Fillable PROV03675 Facility Application V2 FILLABLE (Passport Health Plan)

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PROV03675 Facility Application V2 FILLABLE (Passport Health Plan)

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  • 16 check-boxes
  • 92 other fields

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PROV03675 Reviewed Feb 2020
Facility/Ancillary Service
Application Checklist
• A current copy of the facility’s or organization’s state license.
• A current copy of the facility’s or organization’s CLIA certicate if applicable.
• A copy of the facility’s or organization’s accreditation.
The accreditation cannot be greater than 3 years old.
• If not accredited, a letter and a copy of the survey with passing language from CMS or the applicable
state agency that shows the facility or organization had a site visit and indicates that it passed
inspection must be attached.
This letter cannot be greater than 3 years old.
• A current copy of the facility’s or organization’s professional liability facesheet.
* Additional address locations that share the same NPI and Tax ID may be attached to this application.
Locations with a different NPI and Tax ID must have a new application completed.
Please return these REQUIRED DOCUMENTS with your
COMPLETED APPLICATION for each location of the facility:
PROV03675 Reviewed Feb 2020
Facility/Ancillary Service Application
Please type or print clearly. Do not leave blank spaces. If a response is not applicable, write “N/A”.
Return the COMPLETED APPLICATION with ALL REQUIRED DOCUMENTS to the email(s) or address listed below.
Application Return
Preferred email to: Requesting Evolent Credentialing Coordinator
CC: ProviderCredentialing@Passport.Evolenthealth.com
CC: ProviderEnrollment@Passport.Evolenthealth.com
- or -
mail to: Passport Health Plan
Attn: Provider Enrollment
5100 Commerce Crossings Drive Louisville, KY 40229
Professional Data
Type of Facility/Ancillary Service:
Name:
Corporate Name:
KY Medicaid Number:
NPI: Tax ID:
Medicare Number: Taxonomy Code:
Provider Website/URL:
Location Information* Phone: Fax:
Address:
City: ST: Zip: County
*Additional address locations that share the same NPI and Tax ID may be attached to this application.
Locations with a different NPI and Tax ID must have a separate application completed.
Billing Contact Name:
Email: Phone: Fax:
Address:
City: ST: Zip: County:
Credentialing Contact Name:
Email: Phone: Fax:
Address:
City: ST: Zip: County:
PROV03675 Reviewed Feb 2020
Ofce Manager Name:
Email: Phone: Fax:
Address:
City: ST: Zip: County:
Licensure
State: Number: Effective Date: Expiration Date:
State: Number: Effective Date: Expiration Date:
State: Number: Effective Date: Expiration Date:
CLIA
State: Number: Effective Date: Expiration Date:
State: Number: Effective Date: Expiration Date:
State: Number: Effective Date: Expiration Date:
Insurance
Malpractice Carrier:
Policy Number: Expiration Date:
Claim Limit Occurrence: Aggregate Limit:
Malpractice Carrier:
Policy Number: Expiration Date:
Claim Limit Occurrence: Aggregate Limit:
Other Carriers held in the last 5 years:
* If self-insured, a certicate /letter of self-insurance must be included.
Accreditation
Source:
Effective Date: Expiration Date:
Source:
Effective Date: Expiration Date:
Non-Accredited Facilities/Ancillary Providers must complete this section
Date of Last CMS or State Review (Cannot be greater than 3 years old):
A copy of the survey with passing language must be attached to this application.
PROV03675 Reviewed Feb 2020
1. Does your organization verify the credentials of all professional/paraprofessionals who you are requested
to be licensed/registered?
o Yes o No
2. What is the professional liability insurance arrangement and your stated responsibility for these
professional/paraprofessionals?
3. If applicable, please list the number and category of licensed beds that your organization has.
4. Does your organization have a transfer policy?
o Yes o No
5. Does your organization have a process in place to monitor and improve patient safety?
o Yes o No
6. Has the facility license to do business in any applicable jurisdiction ever been denied, restricted,
suspended, reduced, or not renewed?
o Yes o No
If yes, an explanation is required to be attached.
7. Has the facility been denied participation, suspended from or denied renewal from Medicare or Medicaid?
o Yes o No
If yes, an explanation is required to be attached.
8. Has the facility’s professional liability coverage ever been cancelled but not renewed?
o Yes o No
If yes, an explanation is required to be attached.
9. Has the facility been denied accreditation by its selected accrediting body (e.g. JCAHO), or had its
accreditation status, reduced, suspended, revoked or in any way revised by the accrediting body?
o Yes o No
If yes, an explanation is required to be attached.
10. Has the facility been denied participation, suspended from or denied renewal from Medicare of Medicaid?
o Yes o No
If yes, an explanation is required to be attached.
All questions must be answered. If not applicable, please write N/A
PROV03675 APP_4/20/2020
Authorization, Attestation and Release
I am the authorized agent of the Applicant named below and have the authority to execute this document on behalf of the Applicant. I understand that
as part of the credentialing application process to participate as a Provider (hereinafter, referred to as “Participation”) wit h University Health Care, Inc.
“Contracting Entity”), all Applicants are required to provide sufcient and accurate information for the proper evaluation of all criteria used by the
Contracting Entity for determining initial and ongoing eligibility for Participation. I acknowledge and understand that my coopera-tion in obtaining
information in connection with this application and my consent to the release of information does not guarantee that the Contracting Entity will contract
with the Applicant as a provider of services.
Authorization of Investigation Concerning Application for Participation.
The following individuals including, without limitation, the Contracting Entity, its representatives, employees, and/or designated agent(s); the
