FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION. Facility Name: Legal Name (if different from above):

Size: px
Start display at page:

Download "FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION. Facility Name: Legal Name (if different from above):"

Transcription

1 FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION Florida Blue Provider Number: Facility Name: Legal Name (if different from above): Facility Physical Address: City: State: Zip Code: County: Billing Address (if different from above): City: State: Zip Code: County: Chief Executive Officer or Administrator s Name: Facility Phone Number: Facility Fax Number: Credentialing Contact: Phone Number: Fax Number: Medicare Provider Number: Facility Tax I.D. Number: NPI Number: Medicaid Provider Number: Facility Address: OWNERSHIP INFORMATION Please check all that apply and provide copies Corporation For Profit Hospital Joint Venture Physician/Hospital owned 100% Physician Owned 100% Phys./RPT owned Not For Profit Sole Proprietorship Other 100% Hospital owned HOFF (Hospital owned free standing facility) 1

2 LICENSURE INFORMATION Please check all that apply and provide copies City/County Business Tax Receipt Dept. of Children and Family Services Exempt from Licensure (100% owned) Pharmacy Radioactive Material License State of Florida (AHCA) SERVICES Acute Care/Long Term Hospital Ambulatory Infusion Suite Birthing Center Comprehensive Outpatient Rehab Ctr. Crisis Stabilization Unit Federally Qualified Health Centers Home Health Agency Home Infusion / Injectable Supplier Hospice Independent Diagnostic Testing Facility Mobile Lithotripsy Orthotics /Prosthetics Physical Therapy Group Psychiatric Hospital / Unit Rural Health Center Sleep Center Substance Abuse Facility Urgent Care Center Ambulance Ambulatory Surgery Center Community Mental Health Center Convenient Care Center Dialysis Hearing Aid Center Home Infusion and Ambulatory Suite Home Medical Equipment Independent Clinical Laboratory Medical Supply Company Optical Company Outpatient Rehabilitation Facility Portable X Ray Residential Treatment Facility Skilled Nursing Facility / Unit Specialty Pharmacy 2

3 ACCREDITATIONS AND CERTIFICATIONS Please check all that apply and provide copies AAAHC AMERICAN ASSOCIATION FOR AMBULATORY HEALTH CARE ACHC ACCREDITATION COMMISION FOR HEALTH CARE ABCOP AMERICAN BOARD FOR CERTICATIONS IN ORTHOTICS, PROSTHETICS & PEDORTHICS ACR AMERICAN COLLEGE OF RADIOLOGY CARF COMMISION ON ACCREDITATION OF REHABILITATION FACILITIES CLIA CLINICAL LABORATORY IMPROVEMENT ACT COLA COUNCIL ON LABORATORY ACCREDITATION CAP COLLEGE OF AMERICAN PATHOLOGY CHAP COMMUNITY HEALTH ACCREDITATION PROGRAM FDA FOOD AND DRUG ADMINSTRATION REQUIRED: IF PERFORMING MAMMOGRAPHY SERVICES JCAHO NOW KNOWN AS THE JOINT COMMISSION CABC COMMISION FOR THE ACCREDITATION OF BIRTH CENTERS COA COUNCIL ON ACREDITATION HQAA HEALTHCARE QUALITY ASSOCIATION ON ACCREDITATION NBAOS NATIONAL BOARD OF ACCREDITATION FOR ORTHOTIC SUPPLIERS NIAHO NATIONAL INTERGRATED ACCREDITATION FOR HEALTHCARE ORGANIZATIONS AASM AMERICAN ACADEMY OF SLEEP MEDICINE BOCUSA BOARD OF CERTIFICATION / ACCREDITATION INTERNATIONAL MEDICARE CERTIFICATION if applicable BUREAU OF RADIATION CONTROL REGISTRATIONS (JR no.) if applicable IAC INTERSOCIETAL ACCREDITATION COMMISSION OTHER STATUS WITH REGULATORY AGENCIES 1. Has this facility s license and/or certification(s) ever been subject to any inquiries (including investigation or notice of intent to investigate) and/or any sanctions, suspensions, limitations or revoked by any state, federal or regulatory agency? Yes No If yes, please explain or provide an explanation: 3

