Provider Agency Credentialing

Sandhills Center for MH, DD & SASProvider Agency Credentialing Application to the Sandhills Center NetworkIPRS Services This application is to be completed by provider’s seeking approval to deliver service(s) that are ONLY IPRS reimbursable and not eligible for alternative funding Please submit application to: Credentialing & Contracting Specialist Sandhills Center for MH, DD & SAS P O B o x 9 West End, NC 27376INSTRUCTIONS12/13/11 Provider Agency Credentialing Application (IPRS) 1 A prospective provider agency/facility must apply for and be credentialed with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center enrollees/members. The credentialing process includes: submission of an application, verification of credentials, review of any adverse actions or sanction activity, on-site review, and review of qualifications and current competency. Additionally, agencies must have a signed contract with Sandhills Center to qualify for IPRS funding and reimbursement of services provided to Sandhills Center enrollees/members. NOTE: If the agency/facility has Licensed Independent Practitioners (LIP’s) or Provisional Licensed Practitioners (PLP’s) it is the responsibility of the agency/facility to ensure that each Practitioner completes and submits the “IPRS Uniform Application to Participate as a Health Care Practitioner”. Upon Sandhills Center receipt the Practitioner can begin serving members. Upon approval of the Practitioner’s credentialing status by the Sandhills Credentialing Committee and/or Chief Clinical Officer/Medical Director the agency/facility can submit claims for services provided by the LIP or PLP back to the date of application submission. A. This application must be completed in its entirety, with all questions addressed and required information submitted. An application is considered to be invalid and will be returned to the provider for correction and/or for additional information if: The version date on any of the documents that comprise the provider application packet is prior to 12/13/2011.  All spaces in the application have not been completed. (Please indicate "N/A" or "None" if the question is not applicable).  The “Attestation Statement” Signature is not original.  The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.  The responses are illegible.  Any of the documents or pages that comprise the “Provider Agency/facility Credentialing and Service Application” are missing.  Any of the requested information in any of the documents that comprise the “Provider Agency/facility Credentialing and Service Application” are missing, with the exception of the fax number and e-mail address.B. Sandhills Center shall notify the prospective provider within ten (10) business days of receipt of the completed application or if materials are missing. An application and materials will be returned if incomplete. Sandhills Center Provider Agency/Facility Credentialing and Service Application 12/13/11 Provider Agency Credentialing Application (IPRS) 2Date Submitted: Please complete the application in full. Please TYPE OR PRINT all responses. Note: The submission of this information does not guarantee the execution of a service agreement with Sandhills Center.A. Organizational Information1. Legal Name of Organization:2. Type of Organization: For Profit Not for Profit 3. Primary Mailing Address and County (Administrative) Office: County: 4. Billing Address (if different from Primary Mailing Address):County: 5. Federal Tax ID #: 6. National Provider Indicator (NPI) #: 7. Primary Contact Person for Organization: Name: Title: Office Phone #: Fax #: E-Mail Address: Emergency contact information: Phone#: Pager # (if applicable): Website Address: 8. Specialties/Areas of Clinical Expertise:9. List any special accommodations that your agency/facility provides:Example: interpretation for members with hearing impairments12/13/11 Provider Agency Credentialing Application (IPRS) 310. List other languages that your agency/facility can accommodate for members who speak a language other than English:Has your agency/facility conducted business under another name in the last 5 years? Yes No If yes, please include the legal name below and specify the circumstances that led to the name change (attach additional page if necessary).11. Please submit the NC Department of The Secretary of State Articles of Organization or Articles of Incorporation.12. Insurance Information: Submit an original “Certificate of Liability Insurance” demonstrating proof of compliance with insurance requirements. The following requirements are reflected in the Sandhills Center Service Agreement document. Provider shall have: a. Comprehensive General Liability: Bodily Injury and Property Damage Liability Insurance shall protect the CONTRACTOR and any employee performing work under the Contract from claims of Bodily Injury or Property Damage, which may arise from operations under the Contract. The amounts of such insurance shall not be less than $1,000,000.00 per Occurrence/$3,000,000.00 per Aggregate/$1,000,000.00 Personal and Advertising Injury/$50,000.00 Fire Damage. The insurance shall not include exclusion for contractual liability. b. Professional Liability: The CONTRACTOR shall purchase and maintain professional liability insurance protecting the CONTRACTOR and any employee performing work under the Contract for an amount of not less than $1,000,000.00 per occurrence and proof of coverage at or exceeding $3,000,000.00 in the annual aggregate. In the event that the CONTRACTOR discovers that a claim, suit of criminal/administrative proceeding has been brought or may be brought against the CONTRACTOR and/or Practitioner relating to the quality of services provided under this Agreement, then CONTRACTOR shall notify LME within ten (10) days