Fillable Provider Networks & Provider Applicant Process (University of Utah)

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Provider Networks & Provider Applicant Process (University of Utah)

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Updated 08/10/2021
Page | 1
Provider Networks & Provider Applicant Process
Provider applications to participate in any U of U Health Plan network are considered
based on the following:
• Business needs
• The credentialing process
All providers must be approved through our credentialing process before they may
participate in any network.
Business needs may include and are not limited to:
• Network adequacy requirements based on state and/or federal guidelines
• Network adequacy requirements based on the current or expected population of a
given geographic area (usually defined by county or zip code)
• Network adequacy requirements based on provider type and/or specialty
• Network composition based on scope of services required by payer such as
employer, health plan, union/trust, government entity, etc.
• Network performance requirements in terms of cost/utilization, quality measures,
outcomes, access, and/or patient or physician satisfaction
• Demographic needs including but not limited to languages spoken
• Existing, non-compensated, referral patterns with current network providers and/or
U of U Health Plans members
Benefits of participating with a U of U Health Plan network include:
• Claim payments made to you directly on a weekly basis
• Provider Relations representatives are available to help you and your staff
• Inclusion in our on-line and printed provider directories made available to brokers,
employers and members for the applicable products
• Member benefits are designed to encourage use of network providers
• Participation with Link, our online tool to verify eligibility, check claims status, submit
inquiries, etc.
For consideration in one or more of our networks, fill out the following forms and return via
secure email to ProviderContracting@hsc.utah.edu or fax to 801-281-6121.
For your convenience, the following forms may be filled out electronically.
Page | 2
University of Utah Health Plans Provider Networks
Indicate the networks with which you are interested in participating:
Healthy U – A Utah Medicaid Accountable Care Organization (ACO) network available to
eligible Medicaid members in the entire State of Utah.
Healthy U Behavioral – A Medicaid behavioral and substance abuse network available to
eligible Davis, Salt Lake, Summit, Utah, and Weber county residents.
Healthy Premier – A provider network for employer groups in Utah and Southeastern Idaho.
It is also available on the Utah Individual Marketplace Exchange.
Healthy Preferred – A provider network for employer groups, primarily along the Wasatch
Front. It is also available on the Individual Marketplace Exchange in the following counties:
Davis, Salt Lake, Utah, and Weber. This network is intended to be a narrow provider panel.
In most cases, the reimbursement is less than the Healthy Premier plan.
Advantage U – Medicare Advantage product in Davis, Salt Lake, Tooele, Utah, and Weber
counties. This plan will be available to our Medicare Advantage members effective
January 1, 2021.
Completion of this application does not guarantee a contract or participation with
University of Utah Health Plans.
Briefly describe your services or scope of practice in the space below
(You may attach your marketing material.)
Page | 3
Provider Application – Exhibit B
An electronic roster containing this information may be submitted in lieu of completing this form.
ORGANIZATION INFORMATION
Legal Name of Organization/Parent Company:
(Legal name listed with IRS)
DBA Name of Organization:
(If applicable)
Organization Medicare # (primary) Organization Medicaid # (primary)
Organization TIN (primary) Organization NPI (primary)
Organization or Group’s Specialty
Organization licensed to operate in state?
Yes
No
Is Organization Accredited?
Yes
No
Does organization submit claims electronically?
Yes
No
If no, provide explanation:
Contracting Address
Street Address:
Credentialing Address (if different than Contracting Address)
Street Address:
Address Line 2:
Address Line 2:
City:
City:
State: Zip:
Contact:
Contact:
Email:
Email:
Phone:
Phone:
Primary Location
Location Name:
Billing Address (if different than Primary Location Address)
Group TIN/NPI Number:
Street Address:
Street Address:
Address Line 2:
City:
State:
Zip:
City: State: Zip:
Location Phone:
Location Fax:
Billing Contact:
Location Contact Name:
Billing Email:
Contact Email Address:
Billing Phone:
Is the location handicap accessible?
Yes
No
Does the location provide any ofthe following?
Does the location provide any of the following? Pediatric Services Yes No