4 2. Has this facility ever been subject to restrictions on receipt of payment from Medicare or Medicaid? Yes No If yes, please explain or provide an explanation: 3. Has this facility had within the past five years, or currently pending, any malpractice claims, suits, settlements or arbitration proceedings involving your facility? Yes No If yes, please explain or provide an explanation: LIABILITY COVERAGE Please provide copies of all with limits of liability, coverage amounts, effective and expiration dates. GENERAL LIABILITY CERTIFICATE OF INSURANCE COVERAGE: YES NO PROFESSIONAL LIABILITY CERTIFICATE OF INSURANCE COVERAGE: YES NO EMPLOYERS CERTIFICATE OF LIABILITY COVERAGE required for Ambulance: YES NO AUTOMOBILE CERTIFICATE OF LIABILITY COVERAGE required for Ambulance: YES NO 4

5 **For Independent Diagnostic Testing Facilities ONLY complete the section below before submitting** Physicians Supervisory Certification Statement I hereby acknowledge the fact that I agree to provide (insert IDTC name) physiological lab with general physician supervisory responsibilities in the areas of non invasive and diagnostic services. The supervisory responsibilities include, but may not be limited to, verifying periodically that equipment is functioning properly and produces the quality of results expected from similar equipment. The physician also assumes responsibility for following, on a continuous basis, those technicians performing non invasive and diagnostic testing and assisting them with any problems they encounter while providing such services. It also includes giving direction and recommendations to management on an ongoing basis regarding proper training or refresher training for those technicians performing the testing. Physicians Name (Please type or print) Physicians Signature Florida License Number Date If performing advanced imaging services, please check all that applies and provide supporting copies of accreditation: MRI CT PET NC (includes cone beam CT) 5

6 ATTACHMENTS 1. Current copy of General and Professional Liability coverage limits of liability, coverage and effective and expiration dates 2. Copy of State License if applicable 3. Copy of Occupational or Business Tax Receipt License if applicable 4. Current copy of Medicare Certification if applicable 5. Copy of Accreditation/Certifications if applicable 6. ACR/FDA Certificates/ Documentation of Tube Registrations 7. Copy of Medicare Participation Agreement if applicable 8. Copy of Medicaid Certificate if applicable 9. Copy of Facility s Medical Director or Director of Nursing CV applicable to Home Health 10. Copy of Medical License, Professional Liability and DEA applicable to Urgent Care Center 11. Copy of most recent AHCA and/or CMS Medicare Site Survey Report if applicable ATTESTATION I HEREBY CERTIFY that the preceding information is true and complete. I give my permission to Florida Blue and its affiliates to contact any and all persons or entities to verify these facts. I agree there shall be no liability on the part of, and no action for damages shall arise against, Florida Blue or its affiliates, its representatives, or any individuals or entities providing information in good faith related to the evaluation or verification of the information contained in this application. I also certify that I hold a full unrestricted license in the state in which this facility operates (if applicable), as well as, agree to maintain current malpractice coverage. I will immediately inform Florida Blue of any changes to the above information. I acknowledge and agree that any contract that may be entered into with Florida Blue and/or any affiliates based on this application may, at the option of Florida Blue, be deemed void and ineffective if any of the preceding information is not complete, true and correct. Signature of Facility Representative: Date: 6

Hospital/Facility Provider Application

Hospital/Facility Provider Application Hospital/Facility Provider Application Instructions: In order for the application to be considered complete: 1. All information must be legible. Please print or type all information. 2. A separate application

More information

PROFESSIONAL LIABILITY INSURANCE COVERAGE Do you have Professional Liability (Malpractice) Insurance coverage in force? Yes No

PROFESSIONAL LIABILITY INSURANCE COVERAGE Do you have Professional Liability (Malpractice) Insurance coverage in force? Yes No Aetna Better Health Credentialing Questionnaire Processing 2400 Veterns Memorial Blvd. Ste 200 Kenner, LA 70062 June, 2015 Name: Facility Name: Address 1: Address 2: PH: FAX: Organizational Provider s

More information

HEALTH CARE DELIVERY ORGANIZATION/ANCILLARY/LONG TERM CARE PROVIDER APPLICATION

HEALTH CARE DELIVERY ORGANIZATION/ANCILLARY/LONG TERM CARE PROVIDER APPLICATION HEALTH CARE DELIVERY ORGANIZATION/ANCILLARY/LONG TERM CARE PROVIDER APPLICATION Enclosures Please submit all applicable documents from the list below with your completed and signed application. Failure

More information

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must

More information

Type of Facility (As listed on License or Accreditation) Facility Demographics. Legal Business Name (as reported to the IRS):

Type of Facility (As listed on License or Accreditation) Facility Demographics. Legal Business Name (as reported to the IRS): Facility Credentialing and Recredentialing Application Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable. Attach additional sheets when necessary.

