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

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1 Aetna Better Health Credentialing Questionnaire Processing 2400 Veterns Memorial Blvd. Ste 200 Kenner, LA June, 2015 Name: Facility Name: Address 1: Address 2: PH: FAX: Organizational Provider s 14- digit PIN: (to be filled out by Aetna) Organizational Provider s Medicaid Plan Name: Aetna Better Health of LA Please complete this facility (re)credentialing questionnaire We re committed to the quality of health care services delivered to our members. We have a well-defined and structured facility credentialing process in place. Below, you ll find the information we need to complete our credentialing process, as required by your Aetna agreement. Please note that Coventry Health Care and First Health are now part of Aetna. Please submit the information (including this letter) via fax to , mail to the address above or it to us at within ten (10) days of the date of this letter. Signed and Dated Attestation (bottom of questionnaire) A copy of the facility s current W-9. Tax ID Number (TIN): Medicare Certification Number: Medicare Part A OR Medicare Part B OR Medicare Part C (Ambulatory Surgery only) Medicaid certification number: Copy of current Facility State License, Business Registration, or Certificate of Occupancy (if applicable) Copy of accreditation or certification certificates or letter (if applicable). Refer to page 2. If facility is not accredited, provide most recent CMS or State Survey/Inspection Report including Corrective Action Plan and compliance letters. Copy of Clinical Lab Improvement Amendment (CLIA) (for laboratories only) If submitting one questionnaire for facilities with multiple locations please complete the Additional Locations Supplemental Form of the questionnaire and include site specific information/documentation for each location. PROFESSIONAL LIABILITY INSURANCE COVERAGE Do you have Professional Liability (Malpractice) Insurance coverage in force? Yes No If yes, provide a copy of current Professional Liability Insurance Certificate, including Carrier s Name, effective and expiration dates, policy number, and liability dollar limits or provide details below: Name of Insurance Carrier/Insurer: Policy effective date: Policy expiration date: Policy Number:

2 Amount of coverage per occurrence: $ Amount of coverage per aggregate: $ If you have additional information or additional insurance coverage, please provide below: Additional Professional Liability (including Patient Comp Funds) Self Insured Retention Excess Coverage Umbrella Name of Insurance Carrier/Insurer: Policy Number: Policy expiration date: Amount of Coverage per occurrence: $ Amount of coverage per aggregate: $ Do you have an Advance Directive policy? Yes No Hospital, nursing homes, home health care agency and skilled nursing facility: If you responded No, please include a copy of the specific section of your policy/process, which addresses that you do not maintain Advance directive policies. You do not have to include the complete policy. Please check the applicable box(es) below that describe your facility type and circle applicable accreditation or certification. If applicable, please provide copy of certificate. Hospital Children s hospital Long-term acute care hospital Nursing home or CCAC Skilled nursing facility Home care agency TJC or CHAP or ACHC Hospice agency TJC or CHAP or ACHC Free standing surgical center TJC or AAAHC or or HFAP Voluntary interruption of pregnancy center TJC or or AAAHC Urgent care facility Mental health hospital Chemical dependency/substance abuse hospital Community mental health center or HFAP or COA Residential treatment facility or HFAP or COA Partial hospitalization program Intensive outpatient programs and clinics or HFAP or COA Crisis stabilization program Laboratory CLIA Facility is a draw site only? Yes or No Comprehensive outpatient rehabilitation facility Outpatient physical therapy facility Outpatient speech pathology Outpatient diabetics self-management training providers ADA or IHS End-stage renal dialysis center Portable X-ray suppliers FDA Federally qualified health care centers Rural health clinics Diagnostic radiology center ACR or AIUM or IAC or TJC Services: MRI Mammography Mobile Unit Other: Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, (Aetna). Aetna Behavioral Health refers to an internal business unit of Aetna. For information obtained during verification from primary sources, as an organizational provider, you have the right to correct discrepant or erroneous information. You can work directly with any reporting entities used during the recredentialing proces

3 Response required for the facility types listed below: Federally qualified health care centers Please attest that you currently meet and will continue to meet Medicare conditions of coverage as defined in the Social Security Act 1861(aa)? Yes No If no, please attach an explanation of any deficiencies Comprehensive outpatient rehabilitation facility, end-stage renal dialysis center, outpatient physical therapy, outpatient speech pathology and rural health centers Please attest that you currently meet and will continue to comply with all Centers for Medicare and Medicaid Services or state survey requirements? Yes No If no, please attach an explanation of any deficiencies Attestation By signing below, I know that it is my responsibility to give enough information to Aetna to show that the organization is compliant with Aetna s credentialing process. I know that any false statement or mistake in this questionnaire will be a reason to reject or end the organization s participation in the network. If there are any changes in the information I provided, making the above information no longer correct and complete, I understand and agree that it is my responsibility to let Aetna know within (30) days of the occurrence. I know if I don t provide the necessary information on the organization s behalf within the 30-day timeframe, the organization may not be part of the Aetna network. I certify that the information contained in this survey and all attachments is accurate, complete and true. Name: Title: Signature(s): Date: How to submit your Credentialing Questionnaire Submit via to Submit via fax to Or mail to Aetna Better Health Credentialing Questionnaire Processing 2400 Veterns Memorial Blvd. Ste 200 Kenner, LA If you have questions regarding this request please contact option 2

4 Additional Location Supplemental Form If also completing the questionnaire for additional locations please complete this form and include one copy of shared documents (i.e. W9, Professional Liability, etc.) and separate site specific documents for each additional location (i.e. State License). Additional Location 1 Additional Location 2 Additional Location 3 Additional Location 4 Additional Location 5 Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, (Aetna). Aetna Behavioral Health refers to an internal business unit of Aetna. For information obtained during verification from primary sources, as an organizational provider, you have the right to correct discrepant or erroneous information. You can work directly with any reporting entities used during the recredentialing proces

5 ADDITIONAL FACILITY INFORMATION Facility Provider Type NPI Number License Number Taxonomies On Bus Route Yes No Handicap Assessable Yes No Contact Name Contact Phone Contact Hours of Operation Does your facility/organization have gender limitations? No Yes, Male Only Yes, Female Only Do you have age limits for your facility/organization? Yes No If yes, what are the limits? Does this business offer services to the deaf/hearing impaired? Yes No Services: Sign Language TTD/TTY None Language(s) spoken other than English Do you provide services in counties other than your primary? Yes No If yes, do you provide services statewide: Yes No If yes, please list counties Electronic Claim Submission: Yes No Does Business have internet access: Yes No Electronic Medical Records: Yes No Is the Facility Accredited? Yes No Accredited By: Number of Certified Beds: Does facility have Adjustable Exam Table? Yes No Billing Pay To Name Billing Phone Billing Fax Billing Address

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