HEALTHY PA Facility Credentialing Application
Healthy PA Facility Credentialing Application Page 1 of 13 INSTRUCTIONS:
Who should use the Facility Credentialing Application? PerformCare uses a credentialing process which is driven by National Committee on Quality Assurance (NCQA) standards for Behavioral Health Managed Care Entities. CR 11 of those standards allows the BH MCO to credential certain entities as an Organization. PerformCare has determined that any organization that to be considered an Organization for credentialing purposes, an entity must:
1) hold a license or certification from a State regulatory entity; OR;
2) hold accreditation from a National Organization will qualify for such credentialing AND; submits claims for payment under the Organization’s Medical Assistance enrollment identification number and related NPI; AND Accepts, as a facility, referrals of Members (as opposed to referrals made to a specific clinician).
Organizations are expected to credential their own staff. As part of the credentialing process for the Organization, PerformCare will review the Organization’s credentialing polices, including a very small sample of clinical staff records, to confirm that the Organization follows appropriate credentialing standards that align with PerformCare’s standards.
Who should not use this Organization credentialing application? Practitioners who will have an independent relationship with PerformCare. An independent relationship exists when PerformCare selects and directs its members to see a specific practitioner or group of practitioners who have entered into a Provider Agreement with PerformCare. Practitioners who see members outside the inpatient hospital setting or outside facility-based settings (independent practice). Practitioners who may see patients within a facility but do so as a result of an independent relationship with the Organization. For example, a physician who is, on behalf of a physician group, seeing patients within a facility but is not an employee of the hospital. Practitioners in situations defined above will undergo Individual Credentialing. We strongly encourage use of CAQH for such providers. Completing the Form Please print or type, providing complete answers to all questions. This application must be submitted in its entirety, including attachments. It will be returned if it is not fully completed. An incomplete application may delay the credentialing decision.
Part I of this application applies to the corporate parent organization.
Please be sure to mark which network (or networks) you are applying for. Note that each network will require a separate organizational contract.
Part II pertains to each site within the organization or distinct License, Medical Assistance Provider Identification Number and/or Medicare Number. Please fill out a separate Part II for each site. Include all services delivered at that site that are available. Make as many copies as necessary for each distinct sites/programs.
EXCEL SET UP FORM Complete the EXCEL set up form first. Feel free to reference the set up form in the body of the following application rather than duplicate data entry. The EXCEL Set Up Form is part of your application. The set up form is used primarily to assure proper addresses and payment information is in our system so that referrals are appropriate and that claims are paid correctly based n information you provide. It is necessary to identify your Medicaid Service location code
Healthy PA Facility Credentialing Application Page 2 of 13 PART I – ORGANIZATIONAL INFORMATION
Application for (Circle One):
HEALTHY PA - AmeriHealth Connect HEALTHY PA - Keystone Connect (covers all Pennsylvania counties except (covers Montgomery, Delaware, Bucks, Philadelphia Keystone Connect Counties) and Chester Counties) Name of Contracting Provider:
Corporate Address:
Corporate Mailing Address:
Billing Address:
Tax Id and Address:
Executive Director/CEO: (Name and Title) Corporate Compliance Officer: (Name and Title Contact Person for this Contract: (Name, Title and Phone Number) Contract Contact Telephone Number: Fax: Email address: After-Hours Phone Number:
ACCREDITATION AND LICENSES 1. National accreditations held: Please check all that apply. CARF JCAHO NCQA COA OTHER: ______(Please include current accreditation documents)
2. Applicable State Licensure/Certification: Please list all that apply (use a separate sheet if necessary):
Licensing Authority/State Licensed Services
3. Tax I.D. Number: Please include copy of Taxpayer Identification Number and Certification or TIN label
4. Tax Code Status - circle one { non-profit for profit} Healthy PA Facility Credentialing Application Page 3 of 13 OPERATIONS REQUIREMENTS 1. An organization policy and Procedure Manual is available and reviewed regularly Yes No
