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

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1 Facility Name: Dear Provider: MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY & ANCILLARY PROVIDER CREDENTIALING APPLICATION All facilities and ancillary providers must submit a completed Credentialing Application that includes all documentation listed below before the credentialing process can begin. Note: Additional documents may be requested throughout the processing of your application as needed. NOTE: A separate application is required for each facility or location if separately licensed or separately accredited. Please ensure that the following items are included with your application upon submission: Demographic data for each location (complete page 2 of this application for each service location). Copy of current license to operate. Copy of original CMS designation letter from Medicare is preferred, or a copy of Medicare Certificate Copy of W-9 Signed Attestation (see page 9 of this application) Current copy of accreditation letter and/or certificate If not accredited, please provide the following: 1. a copy of current State site visit or 2. a copy of most recent Department of Health & Human site visit and any findings/correction Action Plan Acceptance Copy of current certificate of general/professional malpractice insurance policy showing limits, policy number and expiration date and other applicable insurance (i.e., auto excess liability insurance). Proof of Worker s Compensation or Employer Liability Insurance (i.e., Texas Occupational Injury Assistance Pan). An explanation of any malpractice actions/claims for the last five years. An explanation of malpractice settlements for the last five years. Staff roster that includes job function and credentials (space provided on page 5). List of Insurance Carriers/Networks with whom provider is affiliated (space provided on page 5). A copy of Quality Assurance/Quality Improvement Plan Copy of current patient transfer policy and a list of facilities or other providers with which you have transfer agreements. Table of Contents for HIPAA Policies and Procedures Copy of Notice of Privacy Practices and Acknowledgement Form provided to patients If you are a member of NDMS, please provide documentation. Master list of policies and procedures (Table of Contents) that includes both administrative and clinical policies and procedures. Please forward the completed application and above documents to the following address: Memorial Hermann Health Solutions, Inc. 929 Gessner, Suite 1500 Houston, TX Attn: Provider Relations Department Please understand that an application is not a guarantee of participation. You will be notified once the credentialing process has been completed. 1

2 MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY/ANCILLARY PROVIDER CREDENTIALING APPLICATION (Duplicate this page and complete for each location) Please type or print legibly I. Facility/Ancillary Provider Name Legal Business Name: DBA if applicable: Tax Identification Number: State License Number: Issuing State: Expiration Date: Medicare Certified? Yes No National Provider Identifier (NPI): Medicare Number: II. Type of Facility/ Ancillary Provider (Check applicable box) 1. Ambulatory Surgical Center [261QA1903X] 5. Durable Medical Equipment/ Supplies [332B00000X] 9. Home Infusion 13. Occupational Therapy 2. Clinical Medical Lab [219U00000X] 6. General Acute Care Hospital [282N00000X] 10. Hospice [315D00000X] 14. Physical Therapy Center [261QP2000X] 3. Diagnostic Radiology 4. Dialysis 7. Hearing and Speech Clinic [261QH0700X] 11. Long Term Care Hospital [282E00000X] 15. Physical Therapy [261QP2000X] 8. Home Health Agency [251E00000X] 12. Magnetic Resonance Imaging [261QM1200X] 16. Radiology, Mammography [261QR0206X] 17. Rehabilitation Clinic [261QR0400X] 18. Rehabilitation Hospital [283X00000X] 19. Rural Health Clinic [261QR1300X] 20. Skilled Nursing Facility [ X] 21. Sleep Lab 22. Substance Abuse Rehabilitation Facility [ X] 23. Urgent Care Center [261QU0200X] 24. Hospital (specify type): 25. Other (Please specify): 26. Taxonomy Code: III. Service Location Information IV. Billing Information 1. Contact Name: 2. Contact Name 3. Street, Suite: 4. Street, Suite: 5. City, State, ZIP: 6. City, State, ZIP: 7. Main Telephone Number: 8. Billing Telephone Number: 9. Fax Number: 10. Fax Number: 11. Address: 12. Address: 13. Hours of Operation: V. Other Information 1. Chief Administrator (Name & Title): Qualifications: (certifications/designations, etc.) 4. Telephone Number: 2. Contracting Contact Person (Name & Title): Qualifications: (certifications/designations, etc.) 5. Telephone Number: 3. Medical Director (Name & Specialty): Qualifications: (certifications/designations, etc.) 6. Telephone Number: 2