and LME will determine whether to terminate this Agreement. c. Automobile Liability: Automobile Bodily Injury and Property Damage Liability Insurance covering all owned, non-owned, and hired automobiles for limits of not less than $1,000,000.00 each person and $1,000,000.00 each occurrence of Bodily Injury Liability and $1,000,000.00 each occurrence of Property Damage Liability. Policies written on a combined single limit basis should have a limit of not less than $1,000,000.00. d. Worker’s Compensation and Occupational Disease Insurance: Insurance Coverage must meet the statutory requirements of the State of North Carolina; and Employer’s Liability Insurance for an amount of not less than: Bodily Injury by Accident $100,000.00 each Accident, Bodily Injury by Disease $100,000.00 each Employee, and Bodily Injury by Disease $500,000.00 Policy Limit.12/13/11 Provider Agency Credentialing Application (IPRS) 4 e. Certificates of Insurance: The CONTRACTOR shall provide the LME with Certificates of Insurance Coverage consistent with the Contract within thirty (30) days following the effective date of the Contract and on an annual basis within ten (10) days of the anniversary date of the Contract, and shall provide a new Certificate within ten (10) days of the expiration date if the Insurance Certificate expires during the contract period. Certificates shall contain the provision that the LME is given thirty (30) days written notice of any intent to amend or terminate by either the CONTRACTOR or the insurance company. The CONTRACTOR shall notify the LME of any cancellation or material change, within forty-eight (48) hours, and within ten (10) days of any change in insurance provider during the period of the Contract. If the CONTRACTOR changes insurance providers during the performance period of the Contract, the CONTRACTOR shall provide evidence to the LME that the LME will be indemnified to the limits specified above for the entire performance period of the Contract, either under the policy or a combination of old and new policies. f. Tail Coverage: Liability insurance may be on either an occurrence basis or on a claims-made basis. If the policy is on a claims-made basis, an extended reporting endorsement (tail coverage) for a period of not less than three (3) years after the end of the contract term, or an agreement to continue liability coverage with a retroactive date on or before the beginning of the contract term, shall also be provided. g. Waivers of Subrogation: CONTRACTOR shall obtain and provide to LME waivers from CONTRACTOR’S workers compensation and occupational disease and commercial general liability carriers of any right of recovery that such liability carriers may have because of payments made by them for injury or damage arising out of work done by CONTRACTOR under this Contract, including contract documents issued under this Contract such as an LME Service Authorization Request Form. 12/13/11 Provider Agency Credentialing Application (IPRS) 5 Article I. Facility/Site InformationIf your organization operates more than one facility/site, copy and complete this section for each. Please attach the facility/site license if applicable. 1. Facility/site name:2. Facility/site Address:City: State: Zip: County: 3. National Provider Indicator (NPI) # (If different from Section A) 4. License Type: License # Expiration Date: *Submit facility license (if applicable)Site contact person: Phone: E-mail (if applicable): 5. Is this service location handicapped accessible? Yes No 6. Hours of operationMONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAYIf outpatient therapy is to be delivered at this site location please specify the available number of service hours per month 7. Is this facility/site staffed and equipped to serve:Physically Handicapped? Yes No Deaf & Hearing Impaired? Yes No Blind/Visually Impaired? Yes No Behaviorally Disruptive? Yes No Sexually Aggressive? Yes No Foreign Languages? Yes No (Specify) 12/13/11 Provider Agency Credentialing Application (IPRS) 6 C. Professional Liability Claims History and Disciplinary ActionsFor the following questions, if the response is yes, please explain in an attachment, including disposition and dates:YES NO Have you ever had a claim against you? Are there any current, unsettled claims? Have you ever had an insurance policy cancelled? Has there ever been any action or investigation against you or any owner or qualified professional in your agency/facility relating to: License? Certification? Registration? Privileges? Billing Practices? Have you or any owners ever been convicted of a crime including but not limited to crimes involving children, fraud or narcotics other than minor traffic violations? Have any adverse actions been filed against you by: Medicaid? Medicare? Other Insurance? Have you or has anyone in your company who has an ownership, managerial or clinical role ever been sanctioned by any professional organization or government agency/facility? Have you ever had a contract cancelled by another area authority/local management entity in North Carolina or similar entity in another state? Do you or anyone in your agency/facility now or have ever had any physical, mental, or substance abuse condition that could/has, without reasonable accommodation, impeded the ability to provide care according to accepted standards of professional performance or posed a threat to the health or safety of members12/13/11 Provider Agency Credentialing Application (IPRS) 7 4/3/2018 Provider Agency Credentialing Application (IPRS) 8 Attestation Statement (IMPORTANT: Submit Original Only) This Application is to be signed by the individual who has authorization to submit an application on behalf of this agency/facility.No Stamps or Copies PleaseI certify that I am authorized to sign this application