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Molina Healthcare, Inc. Health Delivery Organization (HDO) Application

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Molina Healthcare, Inc.
Health Delivery Organization (HDO) Application
Revised: 12/05/2019 Page 1 of 5
INSTRUCTIONS:
Please submit this completed application and required attachments in order to apply for initial credentialing or
recredentialing with Molina Healthcare. During initial credentialing, credentialing must be completed prior to completion of
a contract for any organization/facility not currently contracted with Molina Healthcare. Approval of your credentialing
does not constitute finalization/approval of your contract and network participation.
If your organization has more than one location:
• Complete a separate application for each of your locations if each location has had a separate state, CMS or
accreditation survey.
• Complete one application which will cover all your locations if:
o Your organization has had one state, CMS and/or accreditation survey that covered all your locations on the
same date(s), or
o Your organization is not accredited and not required to be surveyed by any state or federal organization as
part of your licensure, registration and/or certification process.
• This application must be filled out completely with all sections answered:
o Do not use white-out on any part of the application.
o If there is NOT a checkbox in the section header to indicate a why a section is not applicable, the section
should be completed by all applicants.
• The information listed below should accompany the completed application:
Current organizational or facility licenses/certifications/registrations
A copy of the letter verifying approval of CMS participation (if applicable)
Current liability insurance face sheet
W9 form(s) showing all federal Tax Identification Numbers (TINs) used by the organization/facility
(Only Page 1 of this form is needed: http://www.irs.gov/pub/irs-pdf/fw9.pdf)
• If your organization is not accredited by a body listed in Section 4 of this application and your organization is required
to be certified by CMS or the State, we also request a copy of the most recent CMS or State on-site survey results
• Incomplete applications will be returned for completion prior to processing.
• Please return this application and all attachments to MCCVA-Provider@MolinaHealthcare.com.
VA-ALL-PF-2044-21
Molina Healthcare, Inc.
Health Delivery Organization (HDO) Application
Revised: 12/05/2019 Page 2 of 5
1. ORGANIZATION INFORMATION:
(Provide physical location information on the following page)
Legal Name of Organization
(Legal name listed with the IRS)
DBA Name of Organization
(if applicable)
Historic Name(s) of Organization
(if under same ownership)
Organization Medicare # (primary): Organization Medicaid # (primary):
Organization TIN (primary): Organization NPI (primary):
Credentialing Contact Billing Address
(if different than Credentialing)
Street Address: Street Address:
Address Line 2: Address Line 2:
City: State: Zip: City: State: Zip:
Contact
Name:
Contact
Name:
Email: Email:
Phone: Fax: Phone: Fax:
2. CURRENT INSURANCE COVERAGE:
(Please attach a copy of your current facility professional/general liability insurance face-sheet)
Please check here if your facility is not required to carry liability insurance.
Professional Liability Insurance Information (if available)
Current Carrier Name: Policy Number:
Policy Start Date: Policy End Date:
Policy Type
(malpractice, general, etc.):
Coverage amount
per occurrence:
Coverage amount
aggregate:
General Liability Insurance Information (if no professional liability available)
Current Carrier Name: Policy Number:
Policy Start Date: Policy End Date:
Policy Type
(malpractice, general, etc.):
Coverage amount
per occurrence:
Coverage amount
aggregate:
Molina Healthcare, Inc.
Health Delivery Organization (HDO) Application
Revised: 12/05/2019 Page 3 of 5
COMPLETE THE BELOW INFORMATION FOR EACH PRACTICE LOCATION
Only include information for locations that you wish to be listed with Molina Healthcare.
Complete a copy of sections 3-4 of this application for every location where information differs between
locations
3. PHYSICAL LOCATION INFORMATION:
(Include any additional information relevant to this location on a separate sheet)
Location DBA
(if different than the Organization DBA)
Other DBAs Previously Used
(if under same ownership)
Is this location Medicare Certified? Yes No Is this the primary address? Yes No
Site-specific Medicare #: Site-specific Medicaid #:
Site-specific TIN: Site-specific NPI:
Physical Practice Location
State provider # (if applicable, LTC, etc.):
Street Address:
Is this location handicap accessible? Yes No
Address Line 2:
City: State: Zip:
Phone: Fax:
Please list any languages spoken by office personnel:
Practice Limitations (e.g., age, gender, etc.):
Location State License(s) and/or State Registration(s) – (Attach a copy of all)
Please check here if this location is not required to be licensed, certified, or registered by a State agency.
Type of Credential State Number Expiration Date Most Recent Survey Date
State License
State Registration
State Certification
Other:
Additional Location Credentials – (Attach a copy of all)
Please check here if this location holds no additional licenses, certificates, registrations, etc.
Type of Credential State Number Expiration Date Additional Notes/Info
DEA
CLIA
State CSR/CDS/DPS
Other:
Specialty & Federal Taxonomy Code Specialty & Federal Taxonomy Code
Molina Healthcare, Inc.
Health Delivery Organization (HDO) Application
Revised: 12/05/2019 Page 4 of 5
4. ACCREDITATION / CERTIFICATION (check all that apply):
Please check here if the State conducts routine surveys of your organization for license, registration, or clinical oversight.
Please check here if your organization is NOT accredited and NOT required to be surveyed by ANY organization.
Accreditation Organization Date of Last Survey
(CMS) Medicare Certification (attach most recent survey and acceptance letter)