2. A confidentiality/patient rights policy and procedure is in place Yes No
3. A quality assurance plan to detect/correct problems is in place Yes No
4. A Corporate Compliance Officer is appointed Yes No Corporate Compliance Officers Name (REQUIRED):
5. Organization has adopted a Code of Conduct (REQUIRED) Yes No
6. Organization had a Corporate Compliance Plan (REQUIRED) Yes No
7. Consumer/family satisfaction is surveyed regularly Yes No Specify:
8. Clinical outcome measures are in place and tracked Yes No Specify:
9. Staff credentialing processing in place which includes (REQUIRED): a. Verification of licenses directly with Department of State (DOS) Yes No b. Documentation of disciplinary actions identified by DOS Yes No c. Primary source verification of education is conducted for all staff Yes No d. For physicians, the DEA Certification is confirmed to be current Yes No e. The resume reflects continuous work experience – breaks are explained Yes No f. Medicheck is referenced to assure employees are not precluded or excluded from PA Medical Assistance (ongoing review required) Yes No g. HSS-OIG is referenced to assure employees are not excluded from participation in any federal health care program Yes h. EPLS (Excluded Parties List System) is referenced to assure that employees are not excluded from receiving Federal contracts, certain subcontracts and certain Federal financial and non financial benefits Yes i. All three lists (Medicheck, HSS-OIG and EPLS) are checked prior to hiring an employee or contractor Yes No j. All three lists are checked monthly for every employee Yes
Note that PerformCare may ask to review the documents referenced above.
13. Organization policy supports recovery and resiliency principles? Yes No
14. Members are asked if they have a WRAP Plan or Advanced Directive? Yes No
Healthy PA Facility Credentialing Application Page 4 of 13 LIABILITY/MALPRACTICE COVERAGE INFORMATION
Note: If you have different Liability/Malpractice coverage for different programs/sites, you must complete this section for each policy/insurer. PLEASE INCLUDE A COPY OF CURRENT CERTIFICATE(S) OF LIABITY FROM YOUR INSURER. a. Has your organization filed a claim under general or professional liability insurance in the last five years? Yes No b. Are there any claims pending against your organization? Yes No c. Has your organization’s liability/malpractice coverage ever been denied, canceled, or non-renewed? Yes No
If yes to any of the above, please attach a written explanation. Note if you are self-insured, INCLUDE MOST RECENT AUDIT
SANCTIONS/LICENSURE INFORMATION a. Have you ever had your organization or program license(s) or applicable certifications and Accreditations terminated, restricted, or voluntarily relinquished? Yes No If yes, please attach a written explanation. b. Has the organization been sanctioned, placed on probation, or lost accreditation, licensure or certification status during the last three years? 1. State Licensure Yes No 2. Medicare Yes No 3. Medicaid Yes No 4. Champus Yes No 5. Other (specify) ______Yes No * If you answered yes to any of the above, please attach a written explanation providing detail about the sanction or probationary status.
REQUIRED SUPPORTING MATERIALS FOR PART 1 ITEMS TO BE SUBMITTED WITH THIS PART OF THE APPLICATION, AS APPLICABLE
______Updated and current photocopies of general and professional liability coverage documentation
______Copy of the most recent audit, ONLY if self – insured.
______Photocopies of all accreditation certificates
______Copy of Taxpayer Identification Number and Certification or TIN label
______Copy of W-9
______NPI registration letter
______EXCEL Set Up Form
Healthy PA Facility Credentialing Application Page 5 of 13 PART II – SPECIFIC SITE OR PROGRAM INFORMATION
Complete this section for each Site that is part of the organization and included as part of your Medicaid enrollment, including the Service Location Code. Include the provider type and Medical Assistance provider number as well as Medicare provider number (IF APPLICABLE) associated with each site, as applicable. Be as thorough as possible. Please make additional copies as needed.
Provider Name: License Type(s): Medical Assistance ID: Medicaid Service Location Code This Site:
Healthy PA Facility Credentialing Application Page 6 of 13 Office address where members will be seen (physical location, no post office box) : Phone Number: Fax Number: After-hours Phone Number: Mailing Address: (If different)
Billing Address: (If different) Contact Person for this Site: (Name and Title) Contact Person Phone Number: E-mail address: 24 Hour Emergency Access Phone Number for Members Are you a Medicare Provider or do you have Medicare enrolled YES……………NO clinicians at this site? Medicare Number (facility)______
Medicare Enrolled Clinician Names:
This site is accessible to public transportation?