More information

MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY & ANCILLARY PROVIDER CREDENTIALING APPLICATION

MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY & ANCILLARY PROVIDER CREDENTIALING APPLICATION Facility Name: Dear Provider: MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY & ANCILLARY PROVIDER CREDENTIALING APPLICATION All facilities and ancillary providers must submit a completed Credentialing

More information

ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION

ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION Please complete each section thoroughly. Type or print clearly in black ink. Sign and date the application. YOU MUST INCLUDE THE FOLLOWING WITH THIS COMPLETED

More information

Section 5: Credentialing

Section 5: Credentialing Section 5: Credentialing PRACTITIONER CREDENTIALING CRITERIA...124 All Practitioners... 124 All Physicians... 125 Other Licensed Practitioners... 127 Unlicensed Practitioners... 127 Non-Credentialed Practitioners...

More information

Outpatient Medical Rehab Center. Facility Demographics Legal Business Name (as reported to the IRS): Federal Tax Identification Number:

Outpatient Medical Rehab Center. Facility Demographics Legal Business Name (as reported to the IRS): Federal Tax Identification Number: Facility Credentialing and Recredentialing Application Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable. Attach additional sheets when necessary.

More information

A. Clearly print or type information in each block. Complete each section entirely, indicate NOT APPLICABLE (N/A) where necessary.

A. Clearly print or type information in each block. Complete each section entirely, indicate NOT APPLICABLE (N/A) where necessary. Provider Application For use by Physicians and Independent Health Care Professionals BCBSF Provider Number: HCFA UPIN #: NPI #: PURPOSE: This Provider Application will be used for assigning a provider

More information

Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS

Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided

More information

4123-6-02.2 Provider access to the HPP - provider credentialing criteria.

4123-6-02.2 Provider access to the HPP - provider credentialing criteria. 4123-6-02.2 Provider access to the HPP - provider credentialing criteria. (A) The bureau shall establish minimum credentialing criteria for provider certification. Providers must meet all licensing, certification,

More information

CAMSS 42 nd Annual Education Forum

CAMSS 42 nd Annual Education Forum CAMSS 42 nd Annual Education Forum Speaker: Veronica Harris, QM Project Manager, Aetna. Inc. Date: Wednesday, May 29, 2013 Time: 1:45pm 3:15pm Managed Care Credentialing Complexities Topics: Locums and

More information

Molina Healthcare, Inc. Health Delivery Organization (HDO) Application

Molina Healthcare, Inc. Health Delivery Organization (HDO) Application INSTRUCTIONS: Complete all items as noted below and submit this application and attachments to your contracting representative in order to apply for credentialing with Molina Healthcare, Inc. (Molina Healthcare)

More information

FAOIP Enrollment Checklist An FAOIP is a Facility/Agency/Organization/Institution/Pharmacy. A FAOIP includes Hospitals, Nursing Facilities,

FAOIP Enrollment Checklist An FAOIP is a Facility/Agency/Organization/Institution/Pharmacy. A FAOIP includes Hospitals, Nursing Facilities, An FAOIP is a Facility/Agency/Organization/Institution/Pharmacy. A FAOIP includes Hospitals, Nursing Facilities, Laboratories, Pharmacies, etc., and have a Type 2 NPI number associated to them. The table

More information

CHAPTER 600 PROVIDER QUALIFICATIONS AND PROVIDER REQUIREMENTS 600 CHAPTER OVERVIEW... 600-1 610 AHCCCS PROVIDER QUALIFICATIONS...

