Your Answers to the Questions Listed Below Will Be Used to Assess the Suitability of Your

Your answers to the questions listed below will be used to assess the suitability of your organization for participation in Land of Lincoln Health. Please answer all applicable questions and indicate those not relevant to your organization with "N/A."

Multi-site providers: Each Site may require its own application completed and corresponding documentation supplied. Please note that individual sites may score differently and Land of Lincoln Health reserves the right to contract with some sites and not others.

Thank you for your cooperation.

I. Demographics

A. Corporate Information

Corporation Name: Street Address (location):

City: State: Zip:

Phone: Fax: Website Address:

Contact Name Contact Name & Title:

Street Address:

City: State: Zip:

Phone: Fax:

Email:

Land of Lincoln Health is a trademark for Land of Lincoln Mutual Health Insurance Company

222 S. Riverside Plaza, Suite 1900 / Chicago, Illinois 60606 / 888.858.9130 / www.LandofLincolnHealth.org

B. Mailing Notice information

Corporation Name: Street Address (location):

City: State: Zip:

Phone: Fax:

Email address:

C. Credentialing Contact Name Contact Name & Title: Street Address:

City: State: Zip:

Phone: Fax:

Email:

Will your organization seek delegated credentialing? Yes No

Your organization will need to submit a separate delegated credentialing application and submit necessary paperwork for review by LLH Network Operations for review and potential approval. Is your organization NCQA certified for any areas? Yes No

If your organization is not NCQA Certified then an initial onsite visit will be required by LLH staff.

LLH has a roster format that must be submitted for loading upon approval of delegation and all requested data elements must be submitted for providers to be loaded and active in our network.

222 S. Riverside Plaza, Suite 1900 / Chicago, Illinois 60606 / 888.858.9130 / www.LandofLincolnHealth.org D. Main Service location (if additional locations please provide an exhibit with the following information D/E)

Facility Name:

Street Address (location):

City: State: Zip:

Phone: Fax:

Website Address:

NPI: TIN:

E. If centralized billing please provider billing Information below(Please attach copy of W9)

Remittance (Billing) Name:

Street Address:

City: State: Zip:

Phone: Fax:

Tax Identification Number (TIN):

Are all claims for this facility submitted under this one central TIN? Yes No

If No, Please list all tax identification numbers that apply on attached exhibit.

II. Billing Questions

1. Do you bill for all services rendered by your organization? Yes No

2. Can all claims billed under your Tax Identification Number(s) be processed Yes No under one agreement?

3. Does your organization provide any of the following ancillary services:

Radiology (Indicate which types) Therapy Services (PT/OT)

Laboratory Surgical Suite Services

If only billing for professional services indicate who bills for the Technical Services ______

III. Certification/Licensure/Accreditation Please attach copies of certification Medicare Certification American College of Radiology (ACR) Board of Certification/Accreditation (BOC) Joint Commission (JC) [for DME, Prosthetics, Orthotics and Suppliers] Community Health Accreditation College of American Pathologists (CAP) Accreditation Commission for Health Health Quality Association on Accreditation Care (ACHC) (HQAA) American Board of Certification in Other Orthotics and Prosthetics (“ABC”)

Ancillary Provider Types: Please supply additional information as needed Y N Are there any Ancillary Services in addition to Professional Services? Are there multiple locations for your organization? Do all entities bill under one Tax Identification Number? Is billing centralized for all services and providers? Are all Ancillary services accredited?

Only mark if your organization provides ancillary services- NOT ACCREDITED for Ancillary Services (please answer the following question) Has provider had an on-site survey by CMS or State agency?

If no, LLH may require successful completion of an onsite visit will be to complete credentialing. You will be contacted by LLH to schedule the visit. Non accredited 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 letter from government agency stating Facility is in substantial compliance with most recent survey standards. Facilities who 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.

IV. Risk Management A. Evidence of Insurance

222 S. Riverside Plaza, Suite 1900 / Chicago, Illinois 60606 / 888.858.9130 / www.LandofLincolnHealth.org Please provide evidence of your professional and general comprehensive liability insurance. This information must include the following information for each policy in effect:  Carrier

 Type of insurance

 Effective Dates

 Limits for professional per occurrence and aggregate (Required: $1 million/$3 million)

 Limits for general comprehensive per occurrence and aggregate (Required: $1 million/$3 million)

 Or State required minimum

B. Malpractice Matters, Settlements and Judgments

Has this organization had any final malpractice claims paid, settlements or Yes No judgments against it in excess of $50,000 within the past 3 years? If yes, please provide details as a separate enclosure. C. Actions and Sanctions Has the Organization received any final legal and/or governmental action(s) consummated against the facility, its directors, officers or employees, related to, Yes No among other things, fraud, recovery of claims, Medicare/Medicaid sanctions and/or state licensure? If yes, please provide details as a separate enclosure.