YES……………NO Is this site handicapped accessible?
If you provide OUTPATIENT SERVICES (Individual, Group, Family, and Medication Management) do you anticipate serving more than 200 unique PerformCare Members at this location within a 12 month period? (This question is designed to determine if you will be a high volume provider. Answering no will not impact your ability to join the network) YES NO N/A
If residential or inpatient, please include number of beds:
Services at this site (Circle):
Mental Health Outpatient: Individual therapy Group Therapy Family Therapy Partial Hospitalization
Substance Abuse Outpatient: Individual Therapy Healthy PA Facility Credentialing Application Page 7 of 13 Group Therapy Family Therapy Intensive Outpatient Substance Abuse Partial Hospitalization Medication Assisted Therapy (Methadone/Suboxone) Outpatient Detoxification
Substance Abuse Residential Treatment Non Hospital Detoxification Non Hospital Rehabilitation (Short Term) Non Hospital Rehabilitation (Long Term)
Hospital Inpatient Psychiatric Substance Abuse (Detoxification) Substance Abuse (Rehabilitation)
Healthy PA Facility Credentialing Application Page 8 of 13 POPULATION AND SPECIALTY INFORMATION AT THIS SITE
Please identify your clinical interests and populations served by check marking applicable items. This information is for your provider profile and referrals will be made based on your responses. Mark Languages you speak fluently Fluently is defined as able to speak with ease or express effortlessly and correctly ... AL01______Spanish ... AL02______Chinese ... AL03______English ... AL04______French ... AL05______German ... AL07______Hebrew ... AL08______Italian ... AL09______Japanese ... AL10______Korean ... AL11______Latin ... AL12______Portuguese ... AL13______Russian ... AL14______Swahili ... AL15______Thai ... AL16______Urdu ... AL17______Vietnamese ... AL18______American Sign Language ... AL19______Ukrainian ... AL20______Hindi ... AL21______Punjabi ... AL22______Yiddish ... AL23______Telugu
Practice Interests Choose up to 5 and rank them accordingly ... D001______ADHD / ODD ... D002______Anxiety Disorders / Phobias ... D003______Autism/Developmental Disorders ... D004______Chemical Dependency/Co-Dependency ... D005______Dissociative Disorder ... D006______Eating Disorders ... D007______Personality Disorders ... D008______Post-Traumatic Stress Disorder ... D009______Reactive Attachment Disorder ... D010______Depression/Mood Disorder ... D011______Fetal Alcohol Spectrum Disorder
Priority Populations Mark ALL that apply but check AT LEAST 1. ... H01______Persons w/ serious MI ... H02______Child/Adol at risk for SED/SMI ... H03______Child/Adol Substance Abusers ... H04______Pregnant w/children w/ addiction ... H05______IV Drug Users w/addiction ... H06______HIV/AIDS Substance Abusers ... H07______Co-occurring MI/SA Healthy PA Facility Credentialing Application Page 9 of 13 ... H08______Co-occurring MI/MR ... H09______Co-occurring MR/SA ... H10______Complex Medical/SA Issues ... H11______Geriatric ... H12______Homebound Persons ... H13______Homeless Persons ... H14______Adult Substance Abusers
Accessibility Mark all that apply ... M001______Handicap Accessible ... M002______Elevators ... M003______Amplification Device (for deaf and hard of hearing) ... M004______Use of Computer/PC (for deaf and hard of hearing) ... M005______Pen & Paper (for deaf and hard of hearing) ... M006______Interpreter Contracted / Language Bank ... M007______TTY/TDD
Practice Populations Mark all that apply ... P001______Children (13 - 17) ... P002______Adults (18 - 64) ... P003______Children (preschool 0 - 4) ... P004______Gay / Lesbian / Bisexual / Transgendered ... P005______Geriatric (65+) ... P006______Hispanic / Latino ... P007______Deaf / Hearing Impaired ... P008______Faith Based/Spiritual ... P009______Children (5 - 12)
Other Interests / areas of specialization Choose up to 5 and rank them accordingly ... S001______Co-Occurring MH / D&A ... S002______Spanish Speaking ... S003______Sexual Disorders / Dysfunction ... S004______Family / Couple Therapy ... S006______Pain Management ... S007______Dual MH / MR ... S008______Trauma/Physical/Sexual Abuse Issues ... S009______Neuropsych Testing ... S010______Psychological Testing ... S011______Neuropsych Evaluation ... S012______African American ... S013______Adolescent - Sexual Offenders ... S014______Adults - Sexual Offenders ... S015______Play Therapy ... S016______Domestic Violence ... S017______Dialectical Behavioral Therapy (DBT)