CHAPTER 600 PROVIDER QUALIFICATIONS AND PROVIDER REQUIREMENTS 600 CHAPTER OVERVIEW... 600-1 610 AHCCCS PROVIDER QUALIFICATIONS... 600 CHAPTER OVERVIEW... 600-1 REFERENCES... 600-2 610 AHCCCS PROVIDER QUALIFICATIONS... 610-1 EXHIBIT 610-1 AHCCCS PROVIDER TYPES 620 AHCCCS FFS MINIMUM NETWORK REQUIREMENTS... 620-1 630 MEDICAL RECORD

More information

In addition to the completed application, we will need the following:

In addition to the completed application, we will need the following: Thank you for your interest in becoming a Consociate Care Network Provider. In addition to the completed application, we will need the following: Copy of CV Copy of medical license Copy of DEA license

More information

Facility Enrollment Required Document Checklist

Facility Enrollment Required Document Checklist Facility Enrollment Required Document Checklist Facility Classification Ambulatory Infusion Center (AIC) Ambulatory Surgical Facility (ASF) End Stage Renal Disease Facility (ESRD) - Accreditation Commission

More information

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST

HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST Enclosed you will find: A. HMSA Facility/Program Application form Please complete the application and include the requested documentation.

More information

ORGANIZATION/FACILITY CREDENTIALING/RECREDENTIALING APPLICATION

ORGANIZATION/FACILITY CREDENTIALING/RECREDENTIALING APPLICATION ORGANIZATION/FACILITY CREDENTIALING/RECREDENTIALING APPLICATION CURRENT COPIES OF DOCUMENTS TO BE SUPPLIED WITH COMPLETED APPLICATION INCLUDES: Current accreditation certificates Current State license

More information

Facility Classification

Facility Classification Facility Classification Facility Enrollment Required Document Checklist To avoid processing delays gather these items before you get started. If applying to network, complete the application signature

More information

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION GENERAL INFORMATION Primary Practice Facility Location The type of application being submitted: Initial Credentialing Re-Credentialing Hospital (Acute,

More information

Credentialing/Recredentialing

Credentialing/Recredentialing Credentialing/Recredentialing Section F-1 Credentialing Practitioner Credentialing Molina Healthcare of New Mexico, Inc. (Molina Healthcare) credentials practitioners/providers in accordance with internal

More information

Organization Profile and Credentialing Application

Organization Profile and Credentialing Application Organization Profile and Credentialing Application Initial Profile and Application Re-credentialing Application and Profile Review Mark all areas of the application NA for any item not applicable I. Certification,

More information

CareLink Network Provider Application

CareLink Network Provider Application COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE A CONTRACT WITH CARELINK NETWORK Instructions: Please complete one application for each organization and include unique service information for each site

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

$250 copay per admit. $250 copay per admit

$250 copay per admit. $250 copay per admit BENEFIT IN- NETWORK OUT- OF- NETWORK Deductible NONE NONE Out- of- Pocket Maximum $6,350 Single/ $12,700 Family NONE HOSPITAL INPATIENT FACILITY - NON MATERNITY Medical/Surgical Skilled Nursing Facility

More information

Anthem Credentialing Programs Standards

Anthem Credentialing Programs Standards Anthem Credentialing Programs Standards A. Eligibility Criteria Health Care Practitioners Initial applicants must meet the following criteria in order to be considered for participation: 1. Possess a current,

More information

2015 Health Benefits

2015 Health Benefits 2015 Health Benefits Product Cost Sharing - Member's Responsibility Health Care Reform Compliant Health Care Reform Compliant Health Care Reform Compliant Deductible (DED) (Per Person/Family Aggregate)

More information

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates Allied Health Staff Application Instructions We are pleased to provide you with our Allied Health Staff application packet. Please do not write see attached or see resume or CV on the application. All

More information

ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION

ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION Provider has the right to review information submitted to support credentialing, correct erroneous information, to be informed of application

More information

Summary of Services and Cost Shares

Summary of Services and Cost Shares Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

More information

HEALTH CARE FACILITY PROFESSIONAL/GENERAL LIABILITY INSURANCE APPLICATION (NON-GAP)

HEALTH CARE FACILITY PROFESSIONAL/GENERAL LIABILITY INSURANCE APPLICATION (NON-GAP) HEALTH CARE FACILITY PROFESSIONAL/GENERAL LIABILITY INSURANCE APPLICATION (NON-GAP) I. GENERAL INFORMATION A. Name and Address of Applicant: Phone Number: ( ) Federal Tax ID Number: Fax Number: ( ) B.