and the information I have provided is complete and accurate to my knowledge. I understand that any misstatement in this application may constitute grounds for denial of the application or termination of a resulting participating agreement.In making this application for membership or reappointment in the Sandhills Center Provider Network, I acknowledge that I have read and agree to comply with the Sandhills Center contract requirements, Trading Partner Agreement, credentialing criteria and am familiar with the standards and ethics of the national, state, and local associations that apply to and govern the organization and the clinical professions within. I agree to be bound by the terms thereof if the agency/facility is granted provider status, and I further agree to be bound by the terms thereof in all matters relating to the consideration of this application for membership in the provider network.By application for membership or reappointment in the Sandhills Center Provider Network, I signify my willingness to appear for an interview in regard to my application. I authorize Sandhills Center to consult with administrators and members of the agencies, corporations or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my clinical practice, I further authorize Sandhills Center to collect any information necessary to verify the information in the credentialing application.I understand and agree that I, as representative of this agency/facility, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I also hereby release from liability any and all individuals and organizations who provide information to Sandhills Center or its staff in good faith and without malicious intent concerning my competence, ethics, character, and other qualifications for membership in the Provider Network, and I hereby consent to the release of such information.I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center may report the rejection to the appropriate state licensing board.In the event that I am accepted for participation in the Sandhills Center provider network, I consent to Sandhills Center for inspection of member records relating to Sandhills Center members as necessary for its peer and utilization review purposes as permitted by state or federal law and regulation. I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application.Name of Agency/facilityName of Authorized Representative (print) ______Signature of Authorized RepresentativeDate4/3/2018 Provider Agency Credentialing Application (IPRS) 9 Sandhills Center IPRS Service List for Credentialing Applications Service Provision1. Enrollee/Member Age/Disability/Gender Check () all populations served: Age and Disabilities Served (Check (√) all that apply) Child/Adolescent Adult Gender(s) Served Mental Health (MH) Substance Abuse (SA) Male Developmental Disabilities (DD) Female2. Services to be delivered (Please indicate with a  all services you are seeking approval to provide) Sandhills Center is not currently expanding IPRS contracts at this time. Complete this section ONLY if you are an existing IPRS contract provider in the Sandhills Network of providers and wish to continue to deliver IPRS funded services. Check ( ) only the services you have a contract with Sandhills Center to deliverPlace a  for all counties to be served y r d h eEnrollee/Membe Accepting t n t p e n l e m r o e o e o k o √ r Capacity New o n s e m d o g r 1. Periodic o n L t h n a (total # for all Patients H cServices A n M a i H o R counties served) (Y/N) R M a) Assertive Engagement b) Developmental Therapy Emergency Services/Assessments (ED c) Physicians only) d) Geriatric Specialty Team e) Hospital Transition Team f) Inpatient Psychiatric Physician Services g) Jail Diversion 12/13/11 Provider Agency Credentialing Application (IPRS) 10 IPRS Service List for Agency Credentialing Applications (continued)Place a  for all counties to be served y r d h eEnrollee/Member Accepting t n t p e n l e m r o e o e o k o √ Capacity New o n s e m d o g r 1. Periodic o n L t h n a (total # for all Patients H cServices A n M a i H o R counties served) (Y/N) R M a) Personal Assistance b) Respite - Community c) Respite - Hourly d) Substance Abuse Primary Prevention Services e) Other (please specify) Place a  for all counties to be served y r d h eEnrollee/Membe Accepting t n t p e n l e m r o e o e o k o √ r Capacity New o n s e m d o g r 2. Day/Night o n L t h n a (total # for all Patients H cServices A n M a i H o R counties served) (Y/N) R MAdult Developmental and Vocational Program a) (ADVP) b) Developmental Day c) Supported Employment d) Other (please specify) √ Accepting New 3. Residential/24 hour Services Patients (Y/N) a) Facility Based Crisis Program b) Family Living c) Group Living - Low 4/3/2018 Provider Agency Credentialing Application (IPRS) 11 d) Group Living - Moderate IPRS Service List for Agency Credentialing Applications (continued) e) Group Living - High f) Social Setting Detox g) Substance Abuse Halfway House h) Supervised Living I - VI ) Other (please specify) 4/3/2018 Provider Agency Credentialing Application (IPRS) 12 PROVIDER AGENCY CREDENTIALING APPLICATION (IPRS) CHECKLIST Not Attached Applicable Service code list (IPRS Service list for Agency Credentialing Applications) Signed and dated attestation Copy of National Provider Identifier (NPI) Certification Letter for each site Copy of Articles of Incorporation Explanations for confirmation of adverse actions in Section C Facility Licensure for each site Certificate of liability insurance Required documentation per service requested IRS documentation indicating that there are No unresolved tax or payroll liabilities12/13/11 Provider Agency Credentialing Application (IPRS) 13

Provider Agency Credentialing

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