HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST

Transcription

1 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. For each item below please separate with the corresponding numbered tab (1 15): 1. Completed Application Form 2. A copy of your current Professional Liability Insurance Policy which shows limits of liability and expiration dates. All clinical staff with patient contact must be covered by organization policy or have individual coverage. 3. A copy of ALL Current State licenses/certifications for the program or facility. 4. A copy of your Current Joint Commission Accreditation (JCAHO), Rehabilitation Accreditation Commission Certificate (CARF), Certificate of Accreditation (COA), Alcohol and Drug Abuse Division (ADAD) Accreditation or other national accreditation certificates. 5. Staff roster and staff resumes with copies of appropriate licensure and or certification (only clinical staff who have patient contact). Include name and resume of physician designated as the Clinical Program Director/Medical Director. If clinical staff are non-participating HMSA practitioners (MD, PHD, APRN, CSW), please provide policy for credentialing. 6. Organizational chart and staff roster showing positions 7. Board of Directors roster 8. Copy of patient handbook and handbook for significant other, if applicable 9. Patient record sample 10. Patient Bill of Rights. 11. Program Description 12. Treatment protocols 13. Policy for supervision of non- licensed clinical staff 14. Please provide a summary of your procedure for involuntary admission 15. Attach copies of your QI/UM Policy and Procedure MH_Facility_Initial Application_

2 HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM APPLICATION FORM Facility/Program/Program Legal Name: Business Name: TAX ID #: Mailing Address: Location Address: County: Main Phone # : Main Fax #: (Attach additional sheet if more locations) If Applicable (Please attach copy) : Medicare #: Medicaid #: Setting: Category: isorders Clinical Service / Management: Name: Phone#: Fax #: Administrative Contact: Name: Phone #: Fax: MH_Facility_Initial Application_

3 Corporate Owner: Name: Corporate Address: Please list the key contacts at your Facility/Program: (If different from page 1) Contact for Admissions Corporate Office Contact Name: Phone#: Name: Phone#: Medical Director (psychiatric) Name: Phone#: Medical Director (substance abuse) Name: Phone#: Business Office (billing) Name: Phone#: 1. List your geographic service area: 2. How is the Facility/Program/Program licensed? (check all that apply) ter 3. Is your Facility/Program accessible to the handicapped? 4. Chemical Dependency services are based on: -specify: 5. Does your Facility/Program have a university association? If yes, with which university: 6. Does the Facility/Program have a research component? MH_Facility_Initial Application_

4 7. Emergency Room Services a. If no emergency room services, which acute care Facility/Program(s) provide emergency room services? Is your relationship with them contractual? b. Specify hours: c. Emergency substance abuse services evaluation services in ER? Specify hours: d. Other, please specify: 8. Facility/Program License and Accreditation Information. Please list and attach current copies of each that apply: a. State License: Number: Exp. Date: b. Is Facility/Program Accredited: If YES Name of accrediting organization Attach copy of current certificate If NO Are there plans to be accredited? If YES, Date of expected accreditation By whom If NO, please explain below. c. Below, please list any other licenses or certifications that the Facility/Program has acquired. Include current copies of each. If you need more space, please use a separate sheet of paper. License Name: Number: Exp. Date: License Name: Number: Exp. Date: MH_Facility_Initial Application_

5 9. Facility/Program Evaluation: a. Does the Facility/Program conduct regular quality assurance reviews? b. b. Does the Facility/Program conduct regular quality reviews for utilization management? If yes, how often do they occur? Quality/effectiveness: Utilization Management: c. Please send a written sample of your guidelines for measuring quality/effectiveness and utilization management. (Preferably, copies of policy/procedure manuals, reports and any lists of the standards that the Facility/Program is measured against). d. If was checked, specify the criteria that is used to evaluate Facility/Program quality/effectiveness. 10. Liability Information:(Please include a current copy of malpractice face sheet with this application). The limits of liability can not be lower than 1 Million/1 Million. a. Carrier Name: b. Policy Number: c. Coverage Limits: d. Expiration Date: 11. Malpractice Claim History: 1. Has the Facility/Program or any shareholders/owners/partners ever been named in any malpractice action? 2. Has the Facility/Program or any shareholders/owners/partners ever had or currently have pending any legal action? 3. Has the Facility/Program or any shareholders/owners/partners ever had professional liability insurance refused, declined, canceled or accepted on special terms? 4. Has any government agency ever investigated, suspended, revoked, or taken action against your license to conduct business? 5. At any time, has any license or certification been revoked, reduced, denied, or suspended by others or voluntarily given up by the program, or are any actions which may lead to such conclusions under way? MH_Facility_Initial Application_

6 6. At any time, have any memberships in professional organizations ever been revoked, reduced, denied, or suspended by others or voluntarily given up by the program, or are any actions which may lead to such conclusions under way? 7. Has the Facility/Program or any shareholders/owners/partners ever been convicted of a crime, excluding misdemeanors? 8. Has the Facility/Program ever been assessed a penalty, conviction or suspension or is the Facility/Program currently under investigation by a Medicaid or Medicare program? 9. Number of Claims (check one) (more) 10. Has your facility / program ever been excluded from any Federal health programs? MH_Facility_Initial Application_

7 FACILITY/PROGRAM S STATEMENT We certify that all of the above information is true, complete and correct to the best of our knowledge and belief and is made in good faith. We further understand that any false or incomplete information knowingly provided by us may be ground for our dismissal. We hereby authorize HMSA or its designees, to verify and release any and all of the information contained herein as may be necessary to evaluate our application to become a provider with HMSA. Print Name Title Authorizing Signature Date MH_Facility_Initial Application_