More information

HOME HEALTH CARE AND NON-PHYSICIAN MEDICAL STAFFING Professional and General Liability Insurance Application

HOME HEALTH CARE AND NON-PHYSICIAN MEDICAL STAFFING Professional and General Liability Insurance Application HOME HEALTH CARE AND NON-PHYSICIAN MEDICAL STAFFING Professional and General Liability Insurance Application This is an application (the Application ) for a Claims Made Insurance Policy. Please answer

More information

REHAB PROVIDER NETWORK Professional Staff Credentialing Form

REHAB PROVIDER NETWORK Professional Staff Credentialing Form REHAB PROVIDER NETWORK Professional Staff Credentialing Form ***** THERAPIST LICENSE MUST BE ATTACHED TO THIS FORM ***** The information requested on this form is required to certify your status as a licensed

More information

Optum/OptumHealth Behavioral Solutions of California 1 Facility Network Request Form/Credentialing Application INSTRUCTIONS

Optum/OptumHealth Behavioral Solutions of California 1 Facility Network Request Form/Credentialing Application INSTRUCTIONS Optum/OptumHealth Behavioral Solutions of California 1 Facility Network Request Form/Credentialing Application INSTRUCTIONS Read these instructions carefully. It is strongly recommended that an administrative

More information

1. Coverage Indicator Enter an "X" in the appropriate box.

1. Coverage Indicator Enter an X in the appropriate box. CMS 1500 Claim Form FIELD NAME INSTRUCTIONS 1. Coverage Indicator Enter an "X" in the appropriate box. 1a. Insured's ID Number Enter the patient's nine-digit Medical Assistance identification number (SSN).

More information

PENNSYLVANIA PROFESSIONAL LIABILITY JOINT UNDERWRITING ASSOCIATION

PENNSYLVANIA PROFESSIONAL LIABILITY JOINT UNDERWRITING ASSOCIATION PENNSYLVANIA PROFESSIONAL LIABILITY JOINT UNDERWRITING ASSOCIATION Hickory Pointe, Suite 125, 2250 Hickory Road, Plymouth Meeting, PA 19462 (610) 828-8890 - Fax: (610) 825-0688 - E-mail: Insurance@PAJUA.com

More information

Instructions for Completing the CMS 1500 Claim Form

Instructions for Completing the CMS 1500 Claim Form Instructions for Completing the CMS 1500 Claim Form The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. The form is used by Physicians and Allied

More information

ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312

ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312 ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312 INSTRUCTIONS: Please provide answers to all questions. If the answer is none, or

More information

Chapter 8 Billing on the CMS 1500 Claim Form

Chapter 8 Billing on the CMS 1500 Claim Form 8 Billing on the CMS 1500 Claim form INTRODUCTION The CMS 1500 claim form is used to bill for non-facility services, including professional services, freestanding surgery centers, transportation, durable

More information

STATE OF CONNECTICUT

STATE OF CONNECTICUT STATE OF CONNECTICUT DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES A Healthcare Service Agency DANNEL P. MALLOY GOVERNOR PATRICIA A. REHMER, MSN COMMISSIONER CONNECTICUT DEPARTMENT OF MENTAL HEALTH

More information

Facility Name: Street Address: City: County: State: Zip: Web Site Address: Office Manager Name: Phone and Ext: Email:

Facility Name: Street Address: City: County: State: Zip: Web Site Address: Office Manager Name: Phone and Ext: Email: FACILITY CREDENTIALING APPLICATION USI.V5.2009.02 FACILITY INFORMATION Please complete a separate application for each facility. Facility Name: Street Address: City: County: State: Zip: Phone: Fax: Federal

More information

Cost Sharing Definitions

Cost Sharing Definitions SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable

More information

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at

More information

Medicare Beneficiaries (QMB) Provider Enrollment Application

Medicare Beneficiaries (QMB) Provider Enrollment Application Iowa Department of Human Services Medicare Beneficiaries (QMB) Provider Enrollment Application Please copy and complete one for each individual professional and institutional category that is part of this

More information

Rehab Net of Arkansas. Provider Application

Rehab Net of Arkansas. Provider Application Rehab Net of Arkansas Provider Application Discipline P.T. O.T. S.L.P. (1) Business Name Physical Address FACILITY DATA Phone Fax (2) Billing Address Phone Fax (3) Mailing Address (4) Owner/Contact Person

More information

RADIOLOGY CREDENTIALING APPLICATION

RADIOLOGY CREDENTIALING APPLICATION RADIOLOGY CREDENTIALING APPLICATION CREDENTIALING CHECKLIST FACILITY INFORMATION Facility application completed in its entirety and signed/dated by Authorized signatory Copy of all current facility licenses/certifications

More information

PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant

PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant Prior to submitting this application it is required that you contact the Provider

