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Provider/facility and long-term services and supports (LTSS) provider

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https://providers.amerigroup.com
IAPEC-0423-16 July 2016
Provider/facility and long-term services and supports (LTSS) provider application
Provider identification
Legal business name:
Doing business as (if applicable):
Contact person:
Email:
Tax ID number 1:
Tax ID number 2:
Medicaid number 1:
Medicare number 1:
Medicaid number 2:
Medicare number 2:
Long-term care vendor number:
Provider type
Facility/ancillary:
__Ambulance (8)
__Hemophilia center (62)
__Methadone maintenance clinic (84)
__Respite care (169)
__Ambulatory surgery center (8)
__Home health agency (64)
__Nursing home (98)
__Rural health clinic (172)
__Audiology services (12)
__Home infusion therapy (65)
__Occupational therapy (OT) services
(105)
__Skilled nursing facility (173)
__Birthing center (13)
__Hospice care – outpatient (67)
__Organ transplant facility (111)
__Sleep disorder clinic (175)
__Dialysis (31)
__Hospice facility (68)
__Orthotics and prosthetics (112)
__Speech therapy (ST) services (177)
__Dietician/nutritional services
(33)
__Hospital (69)
__Outpatient mental health/substance
abuse facility (115)
__Sub acute/intermediate care
facility (180)
__Durable medical equipment
(DME) and supplies (36)
__Imaging facility (71)
__Outpatient rehab center (116)
__Trauma center (201)
__Early childhood intervention
(37)
__Inpatient mental health/
substance abuse facility
(74)
__Physical therapy (PT) services (148)
__Urgent care center (202)
__Family planning services (41)
__Inpatient rehab hospital (75)
__Psychiatric hospital (153)
__Walk-in clinic (CCCs) (206)
__Federally Qualified Health
Center (FQHC) (293)
__Intensive family intervention
(819)
__Radiology – mobile unit (163)
__Fetal monitoring services (45)
__Interpreter service (77)
__Radiology facility (165)
__Genetic services (50)
__Laboratory (78)
__Residential treatment center
(mental health/substance abuse)
(212)
Page 2
Long-term care/home- and community-based services (HCBS)/waiver programs:
__Core (911)
__Hospice care – outpatient
(67)
__Residential care/assisted living
facility (168)
__Escort attendant (215)
__Hospice facility (68)
__Respite care (169)
__Financial assessment/risk
reduction services (46)
__Intermediate care facility for
individuals with disabilities
(384)
__Respite care – in home (462)
__Habilitation (1067)
__Music therapy (87)
__Respite care – inpatient (456)
__Home-delivered meals (63)
__Nursing home (98)
__Service facilitator/independent
support broker(S825)
__Home health agency
__Nurse registry (213)
__Supportive employment (653)
__Home health aide (235)
__Personal assistant services
(143)
__Supportive living services (629)
__Home infusion therapy (65)
__Personal emergency response
systems (457)
__Transitional living skill (682)
__ Homemaker (216)
__Pest control (145)
__Vehicle modification (713)
__Home modification/repair (66)
__Prevocational services
Primary office/service address
Practice location name:
Address line 1:
Address line 2:
City:
State:
ZIP:
County:
Phone:
Fax:
Primary contact person:
Administrator (full name):
Does provider bill from this address? Yes No
Does this office meet American Disabilities Act (ADA) accessibility requirements? Yes No
Check all that apply:
Handicap accessible:
Building
Parking
Restroom
Services for disabled:
Text telephone
American Sign Language
Mental/physical impairment
Accessible by public transportation:
Bus
Subway
Regional train
Billing information (if different from above)
Name (billing name):
Address line 1:
Address line 2:
City:
State:
ZIP:
Phone:
Page 3
Secondary office/service address (attach separate sheet of paper for additional practice locations)
Practice location name:
Address line 1:
Address line 2:
City:
State:
ZIP:
County:
Phone:
Fax:
Primary contact person:
Administrator (full name):
Does provider bill from this address? Yes No
Does this office meet ADA accessibility requirements? Yes No
Check all that apply:
Handicap accessible:
Building
Parking
Restroom
Services for disabled:
Text telephone
American Sign Language
Mental/physical impairment
Accessible by public transportation:
Bus
Subway
Regional train
Billing information
Name (billing name):
Address line 1:
Address line 2:
City:
State:
ZIP:
Phone:
National Provider Identifier (NPI)
Provider name:
Service address:
Tax ID/EIN:
NPI number:
Taxonomy code(s):
Provider name:
Service address:
Tax ID/EIN:
NPI number:
Taxonomy code(s):
Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each location. If more space is needed, please attach a
separate sheet of paper with name, service address, tax ID/EIN, NPI number and taxonomy code(s).