Contracting Entity’s afliated entities and their representatives, employees, and/or designated agents; and the Contracting Entity’s designated
professional credentials verication organization (collectively referred to as “Agents”), are hereby authorized to investigate information, which includes
both oral and written statements, records, and documents, concerning this application for Participation. The Applicant agrees to allow the Contracting
Entity and/or its Agent(s) to inspect and copy all records and documents relating to such an investigation.
Authorization of Third-Party Sources to Release Information Concerning Application for Participation.
The Applicant hereby authorizes any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials
verication, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care
organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing
and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the
Health Care Integrity and Protection Data Bank, to release to the Contracting Entity and/or its Agent(s), information, including otherwise privileged
or condential information, concerning the qualications of this Applicant, its credentials, accreditations, quality assurance and utilization data, or any
other information reasonably having a bearing on the Applicant’s qualications for Participation with the Contracting Entity. This information shall also
include the details of any action taken by a health care organization, Medicare and Medicaid, their administrators or their medical or other committees
to revoke, deny, suspend, restrict, or condition the Applicant’s Participation, impose a corrective action plan or terminate any contract to which the
Applicant was a party. The Applicant further authorizes its current and past insurance carrier(s) to release this Applicant’s history of claims that have been
made and/or are currently pending against it. The Applicant specically waives written notice from any entities and individuals who provide information
based upon this Authorization, Attestation, and Release.
Release from Liability.
The Applicant hereby releases from all liability and holds harmless any Contracting Entity, its Agent(s), and any other third party for their acts performed
in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Contracting Entity, its Agent(s), or other
third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization,
Attestation, and Release. The Applicant further agrees not to sue any entity, any agent(s), or any other third party for their acts, defamation or any other
claims based on statements made in good faith and without malice or misconduct in connection with the credentialing process. This release shall be in
addition to, and in no way shall limit, any other applicable immunities provided by law for credentialing activities.
In this Authorization, Attestation, and Release, all references to the Contracting Entity, its Agent(s), and/or other third party include their respective
employees, directors, ofcers, advisors, counsel, and agents. The Contracting Entity and its afliates or agents retain the right to allow access to the
application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the
credentialing processes and provided that the customer and/or their auditor executes an appropriate condentiality agreement.
The Applicant understands and agrees that this Authorization, Attestation, and Release is irrevocable for any period during which the entity identied
below is an Applicant or a Provider with the Contracting Entity. The Applicant agrees that it shall execute another form of consent if any law or regulation
limits the application of this irrevocable authorization. The Applicant understands that its failure to promptly provide another form of consent may be
grounds for termination or discipline by the Contracting Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the
Contracting Entity, or grounds for its termination of Participation with the Contracting Entity.
The undersigned certies that all information provided in its application is current, true, correct, accurate and complete to the best of his/her knowledge
and belief, and is furnished in good faith. The Applicant will notify the Contracting Entity and/or its Agent(s) within ten (10) days of any material changes
to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal
convictions, etc.) that has been provided in its application and /or is authorized to be released pursuant to the credentialing process. The Applicant
understands that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted
online or in writing, and must be dated and signed by an authorized agent of the Applicant (may be a written or an electronic signature). The Applicant
acknowledges that it is responsible to provide a complete application and to produce adequate and timely information for resolving questions that arise
in the application process. The Applicant understands and agrees that any material misstatement or omission in the application may constitute grounds
for withdrawal of the application from consideration; denial or revocation of Participation; and/ or immediate suspension or termination of Participation.
This action may be disclosed to the Contracting Entity and/or its Agent(s).
The undersigned acknowledges that he/she has read and understands the foregoing Authorization, Attestation, and Release. A facsimile or photocopy
of this Authorization, Attestation, and Release shall be as effective as the original.
Agreed to and accepted by the undersigned on behalf of the organization:
Name of Applicant: _________________________________________________
Printed Name: _____________________________________________________
Email Address: _____________________________________________________
Date: _____________________________________________________________
Signature: ________________________________________________________
Title: _____________________________________________________________
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PROV03675 Facility Application V2 FILLABLE (Passport Health Plan)

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Completed 19 July 2020

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