More information

Tips for Completing the CMS-1500 Claim Form

Tips for Completing the CMS-1500 Claim Form Tips for Completing the CMS-1500 Claim Form Member Information (s 1-13) 1 Coverage Optional Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if

More information

PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. A Physician Owned Independent Practice Association Serving Central Florida

PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. A Physician Owned Independent Practice Association Serving Central Florida Place you r m essag e h ere. Fo r m axim um i mpact, use two or t hre e se ntenc es. PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. Heading A Physician Owned Independent Practice Association

More information

WRAPAROUND MILWAUKEE Policy & Procedure

WRAPAROUND MILWAUKEE Policy & Procedure WRAPAROUND MILWAUKEE Policy & Procedure Wraparound Wraparound-REACH FISS Project O-Yeah I. POLICY Date Issued: 11/15/07 Effective Date: 1/1/15 Reviewed: 10/20/14 By: WA Last Revision: 10/20/14 Subject:

More information

Provider Validation Information:

Provider Validation Information: Provider Validation Information: Health Care Providers with which we contract (e.g. your PCP or a hospital) submit to COMMUNITY HEALTH OPTIONS, the information contained in our Provider Directory. This

More information

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals The purpose of this document is to clarify who can provide which outpatient services to Iowa Plan Medicaid members.

More information

Healthcare Facility Application Hospital Renewal

Healthcare Facility Application Hospital Renewal Healthcare Facility Application Hospital Renewal PO Box 590009 Birmingham, AL 35259-0009 800.282.6242 Fax 205.868.4040 1. Introductory Information Expiring Policy No. Policyholder Name: City: County: State:

More information

Chapter 5. Billing on the CMS 1500 Claim Form

Chapter 5. Billing on the CMS 1500 Claim Form Chapter 5 Billing on the CMS 1500 Claim Form This Page Intentionally Left Blank Fee-For-Service Provider Manual April 2012 Billing on the UB-04 Claim Form Chapter: 5 Page: 5-2 INTRODUCTION The CMS 1500

More information

Licensed Counselors (LPCC)

Licensed Counselors (LPCC) CREDENTIALING Molina Healthcare of Ohio s credentialing process is designed to meet the standards of the National Committee for Quality Assurance (NCQA). In accordance with those standards, Molina Healthcare

More information

PHYSICIAN APPLICATION FOR EMPLOYMENT

PHYSICIAN APPLICATION FOR EMPLOYMENT PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Email Address Specialty/Sub-specialty

More information

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children This application is exclusively for prescribing practitioners

More information

GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT:

GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT: GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT: Page 1 of 7 WRITTEN BY: T. Deeghan, COO TECHNICAL REVIEW BY: T. Deeghan, S. Mason AUTHORIZED

More information

TYPE AND SPECIALTY LIST AND DOCUMENTATION REQUIREMENTS FOR PROVIDER PARTICIPATION AGREEMENTS

TYPE AND SPECIALTY LIST AND DOCUMENTATION REQUIREMENTS FOR PROVIDER PARTICIPATION AGREEMENTS New Mexico Medicaid Project 1720-A Randolph Road SE Albuquerque, NM 87106 505-246-9988 505-246-8485 (fax) TYPE AND SPECIALTY LIST AND DOCUMENTATION REQUIREMENTS FOR PROVIDER PARTICIPATION AGREEMENTS Please

More information

Online Directory Assistance

Online Directory Assistance P ROVI DR SCARE R Online Directory Assistance 1102 S Hillside Wichita KS 67211 Toll Free (800) 801-9772 Local (316) 683-4111 Fax (316) 683-6255 CustomerService@ProviDRsCare.Net Online Directory http://www.providrscare.net

More information

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009 LAKESHORE BEHAVIORAL HEALTH ALLIANCE Community Mental Health Services of Muskegon County Community Mental Health of Ottawa County Lakeshore Coordinating Council for Substance Abuse Services POLICY Prepared

More information

Los Rios Community College District KAISER PERMANENTE

Los Rios Community College District KAISER PERMANENTE Los Rios Community College District KAISER PERMANENTE GROUP # 602838: Early Retiree DHMO Plan (under age 65 or over 65 w/o Medicare A & B) Senior Advantage (age 65+ with Medicare A & B) In order to continue