Page 4
Licensure (attach a copy of current licensure and Clinical Laboratory Improvements Amendment [CLIA]
certification, if applicable)
State:
Date of license:
License number:
Expiration date:
State:
Date of license:
License number:
Expiration date:
CLIA certificate number:
Accreditation/certification (attach a copy of current accreditation certificate or survey)
A.
AASM
AAAHC
AAAASF
ABC
ACHC
ACR
BOC Int’l.
CABC
CAP
CARF
CCAC
CHAP
COA
DNV
HFAP
HQAA
IAC
NABP
NBAOS
TJC
Not accredited (complete section B below)
Date of initial accreditation: _____/_____/_____ Date of next survey: _____/_____/_____
Date of last survey: ___/_____/_____
B.
Has provider had an onsite survey by CMS or state agency? Yes No Date of last state survey: _____/_____/_____
If no, successful completion of a health plan onsite visit will be required to complete credentialing. You will be contacted by the
health plan to schedule the visit.
Nonaccredited providers must provide a copy of their most recent government agency survey (may not be older than 36
months), along with your corrective action plan (if deficiencies were cited), or attach the letter from the government agency
stating facility is in substantial compliance with most recent survey standards.
Facilities that don’t meet the requirements above require an onsite visit before network status may be granted. Failure to
provide documentation or complete the onsite survey may delay your ability to become a participating provider.
General and professional liability insurance
General liability coverage
Current carrier name:
Policy number:
Coverage type:
Occurrence-based Claims-based
Effective date:
Expiration date:
Per incident: $
Aggregate: $
Professional liability coverage
Current carrier name:
Policy number:
Coverage type:
Occurrence-based Claims-based
Effective date:
Expiration date:
Per incident: $
Aggregate: $
Page 5
Credentialing questions
Does the facility/ancillary/long-term care provider have:
1. Evidence of all subcontractors’ professional liability claims history? Yes No
2. Any disciplinary action taken against any business or professional license held in this or
any other state or surrendered a license in this or any state? Yes No
3. Any history of loss or limitation of privileges or disciplinary activity? Yes No
Please include an explanation on a separate sheet for any questions answered “Yes.”
Attestation and information release authorization
All information provided in this, or in connection with this application, is complete and accurate to the best of my knowledge, and
I shall immediately notify Amerigroup Iowa, Inc. of any changes thereto. I understand that this application does not entitle me to
participation in the Amerigroup network. By applying for appointment as an Amerigroup participating provider, I authorize the
plan, its medical director and appropriate representatives to consult with administrators and members of other institutions where
I have been associated, including past and present malpractice carriers who may have information bearing on my professional
competence, character and ethical qualifications. I hereby further consent to the inspection by Amerigroup, its medical director
and appropriate representatives, of all records and documents, excluding medical records of nonmembers of Amerigroup plans,
that may be material to an evaluation of any professional qualifications and competence to carry out the requested duties, as well
as my moral and ethical qualifications for participating provider status with Amerigroup. I consent and agree that Amerigroup will
complete a criminal history background check to determine if I, or any subcontracted providers, have any history of felony
convictions, including adjudication withheld on a felony, plea or nolo contendere to a felony or entry into a pretrial for a felony. I
agree to obtain any consents or approvals required for my subcontracted providers to undergo such background checks. I hereby
release Amerigroup and its representatives from liability for their acts performed in good faith and without malice in connection
with evaluating my application, credentials and qualifications. I hereby release any individuals and organizations from any liability
that provide information to Amerigroup or its staff in good faith and without malice concerning my professional competence,
ethics, character and other qualifications, and I hereby consent to the release of such information. By executing this application, I
confirm that I am bound by the terms of the ancillary agreement between me or my group and Amerigroup, as such terms may be
applicable to me.
I understand that as an applicant for participation in Amerigroup, I have the right to review information obtained from primary
verification sources during the credentialing process. I further understand that upon notification from Amerigroup, I have the
right to explain any information obtained that may vary substantially from that provided by me and correct any erroneous
information submitted by another party. This shall be accomplished by my submission of a written explanation or by appearance
before the credentialing committee, if they so request. I further understand that I may appeal the committee’s decision either in
writing or by appearance before the credentialing committee, if they so request.