3 MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY/ANCILLARY CREDENTIALING APPLICATION Please answer the questions pertaining to the last three years. If the answer is yes to any question, please provide details on a separate sheet of paper. VI. Licensure 1. Has the facility s license been suspended, revoked, made subject to probationary conditions or otherwise adversely affected by any accrediting or regulatory agency? Yes No Have there been any Medicare/Medicaid sanctions in the last Three (3) years? Yes No 3. Does your organization have any current State or Federal sanctions or limitations? Yes No VII. Malpractice Insurance/Claims 1. Has the facility had any pending/open malpractice claims? Yes No 2. Has the facility had any settled malpractice claims within the past 10 years? Yes No 3. Has the facility had any closed malpractice claims for the past 10 years? Yes No 1. Has the facility ever been denied professional liability insurance? Yes No 2. Has the facility s professional liability insurance been canceled or denied renewal? Yes No 3. Has the facility been party to a malpractice settlement in the last five years? Yes No If yes, please provide an explanation for the last five years. 4. Does the facility have insurance coverage other than Professional/ General Liability (ex: auto liability insurance and/or Worker s Compensation)? Yes No If yes, please attach a copy of declaration page. 5. Have you had any malpractice actions/claims within the past 5 years exceeding $1,000,000 (Amount includes deductible and amount paid by insurance)? Yes No Please attach an explanation of any malpractice actions/claims for the last five years. VIII. Accreditation 1. Is your facility accredited? Yes No Accrediting Agency Date Last Accredited If not accredited, please provide information indicated on cover page of application. 2. Has the facility ever applied for and been denied accreditation by any accrediting organization? Yes No 3. Does the facility intend to renew accreditation upon expiration? Yes No 4. Are there any contingencies for significant recommendation(s) from your last survey? Yes No IX. Quality/Utilization Review 1. Are the credentials/certifications of professional staff members and admitting physicians verified? Yes No If yes, how frequently? 2. Is continuing education or re-certification required of your staff? Yes No 3 Is a criminal background check conducted on all professional staff prior to employment? Yes No Please list the name of the agency used to conduct background checks: 4. Is there a formal patient grievance/resolution procedure in place? Yes No 5. Is there a formal patient satisfaction or patient advocacy program? Yes No 3

4 6. Does the facility have a written quality assurance/quality improvement (QA/QI) plan? Yes No If yes, please provide a copy. 7. Is there a QA/QI Committee? Yes No If yes, how frequently does the QA/QI Committee meet? 8. Is there a Utilization Review Committee? Yes No If yes, how frequently does the Committee meet? X. Additional Information 1. Has the facility ever been denied membership or renewal or been reprimanded, censured, suspended, terminated, placed on probation or otherwise sanctioned, by any healthcare organization, including but not limited to hospitals, community health facilities, other healthcare facilities, HMOs, PPOs, professional associations or peer review organizations? 2. How many licensed beds does the facility have? Type of beds: Yes No Not applicable: 3. Can services be performed on a STAT basis within 2 Hours? Yes No 4. What is the normal wait time to schedule a Non Emergency appointment? 5. What is the normal turnaround time for reporting Diagnostic testing results? Not applicable: 6. Is the facility a NDMS member? Yes No If yes, at what level? *Please provide documentation with this application of your NDMS membership. XI. Licensure and Insurance Renewal Please provide a contact within your organization who can be contacted by the health plan when current copies of licenses and insurance need to be obtained. Contact Name: Phone Number: Address: Ownership Contact Title: Fax Number: Circle One: Sole Proprietorship Limited Partnership Corporation Other (please specify) Provider Relationships If the answers to the questions in this section are the same for all locations, indicate below and complete this section for one location only. 1. Please list all individuals or entities that own any portion of this organization along with their percentage of ownership. Name Share Name Share 1. Are any of the key owners listed above a local physician, immediate family member of a local physician, or a physician group that refers patients to this site? If yes, indicate which physicians by listing the number from the previous question. 2. Is there any special monetary bonus or penalty for any owner that depends on the volume of patients or tests that the owner refers to the facility? 4

5 Staff Roster Please list in section below or provide an attachment. Job Titles Credentials 1. Are any of your employees a local physician, immediate family member of a local physician, or a physician group that refers patients to this site? If yes, please list those employee(s) below: 2. Is there any special monetary bonus or penalty for any employee that depends on the volume of patients or tests that the employee refers to the facility? Contracted Insurance Plans Please list below the insurance plans/networks that the facility is currently contracted with. 5

6 MEMORIAL HERMANN HEALTH SOLUTIONS, INC. FACILITY/ ANCILLARY PROVIDER CREDENTIALING APPLICATION SCOPE of SERVICES [COMPLETE FOR FACILITIES ONLY] Facilities include, but are not limited to the following providers: Acute Care Facilities, Inpatient Rehabilitation, Skilled Nursing Facilities, Outpatient Surgical Centers (Ambulatory Surgical Centers) and Home Health Agencies. Please indicate the services that the facility provide, and also indicate whether the services are contracted out. Service Medical Intensive Care Renal Dialysis Coronary Intensive Care Burn Intensive Care Surgical Intensive Care of Intensivist or Full Time Director of Intensive Care Neuro Intensive Care Pediatric Intensive Care Newborn Intensive Care Neonatal Intensive Care Isolation Intensive Care Pulmonary Intensive Care Communicable Disease Isolation Care Protective Isolation Care Definitive Observational Care Telemetry Care Newborn Nursery Care Premature Nursery Care Post-Partum Care Intermediate Care Rehabilitation Care Medical Acute Care Surgical Acute Care Neonatal Acute Care Pediatric Acute Care Hospice General Surgery OR Dental Surgery Podiatry Surgery Urologic Surgery Lithotripsy Otolaryngologic Surgery Plastic Surgery Surgical Day Care (One Day) Gynecologic Surgery Open Heart Surgery Heart Cath/Sterile Room Cystoscopy Service Endoscopy Service Neurologic Surgery Ophthalmologic Surgery Orthopedic Surgery 24 Hr. OB Anesthesia Oncology Delivery Room Provided by Facility Contracted Out Service Alternative Birth Center Abortion Hematologic Anatomic Pathology Clinical Laboratory Pulmonary Laboratory Ostomy Organ Bank Blood Bank Electroencephalography Electrocardiography Electromyography X-ray Examination Cobalt Therapy Radium Therapy Diagnostic Radioisotope Therapeutic Radioisotope Computerized Axial Tomography Full Body Partial Magnetic Resonance Imaging (MRI or NMR) Pharmacy w/ FT Registered Pharmacist Clinical Pharmacologic Physical Therapy Occupational Therapy Rehabilitation Therapy Cardiac Rehabilitation I.V. Therapy Total Parenteral Nutrition Inhalation Therapy Blood Collection and Processing Interpretive Cardiology Interpretive Neurology Interpretive Radiology Interpretive Pathology Provided by Facility Contracted Out 6