(AAAHC) Accreditation Association for Ambulatory Health Care
(ACHC) Accreditation Commission for Health Care
(AAAASF) American Association for Accreditation of Ambulatory Surgery Facilities
(ABCOP) American Board for Certification in Orthotics/Prosthetics
(ACR) American College of Radiology
(ASHI) American Society for Histocompatibility and Immunogenetics
(BOC) Board of Certification / Accreditation, International (O&P or DMEPOS)
(CAP) College of American Pathologists
(CARF) Commission on Accreditation of Rehabilitation Facilities
(COLA) Committee of Laboratory Accreditation
(CHAP) Community Health Accreditation Program
(CT) The Compliance Team
(COA) Council on Accreditation
(DNV) Det Norske Veritas
(HFAP) Healthcare Facilities Accreditation Program - AOA
(HQAA) Healthcare Quality Association on Accreditation
(IAC) The Intersocietal Accreditation Commission
(NABP) National Association of Boards of Pharmacy
(NBAOS) National Board of Accreditation for Orthotics Suppliers
(NCQA) National Commission for Quality Assurance
(TJC) The Joint Commission
(URAC) URAC, (aka, American Accreditation Healthcare Commission)
(*CABC) *Commission for the Accreditation of Birth Centers
* Molina only recognizes accreditation by CMS ‘Deemed’ bodies except for
The CABC for ‘Birthing Centers’ and PPFA for ‘Planned Parenthood’ facilities.
Molina Healthcare, Inc.
Health Delivery Organization (HDO) Application
Revised: 12/05/2019 Page 5 of 5
ATTESTATION AND RELEASE OF INFORMATION FORM
Modifications Will Not Be Accepted
RELEASE OF INFORMATION:
As part of the application process and for the purpose of verifying any information provided on this application, I, the undersigned
authorized agent of the applicant facility/organization, grant Molina Healthcare permission to contact any individual, institution, facility or
agency identified on, or relative to, this application. Further, I hereby consent and authorize Molina Healthcare to request, receive and
inspect any and all records pertinent to consideration of this application.
As a Molina Healthcare facility/organization applicant, I, the undersigned authorized agent, acknowledge that I am required to supply
Molina Healthcare with any information and documentation necessary and relevant to the review of this application.
SITE REVIEW AUTHORIZATION:
I hereby grant permission for Molina Healthcare to conduct on-site and medical record reviews as necessary. I further agree that this
facility will participate in and support Molina Healthcare’s quality improvement and utilization review programs.
ATTESTATION:
I certify the information on this entire application is complete, accurate, and current. I acknowledge that any misstatements in or
omissions from this application constitute for denial or summary dismissal. A copy of this application has the same force and effect as
the original. I have reviewed this information as of the most recent date listed below. I attest that the organization on this application
maintains liability insurance as outlined by state requirements.
I acknowledge that decision of participation for the organization on this application will be delayed until all required information is
received and/or verified. I acknowledge that acceptance of this application does not constitute approval or acceptance or participating
status with Molina Healthcare and does not grant this facility any rights or privileges of participation until such time as a contract is
consummated and written notice of participating status is issued to this facility by Molina Healthcare. All services rendered to Molina
members must be individually authorized until a written notice of participation and conditions of participation is issued by Molina
Healthcare.
This facility complies with all federal, state, and local handicapped access requirements as well as the standards required by the 1992
Federal Americans with Disabilities Act.
I certify that the appropriate state license or certification source is checked for all new employees or contracted service providers prior
to the first provision of service. I certify that the appropriate state license or certification source is checked at least annually for existing
and contracted service providers in order to ensure that every licensed individual providing services as a representative of the applicant
holds a current license or certification to provide services. I certify that criminal background checks are conducted for all new
employees or contracted service providers prior to the first provision of service. I certify the applicant does not employ or contract with
any individual convicted of a felony for a health-care related crime, including but not limited to health care fraud, patient abuse and the
unlawful manufacture, distribution, prescription, or dispensing of controlled substance.
I certify that the on-line exclusion lists for the Health and Human Services Office of Inspector General (https://exclusions.oig.hhs.gov/)
and System for Award Management (https://www.sam.gov/SAM/) are checked for all new employees or care providers prior to the first
provision of service and for existing employees or contracted service providers on a monthly basis to ensure that no state or federally
excluded individuals perform any function related to any state or federal health care program. I certify that I will remove any employee
or contracted service provider found on one of the above referenced federal exclusion lists from any functions related to a state or
federal health care program.
The individual executing this Attestation is duly authorized and has the proper authority and proper authorization to execute
this Attestation and does so with the intent to fully bind Facility to the truthfulness of its answers.
Signature:
(Stamped signature is not acceptable)
Printed Name: Date:
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Molina Healthcare, Inc. Health Delivery Organization (HDO) Application

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Completed 23 December 2021

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