Owner/registered/authorized agent printed name: _________________________________ Date:_________________
Owner/registered/authorized agent signature: ________________________________ Title:_______________________
SSN: ____/____/____ Date of birth: ___/___/____
click to sign
signature
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Page 6
Enclosures
Please submit all applicable documents from the list below with your completed and signed application.
Failure to provide this information will prohibit Amerigroup from completing your credentialing and/or
contracting process.
Copy of all federal, state and/or local licenses required to operate as a health care facility (by location)
Copy of accreditation certificate or letter
Copy of most recent CMS or state survey, including your corrective action plan if deficiencies were
cited or cover letter from CMS/state agency stating facility is in substantial compliance
Copy of CLIA certificate for each location, as applicable
Page 7
Amerigroup disclosure form for provider entities
Directions: Please answer all questions. For any “Yes” response, please provide an explanation or listing as required. If you
do not believe a question is applicable to you or your organization/entity, you should answer the question “NA.” If you need
additional space to respond to a question, please add a separate sheet of paper: Include your entity name on each sheet
and identify the question and header for the listing. One disclosure entity form is required per TIN. No questions should be
left blank.
Dates of birth and Social Security numbers (SSNs) must be provided for validation purposes, as outlined in 42 CFR
455.104 (b) (1) (ii).
I. Identifying information
Provider entity name:
Doing business as name
(if different from provider entity name):
Provider federal tax ID
number:
Provider NPI number:
Medicaid ID number:
Provider telephone number:
Provider address: Must include at least one street address. (Attach a
separate sheet if needed.) List all practice locations:
City:
State:
ZIP:
II. Ownership and control information
Directions: The entity/organization must list all controllers, owners, agents and managing employees on the master list. For
the purposes of this form, these terms are defined as follows:
Controller: includes all directors, trustees and officers of a corporation or partners in a partnership. If the entity is
a non-profit or not-for-profit entity, please respond “N/A” to the percentage of ownership question below, but still
list all controllers
Owner: includes any person or business entity that owns 5 percent or more of the assets, stock or profits of the
provider entity either directly or indirectly
Agent: includes any person or entity that has the authority to obligate the provider to a contract, mortgage or loan
that may or may not be secured by the entity’s assets
Managing employee: includes anyone who has the authority to make material business decisions on behalf of the
provider entity
Page 8
A. Master list (use additional pages if needed)
Full name
Address (street
and/or P.O. Box)
City
State
ZIP
Date of
birth
SSN for
individuals or
Tax ID for
business entities
Percent
owner-
ship
Title
Page 9
B. Specific questions
1) Is any person listed in the master list related to another person on the master list as a spouse, parent,
child or sibling?
Yes No If Yes, please provide the following information about the related persons. If No, go to the
next question.
Full name of first related person:
Full name of second related person:
Type of relation:
2) Does any person or entity listed in the master list have an ownership or control interest in any other
provider entity?
Yes No If Yes, please provide the following information about the other provider entity the person
on the master list has an interest in. If No, go to the next question.
Name of other provider entity:
Address:
City:
State:
ZIP:
Tax ID:
3) Has any person or entity listed in the master list been convicted of a criminal offense related to that
person or entity’s involvement in any program under Medicare, Medicaid, TRICARE or the CHIP services
program since the inception of those programs?
Yes No If Yes, please provide the following information. If No, go to the next question.
Name on court
records:
SSN/
Date
of
birth:
Matter of the offense:
Date of the
conviction:
Exclusion period of the offense, if excluded by
the federal Office of the Inspector General
(OIG):
4) Has any person or entity listed in the master list ever been debarred from participation in federal
government contracts? Debarred means an individual is prohibited from participation in contracts paid for
by the federal government, whether or not those contracts are in the health care area.
Yes No If Yes, please provide the following information. If No, go to the next question.
Date of debarment:
Length of debarment:
Reason for debarment:
Page 10
5) Has any person or entity listed in the master list ever been excluded from participation in federal health
care programs (Medicare, Medicaid, CHIP or TRICARE) in the past? Excluded means a provider or entity
has been notified by the Department of Health and Human Services, Office of the Inspector General (HHS,
OIG) that they are prohibited from participating as a provider in any federally funded health care
program.
Yes No If Yes, please provide the following information. If No, go to the next question.
Full name of individual or
entity
Beginning date of
exclusion or
termination
End date of exclusion or
termination
Reason for exclusion or termination
6) Has any person or entity listed in the master list ever been terminated from a state’s Medicaid or CHIP
program for reasons having to do with program integrity (fraud or abuse)? Terminated means the
provider lost the right to bill a state’s Medicaid and/or CHIP programs for a cause related to fraud or
abuse.