More information

Ohio Medicaid Web Portal Enrolling Provider Checklists by Request Type

Ohio Medicaid Web Portal Enrolling Provider Checklists by Request Type Ohio Medicaid Web Portal Enrolling Provider Checklists by Request Type Ohio Department of Job and Family Services TABLE OF CONTENTS General Instructions...3 Provider Enrollment Application Checklist: Individual

More information

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals IOWA PLAN F BEHAVIAL HEALTH RE: Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals The purpose of this document is to clarify who can provide which outpatient services

More information

CMS 1500 (02/12) CLAIM FORM INSTRUCTIONS

CMS 1500 (02/12) CLAIM FORM INSTRUCTIONS CMS 1500 (02/12) CLAIM FORM INSTRUCTIONS FIELD NUMBER FIELD NAME 1 a INSURED S ID NUMBER INSTRUCTIONS Enter the patient s nine digit Medicaid identification number (SSN) 2 PATIENT S NAME Enter the recipient

More information

professional billing module

professional billing module professional billing module Professional CMS-1500 Billing Module Coding Requirements...2 Evaluation and Management Services...2 Diagnosis...2 Procedures...2 Basic Rules...3 Before You Begin...3 Modifiers...3

More information

MICHIGAN ASSOCIATION OF HEALTH PLANS Standard Practitioner Application

MICHIGAN ASSOCIATION OF HEALTH PLANS Standard Practitioner Application MICHIGAN ASSOCIATION OF HEALTH PLANS Standard Practitioner Application This document was developed by the Michigan Association of Health Plans (MAHP) to serve as a standard, single application for practitioner

More information

Regulatory Compliance Policy No. COMP-RCC 4.07 Title:

Regulatory Compliance Policy No. COMP-RCC 4.07 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.07 Page: 1 of 7 This policy applies to (1) any Hospital in which Tenet Healthcare Corporation or an affiliate owns a direct or indirect equity interest

More information

APPLICATION FOR ALLIED PROFESSIONAL STAFF

APPLICATION FOR ALLIED PROFESSIONAL STAFF Office of Medical Affairs 736 Irving Ave Syracuse NY 13210 Phone: 315-470-7646 APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal

More information

The Deductible is applicable to all covered services except for flat dollar Copayment services.

The Deductible is applicable to all covered services except for flat dollar Copayment services. PRIORITY HEALTH www.priorityhealth.com/mpsers PRIORITYHMO SM PLUS PLAN MICHIGAN PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM (MPSERS) Effective January 1, 2016 through December 31, 2016 The HMO Plus plan

More information

Credentialing Requirements for Physicians & Facilities

Credentialing Requirements for Physicians & Facilities Credentialing Requirements for Physicians & Facilities Thank you for attending! Welcome to Geisinger Health Plan s online learning center. We appreciate your time attending and welcome your feedback. After

More information

Mississippi Medicaid Enrollment Application (Ordering/Referring/Prescribing Provider)

Mississippi Medicaid Enrollment Application (Ordering/Referring/Prescribing Provider) This application is for the sole purpose of ordering/referring/prescribing items and services for MS Medicaid beneficiaries. This type of enrollment does not allow MS Medicaid to reimburse the applicant/provider

More information

NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security #

NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security # Page 1 NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION Last Name First Middle Place of Birth Social Security # Home Address City State Zip Office Address City State Zip DOB Emergency

More information

The first step to becoming BWC certified is to complete the Application for Provider Enrollment and Certification (MEDCO-13).

The first step to becoming BWC certified is to complete the Application for Provider Enrollment and Certification (MEDCO-13). Application for The first step to becoming BWC certified is to complete the Application for Provider Enrollment and Certification (). We review all applications to ensure eligible providers meet the minimum

More information

PART I - ALL APPLICANTS MUST COMPLETE. (City) (State) (Zip)

PART I - ALL APPLICANTS MUST COMPLETE. (City) (State) (Zip) APPLICATION FOR NURSING HOME, ASSISTED LIVING AND HEALTHCARE FACILITIES PROFESSIONAL AND GENERAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer all questions. If the answer

More information

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner orth Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner ote: Please send completed applications directly to the organizations with which you seek to contract.