Visual impairment accommodations Yes
No
Virtual Visits Yes No
Language translation/interpretation services
Yes No
Mental Health Treatment Yes No
Yes No Substance Abuse Treatment Yes No
Yes
Please explain:
Yes Please explain:
Yes
Please explain:
Hearing impairment accommodations
Extended hours
Does the location have age restrictions?
Does the location havegender restrictions?
Does the location have any other restrictions?
Is domestic vio
lence support available?
Yes
No
Most recent Cultural Competency training date:
Please explain:
No
No
No
No
Yes
Page | 4
LOCATION #3
Location Name:
Billing Address (if different than Primary Location Address)
Group TIN/NPI Number: Street Address:
Street Address:
Address Line 2:
City:
State:
Zip:
City: State: Zip:
Location Phone:
Location Fax:
Billing Contact:
Location Contact Name:
Billing Email:
Contact Email Address:
Billing Phone:
Is the location handicap accessible? Yes
Does t
he location provide any of the following?
Does the location provide any of the following? Pediatric Services
Virtual V
isits
Mental Health Treatment
Substance Abuse Treatment
LOCATION #2
Location Name:
Billing Address (if different than Primary Location Address)
Group TIN/NPI Number: Street Address:
Street Address:
Address Line 2:
City:
State:
Zip:
City: State: Zip:
Location Phone: Location Fax:
Billing Contact:
Location Contact Name:
Billing Email:
Contact Email Address:
Billing Phone:
Additional locations may be added by including all information on separate sheets.
Is the location handicap accessible?
Does the location provide any of the following?
Does the location provide any of the following?
Yes No
Pediatric Services
Virtual Visits
Mental Health Treatment
Yes No
Yes No
Visual impairment accommodations No
Language translation/interpretation services
Substance Abuse Treatment
Hearing impairment accommodations
Extended hours
Does the location have age restrictions?
Does the location have gender restrictions?
Does the location have any other restrictions?
Is domestic violence support available?
Most recent Cultural Competency training date:
Yes No
Yes
N
o
Yes
No
Yes No
Yes
No
No
Yes
Yes
Yes
No
No
No
Please explain:
Please explain:
Please explain:
Please explain:
Ye
s
Yes No
Yes No
Yes
No
No
Visual impairment accommoda
tions
Language translation/interpretation services
Hearing impairment accommodations
Extended hours
Does the location have age restrictions?
Does the location have gender restrictions?
Does the location have any other restrictions?
Is domestic violence support available?
Yes No
Yes
N
o
Yes
No
Yes No
Yes
No
No
Yes
Yes
No
Please explain:
Please explain:
Please
explain:
Please explain:
Ye
s
Yes No
Yes No
Most recent Cultural Competency
training date:
No
Page | 5
Provider Information – Exhibit B (Continued)
•
Do not include Locum Tenens Provider in this application.
•
You may submit Provider Information using your existing provider roster; however, it must
contain all of the information requested in this form.
Provider #1
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Provider #2
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Provider #3
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Page | 6
Provider #4
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Provider #5
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Provider #6
Name:
(Last, First, Middle, Degree)
Provider’s Tax ID:
(If different than group)
Provider’s Date of Birth:
(mm/dd/yy)
Provider’s Individual NPI:
Provider’s Gender:
Provider’s CAQH Number:
(Council for Affordable Quality Healthcare)
To self-apply to CAQH, visit www.caqh.org
Languages other than English spoken fluently by provider:
Hospital Privileges
(If applicable)
Provider’s Specialty(s):
Areas of Interest:
If provider has more than one location, specify the primary location and additional practice location(s)
Additional providers may be added by including all information on separate sheets.
Provider agrees University of Utah Health Plans may share provider application and related credentialing information with any group or entity that
has delegated or contracted with U of U Health Plans to provide such activities on their behalf. Information cannot be shared for any reason except
for provider directory/demographic and credentialing activities.
U of U Health Plans does not discriminate based on race, gender, nationality, age, sexual orientation, or the type of procedure or patient in whom the
practitioner specializes.
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Provider Networks & Provider Applicant Process (University of Utah)

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Completed 19 January 2022

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