V. Services Provided (Check all that apply within the section that is appropriate to your facility)

A. Do you provide services nationally? Yes No

B. Home Health Care Services DME Home Nursing Orthotics/Prosthetics High Risk OB Care Infusion Therapy Respiratory Therapy C. Imaging Center Bone Densitometry MRI Radiology/Oncology CT Scan Mammography Ultrasound General X-Ray PET Scans

Other:

D. Laboratory Drawing Station Genetic Testing Laboratory Other:

E. Rehabilitation Group Cardiac Rehabilitation Occupational Therapy Physical Therapy Physical Therapy Speech Therapy F. Other Services

Free Standing Free Standing Birthing Dialysis Centers Walk In Care Clinic

Retail Clinic Sleep Center

G. Other:

VI. Miscellaneous Information (Any additional information or clarification of information provided in sections I – V above).

222 S. Riverside Plaza, Suite 1900 / Chicago, Illinois 60606 / 888.858.9130 / www.LandofLincolnHealth.org QUESTIONNAIRE (*Please answer all questions and provide explanation for affirmative answers.) Applications that do not include all requested responses and explanations will not be able to be processed.

1. Has the license to do business for Organization or covered entities in any applicable jurisdiction ever been denied, restricted, suspended, reduced or not renewed? Y N 2. Has the Organization or covered entities been denied participation, suspended from or denied renewal from Medicare or Medicaid? Y N 3. Has Organization or covered entities ever had its professional liability coverage cancelled but not renewed? Y N 4. Has the Organization or covered entities been denied accreditation by its selected accrediting body (e.g. TJC), or had its accreditation status reduced, suspended, revoked or in any way revised by the accrediting body? Y N N/A 5. Have there been or are there currently pending any malpractice claims, suits, settlements or proceedings involving your Facility or covered entities? Y N 6. Has the Organization or covered entities ever been disciplined, fined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Y N 7. Has the Organization or covered entities ever been subjected to sanctions by a Professional Review Organization (PSRO or PRO), a Third Party Payor, or a Regulatory Agency (CLIA, OSHA, etc.)? Y N 8. Has an officer of the Organization or covered entities ever been convicted of, pled guilty to, or pled “no lo contendere” to any felony including an act of violence, child abuse or a sexual offense? Y N 9. Has the corporation, an officer or a board member of the Facility or covered entities ever been convicted of a felony? Y N

ATTACHMENTS NEEDED Please include the following with your completed application: □ W-9 Form completed, signed and dated □ Copy of current State License/Approval (as applicable) □ Copy of Medicare/Medicaid Participation Certification (as applicable) □ Copy of Certifications and/or Accreditation Certificates (e.g. TJC, Medicare, etc.) □ Copy of CLIA certification (as applicable) □ Copy of Declaration Sheet and/or Certificate of Insurance: BOTH ARE REQUIRED and must name covered entities Current Professional Malpractice and Comprehensive General Liability Insurance Policies

STATEMENT OF APPLICATION/AUTHORIZATION FOR RELEASE OF INFORMATION

In order to evaluate this application for participation in and/or continued participation in the Plan, the Facility hereby gives permission to the Plan to request from other entities information regarding the Facility’s credentials and qualifications. This includes consent to contact the Facility’s accreditation agencies, State Regulatory and Licensing Departments, professional liability and workers compensation insurance carriers. The Facility understands that the Plan will use this information in a confidential manner on its own behalf and, if applicable, as an agent for one of its affiliated networks in connection with the administration of the Plan. The Facility certifies that the information provided and the answers to the questions on this application are accurate and complete. While this application is being evaluated, and if this Facility/Subcontractor is selected or retained, after such selection or retention, the Facility agrees to inform the Plan in writing within 15 days of any changes in the information provided and the answers to questions on the application as a result of developments subsequent to the execution of this application. The Facility agrees that submission of this application does not constitute selection or retention by the Plan on its own behalf or, if applicable, as an agent for one of its affiliated Plans and if the Facility is initially applying for participation, grants this Facility no rights or privileges in any Plan programs or any program or one of its affiliated Plans until such time as this Facility receives notice of selection. All information submitted in this application is true and complete to the best of my/our knowledge and belief. A photo copy of this original constitutes our written authorization and requests to release any and all documentation relevant to this application. Said photo copy shall have the same force and effect as the signed original.

222 S. Riverside Plaza, Suite 1900 / Chicago, Illinois 60606 / 888.858.9130 / www.LandofLincolnHealth.org Ancillary Application Attestation

TESTIMONIAL: I hereby submit this application for participation with Land of Lincoln Health, through the Land of Lincoln Health Network on behalf of the above named provider/facility and understand that this application will be reviewed based on the information I have provided herein. I hereby certify that the information contained in this form, including any and all enclosures and/or attachments submitted as part of this Request for Information, is accurate and complete, that this provider/facility, and its owners, are in full compliance with all applicable Federal and State laws, including but not limited to anti-self referral laws including Stark I and Stark II laws. Information found to be false could result in denial or subsequent termination of this provider’s/facility’s participation in the Land of Lincoln Health Network.

Signature of Individual Completing Application

Print Name and Title of Individual Completing Application Date

Signature of Network Contractor

Date: Name of Network Contractor Evaluating and Approving Application