Yes No If Yes, please provide the following information. If No, go to the next question.
Full name of provider
State of
practice when
terminated
Reason for termination
Date of
termination
7) Has any person or entity listed in the master list ever had civil monetary penalties (CMP) assessed against
them? A CMP is a type of fine assessed against a provider by a governmental agency that manages a
federal health care program.
Yes No If Yes, please provide the following information. If No, go to the next question.
Full name of individual or entity:
State of practice when CMP
assessed:
Reason for CMP:
Amount of
CMP:
Date of
CMP:
8) Has any person listed in the master list obtained an ownership interest in a provider entity: (1) As a result
of a transfer of ownership from someone who was about to be excluded or terminated from participation
in a federal health care program, or was, in fact excluded or terminated from participation in a federal
health care program, (2), where the original owner is or was a member of the current owner‘s immediate
family or member of the current owner’s household at the time of the transfer of ownership? (Immediate
family is defined as a person's husband or wife; natural or adoptive parent; child or sibling; stepparent,
stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law;
grandparent or grandchild; or spouse of a grandparent or grandchild. Member of household means, with
respect to a person, any individual with whom they are sharing a common abode as part of a single-family
unit, including domestic employees and others who live together as a family unit. A renter or boarder is
not considered a member of the household.)
Yes No If Yes, please provide the following information. If No, go to the next question.
Page 11
Full name of original owner:
SSN or TAX ID of original owner:
Place of transfer:
Date of
transfer:
9) Does any person or entity listed in the master list have a direct or indirect ownership interest of at least
5 percent in a subcontractor of the provider entity? A subcontractor is a person or company that the
provider entity has contracted with to provide some of the provider entities’ management functions (i.e.,
billing agent) or provide medical services (i.e., a medical lab).
Yes No If Yes, please list each subcontractor. If No, go to Section III.
Full name of subcontractor:
Address:
City:
State:
ZIP:
Tax ID:
a) For each subcontractor listed in 9 above, please provide the following information about the
individuals with an ownership or control interest in the subcontractor. See the directions for
Section II above for a definition of these terms. Attach a separate sheet, if necessary.
Full name:
Address (street
and/or P.O. Box ):
City:
State:
ZIP:
Date
of
birth:
SSN for
individuals or
Tax ID for
business
entities:
Percent
of
owner-
ship:
Title:
Page 12
b) Is anyone listed in 9a related to any person in the master list?
Yes No If Yes, please provide the following information about the related persons. If
No, go to Section III.
Full name of first related person:
Full name of second related
person:
Type of relation:
III. Business transactions
1) Has the provider entity entered into any financial transaction(s) with any subcontractor totaling more than
$25,000 or any significant business transactions with any subcontractor?
Yes No If Yes, please provide the following information. If No go to next question.
List the ownership of any subcontractor with whom this provider has had one or more business transactions
totaling more than $25,000 during the previous 12-month period and any significant business transactions
between this provider and any wholly-owned supplier, or between the provider and any subcontractor
during the past five-year period.
Full name:
Address:
City:
State:
ZIP:
2) Does the provider entity wholly own a supplier? Supplier means an individual, agency or organization from
which the provider entity purchases goods and services used in carrying out its responsibilities under Medicaid
(e.g., a commercial laundry, a manufacturer of hospital beds or a pharmacy).
Yes No If Yes, please provide the following information. If No, go to next question.
Name:
Address:
City:
State:
ZIP:
NPI:
TIN:
Page 13
IV. Signature
The state or federal Medicaid agency may refuse to enter into, renew or terminate an agreement with a provider if it is
determined that a provider did not fully, accurately and truthfully make the disclosures required by this statement.
Additionally, false statements or representations of the required disclosures may be prosecuted under applicable federal
or state laws. The signature below MUST be the written signature of an individual who can legally bind this provider.
In compliance with 42 CFR 455.104(c), provider shall complete this disclosure of ownership upon application for network
participation and/or prior to execution of a provider agreement, at the time of recredentialing/reenrollment, and within
35 days after any change in ownership by the provider. In compliance with 42 CFR 455.105(b), provider certifies that it
will submit within 35 days of the date on a request by the secretary or the Medicaid agency, full and complete
subcontractor information as outlined in Section III, business transactions, above.
Name of person (printed):
Signature of person:
Title:
Date:
Name of person completing form:
Phone number of person completing form:
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Providerfacility and long-term services and supports (LTSS) provider

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Completed 8 October 2020

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