GEOGRAPHIC COVERAGE/ACCESS AT THIS SITE Healthy PA Facility Credentialing Application Page 10 of 13 State:
County(ies) in which this site is located
County(ies) Served
What are your normal business hours at this site for seeing clients? Monday Tuesday Wednesday Thursday Friday Saturday Sunday
CULTURAL COMPETENCY SITE SURVEY Q1 Is there a process in place to address telephone calls from Spanish speaking clients? Yes No Q2 Calls from Spanish or Non-English speaking persons are received more than 3 times per month? Yes No Q3 For deaf/hard of hearing TTD/TTY or PA Relay service is available? Yes No Q4 Staff are trained to use TTD/TTY or PA Relay service? Yes No Q5 One or more calls are received per month on average via TTD/TTY/Relay? Yes No Q6 Provider has an amplification device for hearing impaired? Yes No Q7 PC or paper/pencil available to communicate with persons who are hearing impaired until arrangements are made for ongoing services? Yes No Q8 Can you respond to clients who speak a variety of languages? (ie… AT&T Language Line) Yes No Q9 Are you able to accommodate specific requests for treatment assignment to male, female or African American clinicians? Yes No Q10 Does staff represent the population you are serving? Yes No Q11 Provider has staff who are fluent in other languages? Yes No Fluent is defined as able to speak with ease or express effortlessly and correctly
LANGUAGES SPOKEN FLUENTLY BY CLINICAL STAFF AT THIS SITE
______Physician(s): Language(s):______Service:______
______Therapist(s): Language(s):______Service:______
______Other (list): Language(s):______Service:______
Fluently is defined as able to speak with ease or express effortlessly and correctly
Name(s) of Board Certified Psychiatrist at this site: ______
Name(s) of Board Eligible Psychiatrist at this site: ______
Healthy PA Facility Credentialing Application Page 11 of 13 I certify that the information provided in this application is correct to the best of my knowledge. I understand that any information contained in this application that subsequently is found to be false, could result in denial of the application or termination from network participation.
Signature Date
Return completed application to: Attention: PerformCare, Credentialing Department, 8040 Carlson Road, Harrisburg, PA 17112
REQUIRED SUPPORTING MATERIALS FOR EACH PART II The items noted below must be submitted with each part ii application, as applicable
______Copy of current license(s) / Certification for this site
______Staff Roster of licensed (physicians, LSW, LCSW, RN and licensed psychologists) and unlicensed clinicians that will provide services under the contract (Attachments A and B or an equivalent)
______CMS or State Licensing Site Visit Reports (Note: NCQA permits that a CMS or State review be used in lieu of the required site visit for non-accredited facilities). State licensing tools are acceptable to meet standards. Should the organization have not obtained full licensure, PerformCare must conduct a site visit – Please submit copies of your most recent licensing visits for this site/program, if applicable. If the sites visit reports cannot be submitted or indicates you have a provisional license, PerformCare will conduct a site visit.
For Internal Use Only:
Initial of review and Date application received from Provider:
Date application was returned to provider if applicable:
Date re-reviewed if applicable: Data Entry Complete Date:______
Credentialed Date: Reviewer:______
Healthy PA Facility Credentialing Application Page 12 of 13 LICENSED CLINICIANS AT THIS SERVICE SITE Attachment A (PART 2) Providers must have Policy and Procedure in place to assure that employees have appropriate credentials. You may submit this information in an alternate format.
Clinician(s) License/Certification License Number License Expiration Clinical Specialties / Areas of Interest (Alphabetically) (specify) Date *list for each clinician* *list for each site* *list for each clinician* *list for each clinician* *list for each clinician*