More information

Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners

Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

HALFWAY HOUSE FACILITY APPLICATION FOR PARTICIPATION IN BCBSM S MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORK(S) GENERAL INFORMATION

HALFWAY HOUSE FACILITY APPLICATION FOR PARTICIPATION IN BCBSM S MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORK(S) GENERAL INFORMATION HALFWAY HOUSE FACILITY APPLICATION FOR PARTICIPATION IN BCBSM S MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORK(S) GENERAL INFORMATION I. BCBSM s Halfway House Facility Program for the State of

More information

Facility/Organizational Providers Approval Signatures: Available Upon Request

Facility/Organizational Providers Approval Signatures: Available Upon Request 12/04/2006, 7/2/2007, Page 1 of 20 I. Purpose: A. To ensure facility/organizational provider applicants meet ValueOptions of California (VOC) credentialing criteria. B. This policy replaces ValueOptions,

More information

APPENDIX C Description of CHIP Benefits

APPENDIX C Description of CHIP Benefits Inpatient General Acute and Inpatient Rehabilitation Hospital Unlimited. Includes: Hospital-provided physician services Semi-private room and board (or private if medically necessary as certified by attending)

More information

Legal Name of Applicant Website Tax ID Number

Legal Name of Applicant Website Tax ID Number 500 Virginia St. E. Ste 1200 Tel: 304.343.3000 Charleston, WV 25301 Toll-Free: 888.998.7642 P.O. Box 3697 Fax: 304.342.0985 Charleston, WV 25336-3697 www.wvmic.com Agency Address Producer Agent Information

More information

CHAPTER 7: UTILIZATION MANAGEMENT

CHAPTER 7: UTILIZATION MANAGEMENT OVERVIEW The Plan s Utilization Management (UM) program is collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current utilization

More information

(A) Information needed to identify and classify the hospital, include the following: (b) The hospital number assigned by the department;

(A) Information needed to identify and classify the hospital, include the following: (b) The hospital number assigned by the department; 3701-59-05 Hospital registration and reporting requirements. Every hospital, public or private, shall, by the first of March of each year, register with and report to the department of health the following

More information

Home Health Services Billing Manual

Home Health Services Billing Manual Home Health Services Billing Manual F245-424-000 (07-2015) Home Health Services Billing Instructions About Billing Instructions... 1 Where can you find help with L&I billing procedures?... 1 About Labor

More information

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey

More information

New Jersey Physician Recredentialing Application (Please type or print)

New Jersey Physician Recredentialing Application (Please type or print) New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1 Personal Information

More information

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first Network Providers Non Network Providers** DEDUCTIBLE (Per Calendar Year) None $250 per person $500 per family OUT-OF-POCKET MAXIMUM (When the out-of-pocket maximum is reached, benefits are paid at 100%

More information

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined

More information

CHAPTER 6: CREDENTIALING PROCEDURES

CHAPTER 6: CREDENTIALING PROCEDURES We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider

More information

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20 PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA2000-20 Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when

More information

Last Name First Middle

Last Name First Middle P.O. Box 327 Seattle, WA 98111-0327 DENTAL PROVIDER CREDENTIALING APPLICATION This application is not a contract. The information provided in this application is used to determine whether a practitioner

More information

PROVIDER APPLICATION

PROVIDER APPLICATION COMMUNITY MENTAL HEALTH AFFILIATION OF MID-MICHIGAN PROVIDER APPLICATION Thank you for your interest in becoming a provider of the Community Mental Health Affiliation of Mid-Michigan (CMHAMM) provider

More information

How Premier Members access the Verizon Member Agreement from the Premier website.

How Premier Members access the Verizon Member Agreement from the Premier website. How Premier Members access the Verizon Member Agreement from the Premier website. These instructions are designed to connect your organization to the Verizon Wireless Agreement via the Premier Inc website

More information

Office Printed copies are for reference only. Please refer to the electronic copy for the latest version.

Office Printed copies are for reference only. Please refer to the electronic copy for the latest version. Document Owner: Teresa Onken PI Team: Created: 01/01/1992 N/A Approver(s): Karyn Delgado, Teresa Onken Approved: 12/28/2012 06/01/2011 Location: Saint Joseph Regional Medical Center-Mishawaka POLICY: Department:

More information

EXCESS CASUALTY HOSPITAL SURVEY - MISSOURI

EXCESS CASUALTY HOSPITAL SURVEY - MISSOURI EXCESS CASUALTY HOSPITAL SURVEY - MISSOURI 1. Legal name and address of hospital: 2. List all affiliates and subsidiaries to which this insurance is to apply. Include a complete description of the operations

More information