7 MEMORIAL HERMANN HEALTH SOLUTIONS, INC.FACILITY/ANCILLARY PROVIDER CREDENTIALING APPLICATION SCOPE of SERVICES [COMPLETE FOR ANCILLARY PROVIDERS ONLY] Ancillary providers are considered to be those applicants not listed on Page 6. Please indicate the services that are available at your facility, and indicate whether the services are contracted out. Service Ambulatory Surgery Ophthalmologic Surgery Orthopedic Surgery General Surgery Dental Surgery Podiatric Surgery Otolaryngologic Surgery Plastic Surgery Gynecologic Surgery Urologic Surgery Cystoscopy Service Endoscopy Service Home Health RN Home Health LVN Home Health Nurses Aid Home Health Physical Therapy Home Health Occupational Therapy Home Health Speech Therapy Home Health Medical Service Worker Total Parenteral Nutrition Home Infusion Antibiotic Therapy Home Infusion Hydration Home Infusion Enteral Therapy Home Infusion T PN Home Infusion Cath Care Home Infusion Chemotherapy Home Infusion IVIG Renal Dialysis Radiology X-ray Magnetic Resonance Imaging Open MRI Computerized Axial Tomography Partial Body Full Body Positron Emissions Tomography Electrocardiography Electromyography Provided by Facility Contracted Out Service Electroencephalography Anatomic Pathology Clinical Laboratory Pulmonary Laboratory Ostomy Supplies Orthodics and Prosthetics Durable Medical Equipment Inpatient Hospice Home Hospice Physical Therapy Occupational Therapy Rehabilitation Therapy Speech Therapy Inhalation Therapy Alternative Birthing Center Cardiac Rehabilitation Urgent Care Check If Provided by Facility Check If Contracted Out Please list what services are included in urgent care: 7

8 Memorial Hermann Health Solutions, Inc. Credentialing Components Grid For mail order only providers, the diamond ( ) indicates you must be licensed in the state of operation. Facility/ Provider Type *Licensure *Certification Accreditations TJC, HFAP, NIAHO Acute Care Hospital TJC, HFAP, AAAHC, IMQ Ambulatory Surgery Center TJC, AAAHC, CABC Birthing Center TJC, AAAHC Cardiovascular Care Center Dialysis Durable Medical Equipment Home Health Home Infusion Hospice Inpatient Rehab Facility Laboratory Long Term Acute Care and CLIA accredited TJC and AOA TJC, CLIA, COLA, CAP TJC Optical shops, Hearing Aids, other supplies Orthotics and Prosthetics Physical/ Occupational/ Speech Therapy (freestanding, outpatient) Radiation Therapy Center Radiology (freestanding, outpatient) Skilled Nursing Facilities and ACR CARF ACR, AAAHC ACR, AAAHC TJC Sleep Lab AAAHC, CLIA, ACR Urgent Care 8

9 Attestation Authorization and Release All information provided on this application or in connection with this application is complete and correct to the best of the facility s knowledge. The facility understands that this application does not entitle the facility to participation in Memorial Hermann Health Solutions, Inc.(MHHSI) networks. The facility agrees that entities providing information in good faith, pursuant to this release, shall not be liable for any act or omission related to the evaluation or verification of information contained in this application. All information submitted to MHHSI by such entities will be treated as confidential. It is further understood that if the facility is accepted as a MHHSI. Participating Facility, it shall provide ready access and copies to MHHSI upon request, of any and all medical records that the facility maintains for any MHHSI members. The facility further agrees to notify MHHSI in a timely manner of any changes to the information provided on the application. The facility hereby authorizes any accrediting body, governmental entity, association, organization, person or insurance company to release the information requested herein and to provide confirmation of the answers contained herein to MHHSI or any affiliate or subsidiary of MHHSI This authorization shall be valid for so long as the facility is a MHHSI contracted provider. A copy of the signature is as binding as the original. Signature of Chief Administrator or Authorized Designee Date Print Name of Chief Administrator or Authorized Designee Facility Name Address City, State, ZIP Code Phone Number: Fax Number: 9

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