: Organizational NPI: Does your facility have a signed Medicare participation agreement? (please attach a copy) Idaho State License/Certification Number: (please attach a copy) Other License/Certification Number(s): (please attach a copy) 2016 Blue Cross of Idaho an Independent Licensee of the Blue Cross and Blue Shield Association Form No. 9-165NI (10-16) 1
Insurance Information Malpractice Insurance Carrier: (please attach a copy of insurance certificate) Address: Policy # Expiration Date: Coverage: Worker s Compensation Insurance Carrier: (please attach a copy of insurance certificate) $ /$ Address Policy # Expiration Date: Coverage: $ /$ Accreditation Is your organization accredited? (if yes, please attach a copy) If yes, by whom? o Yes o No Date of last accreditation: List All Services Your Facility is Licensed to Provide: Please List The Job Titles For Each Different Class of Health Care Professionals/Technician Based In Your Facility 2
General Questions What is a typical wait time for patient access to your facility? What are your days and hours of operation? (check days and indicate hours) o Monday o Tuesday o Wednesday o Thursday o Friday o Saturday o Sunday Name the Top Five Intitiatives Your Facility has Undertaken in the Past Two Years to Eliminate Medical Errors and Improve Patient Safety: (If Necessary Attach Separate Sheet Of Paper) 2. 3. 4. 5. 3
ATTESTATION QUESTIONS To be Completed by Authorized Representative Please circle your answer to EACH of the following questions. A B SANCTIONS (If you circle Yes, provide details on a separate sheet. If you attach additional sheets, sign and date each sheet.) Has the facility ever been disciplined, reprimanded, or fined by any state licensing agency, or other authorizing agency, or by any Professional Conduct Board, or other state agency? Or have you voluntarily or involuntarily relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct? a. Health and Human Services/Office of the Inspector General b. Medicare, Medicaid, FDA, governmental, national or international regulatory agency or any public program c. Participation/membership in an HMO, PPO, IPA, PHO or other plan CRIMINAL HISTORY (Please provide details as specified on a separate sheet. If you attach additional sheets, sign and date each sheet.) Is anyone in your organization currently under governmental investigation? (if yes, please explain) 2. Has anyone in your organization been convicted of a criminal violation (misdemeanor or felony)? (if yes, please explain) 3. Does your organization perform regular Criminal History checks on all employees? (if no, please explain) C PATIENT SAFETY (Hospice, Home Health, Surgery Center, Skilled Nursing, Dialysis, etc.) Is there a written quality program to monitor and evaluate the services provided by the facility? 2. Is there a crash cart including defibrillator and back-up power generator? 3. Is there a written plan for patient transfers to participating hospitals when hospitalization is indicated? 4. Is there a licensed physician on the premises at all times when patients are in the facility? 5. Is there an Advanced Certified Life Support accredited staff member on the premises during all hours of operation? D PATIENT SAFETY (Hospitals only) Does your facility have a system to identify and correct medical treatment errors and adverse drug reactions? 2. Is there a pharmacist dedicated to the ICU to review and monitor physician medication orders? 3. Does a pharmacist make patient rounds with physicians in the ICU? 4. Is there a committee that reviews patient falls? 5. Does you facility have a system for tracking medication errors? 6. Does your facility provide 24 hour, 7 days/week availability for intake and referral? 7. Does your facility have patient safety and/or error management as a strategic goal? 8 Has your facility implemented measures to reduce the fear of co-workers when reporting patient safety and/or errors? E LITIGATION AND MALPRACTICE COVERAGE HISTORY (If you circle Yes, provide details on a separate sheet. If you attach additional sheets, sign and date each sheet.) Have allegations or claims of professional negligence been made against you or your organization at any time, whether or not you were individually named in the claim or lawsuit? 2. Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a professional malpractice claim (not necessarily a lawsuit) and/or to satisfy a judgment (court-ordered damage award) in a professional lawsuit? 3. Are there any such claims being asserted against you now? 4. Has your organization ever been denied professional liability coverage or has your coverage ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged)? 5. Are any of the privileges that your organization is requesting not covered by your current malpractice coverage? F Attestation I warrant that all the statements made on this form and on any attached information sheets are complete, accurate, and current. I understand that any material misstatements in, or omissions from, this statement constitute cause for denial of membership or cause for summary dismissal from the entity to which this statement has been submitted. Print Name: Title: Date: Signature (Stamped signature is not acceptable) 4
Authorization for Release of Information By submitting this Authorization for Release of Information form in conjunction with this application, I understand and agree as follows: I understand and acknowledge that, as an applicant for participating status with Blue Cross of Idaho, I have the burden of producing adequate information for proper evaluation of my organization s credentials and qualifications in a timely manner. I understand that the application will not be processed until Blue Cross of Idaho deems the application complete. 2. I further understand and acknowledge that Blue Cross of Idaho or designated agent will investigate the information in this application. By submitting this application, I agree to such investigation and to the disciplinary reporting and information exchange activities of Blue Cross of Idaho as part of the verification and credentialing process. 3. I authorize all individuals, institutions, entities or organizations with which my organization is currently or has been associated who may have information bearing on my organization s credentials and qualifications to release the aforementioned information to Blue Cross of Idaho, their staffs and agents. 4. I consent to the inspection of records and documents that may be material to an evaluation of my organization s qualifications. I authorize each and every individual and organization in custody of such records and documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested. 5. I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction with providing information, investigating and evaluating my organization s application and qualifications, and my organization waives all legal claims against any representative of Blue Cross of Idaho or its respective agent(s) who act in good faith and without malice in connection with the investigation of this application. 6. I understand and agree that the authorizations and releases given by me herein shall be valid so long as my organization is an applicant for or has participating status at Blue Cross of Idaho, unless revoked by me in writing. 7. I acknowledge that I have been informed of, and hereby agree to abide by Blue Cross of Idaho contractual agreements and policies. 8. I acknowledge that I am responsible for notifying Blue Cross of Idaho of any changes/challenges to licensure, DEA, criminal convictions, or other disciplinary actions. 9. I attest to the accuracy, currency and completeness of the information provided. I understand and agree that any misstatements in or omissions from the application and attachments hereto may constitute cause for denial of the application or summary dismissal or termination of participation agreement. 10. I agree to exhaust all available procedures and remedies as outlined in the, rules, regulations, and policies, and/or contractual agreement of Blue Cross of Idaho before initiating judicial actions. 1 I understand that completion and submission of the authorization for Release does not automatically grant my organization participating status with Blue Cross of Idaho. 12. I further acknowledge that I have read and understand the foregoing Authorization for Release of Information. A photocopy of this Authorization for Release of Information shall be as effective as the original and authorization constitutes my written authorization and request to communicate any relevant information and to release any and all supportive documentation regarding this application/attestation. Print Name: Title: Signature: Date: Stamped signature is not acceptable Modification to the wording or formation of the Authorization for Release of Information may invalidate an application. 5