CareLink Network Provider Application

Transcription

1 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 where care will be provided. Each organization with a separate Tax Identification Number must have a separate application. Please legibly print or type the information on the application. Incomplete applications may be returned. If you have additional questions or concerns, please call the contracting department at Please attach the following documents with each application: Copy of all current accreditations (NCQA, JCAHO/TJC, CARF, AOA, COA, other); Include accreditation certificates and letters. Copy of any current state licenses and certificates Copy of general and professional liability insurance (minimum of $1 mil/$3mil will required for contracting) Completed W-9 form (can be obtained at or on the IRS website) Signed Direct Care Wage Attestation Form, if applicable Copy of organizational chart Staff Roster for residential providers only (page 7 all information must be entered) Number of FTEs (Full Time Equivalent) Resume of Licensee/Provider residential facilities only (Resumes of Direct Care Workers are not required) For Free Standing Psychiatric Hospitals (or IMDs) only copy of the Agreement for Provision of Medical Care Services How many CareLink members are you currently providing services for? How many years of experience does the organization have servicing people with mental illness (MI)? Describe: Does anyone in your organization speak other languages fluently? No Yes Please list according to each site identified on the next page: A. General Information (Please print) Corporation: Mailing /Billing Address: City: State: Zip Code: Telephone #: ( ) Alternate #: ( ) Facsimile #: Address: Website address: Have you ever contracted with another MCPN? If so, which site and which MCPN? Was the contract ever terminated? Reason 1

2 List addresses for ALL sites you are applying for where services will be provided under the corporation listed on the first page; include the License, Insurance and Accreditation information if applicable. (If additional pages are needed, this page may be copied.) 1. Site Name: Site Address: Cross Streets: City: State: Zip Code: County: Site Telephone #: ( ) Site Fax Number: ( ) Site Contact Person: Title: Contact Person Phone Number: Contact Person Residential providers: Capacity: Vacancies: Style of Home (ranch, colonial etc.): Are languages other than English spoken in this facility? No Yes-List language (s) Wheelchair Accessible (inside & outside of facility) First Floor bedroom? Barrier Free Inside? Do you provide transportation? Family Live In? Willing to accept: Age range Rate range: Male Female Both Number of CareLink members at this facility: *Total number of people served at this site: * Please include all consumers 2. Site Name Site Address: Cross Streets: City: State: Zip Code: County: Site Telephone #: ( ) Site Fax Number: ( ) Site Contact Person: Title: Contact Person Phone Number: Contact Person Residential providers: Capacity: Vacancies: Style of Home (ranch, colonial etc.): Are languages other than English spoken in this facility? No Yes-List language (s) Wheelchair Accessible (inside & outside of facility) First Floor bedroom? Barrier Free Inside? Transportation provided to clients? Family Live In? Willing to accept: Age range Rate range: Male Female Both Number of CareLink members at this facility: * Total number of people served at this site: * Please include all consumers 2

3 B. Contact Person(s) for the Corporation 1. Primary Contact: Phone Number: Title: Alternative Number: 2. Alternative Contact: Phone Number: Title: Alternative Number: 3. President/CEO/Owner: Phone Number: Title: Alternative Number: 4. Billing Contact: Phone Number: Title: 5. Person Completing Application: Telephone Number: C. Classification of Business (all that apply) Private Public Not-for-profit Tax ID Number: NPI Number: D. If facility/program is a subsidiary of, in partnership with, or administratively organizationally linked with another entity, please provide the following information regarding each entity. If not applicable, indicate N/A. Corporate Name: DBA/Trade Name: Primary Mailing Address: City: State: Zip Code: County: Telephone Number ( ) Fax Number: ( ) E. Accreditation/Certifications (Check yes or no), attach copy of certificate and accreditation letter: NCQA: If yes, indicate Expiration Date: TJC/JCAHO If yes, indicate Expiration Date: CARF If yes, indicate Expiration Date: AOA If yes, indicate Expiration Date: COA If yes, indicate Expiration Date: Other If yes, indicate Expiration Date: Medicaid Certified Number: Expiration Date: Medicare Certified Number: Expiration Date: F. Legal Description of Program/Facility: 3

4 G. Liability/Insurance Information Please complete AND attach a copy of the certificate: Name of Liability Carrier: Policy Number: Effective Date: Expiration Date: Professional and General Liability Limits: H. General Liability History Per Occurrence: Aggregate: This information will be reviewed in order to determine acceptance or denial of this application for credentialing or recredentialing. If you respond yes to any of the questions below, please submit an explanation of the situation or event involved (specific client names may be deleted), and the actions taken, including pending status. Such documentation should include, but is not limited to the following: Sanction letters and/or related documents from any licensing, certifying or credentialing entity Settlement agreements, petitions, complaints, responses and letters of demand concerning malpractice claims that name the organization or specific program Claim history from your insurance company for the last three years Description of relevant quality improvement activities or changes resulting from the sanction, lawsuit, settlement. 1. Has the facility/program been named in any malpractice action over the last five years? 2. Has the facility/program been named in any currently pending legal actions? 3. Has any government agency investigated, suspended, revoked or taken other action against the facility/program s license to conduct business within the past five years? 4. Has the facility/program had professional liability insurance revoked, suspended, declined, or accepted on special terms over the last five years? 5. Has the facility/program members or staff been removed, sanctioned or suspended from membership in a professional association for violation(s) of its ethical code of practice within the last five years? 6. Has the facility/program, members of the program, or staff been penalized, expelled or suspended from receiving payment under the Medicaid or Medicare programs within the last five years? 7. Have any facility/program owners, or staff been convicted of a crime excluding misdemeanors? I. Fiscal Stability 8. Have any facility/program owners, officers ever had or have an IRS levy instituted? 1. Provide a copy of the organization s most recent financial statement, along with the preparer s name address telephone number 2. List the name and address of any CareLink Network Board member or employee with whom a staff member or director of the organization has had a substantial financial relationship with the past twelve (12) months on page 5. If not applicable, indicate N/A. 3. List all debts owed to or loans obtained from CareLink Network board members or employee by a staff member or director of the organization on page 5. If not applicable, indicate on the attachment. 4

5 Name of Organization: List CareLink Network, board member(s), staff or affiliates with whom a member of the applicant s organization has had a financial relationship within the past twelve (12) months Name Address Organization Position List of all debts owed to, or loans obtained from a CareLink Network board member or employee by a staff member or director of the organization: Name Address Organization Position CareLink Network Board of Directors Nicole Wells Stallworth Tony Rothschild Dr. Suzanne Keller Carrie Floyd Sarah Clark Eric De La Rosa Bessie Tyler Veronica Madrigal 5

6 J. Provider Services - Usual and Customary Fees: Please select the service(s) that your agency has the ability and is requesting to provide by marking an x in the box to the left of the service description and indicate your usual and customary fees. Selection Service Description Usual and Customary Fees Assessment/Evaluation S Case Management $ Clubhouse/Peer Directed/Consumer Run $ Community Living Support $ Family Skills Development $ Home Based Services (must be approved by MDHHS and enrolled with DWMHA) $ Inpatient Mental Health $ Intensive Crisis Stabilization (must be approved by MDHHS and enrolled with DWMHA) $ Medication Administration $ Mental Health Therapy/Counseling $ Nursing/Private Duty Nursing $ Occupational Therapy $ Outpatient Partial Hospital Services (must be approved by MDHHS and enrolled with DWMHA) $ Person Centered Planning $ Personal Care Services $ Physical Therapy $ Psychosocial Rehabilitation (must be approved by MDHHS and enrolled with DWMHA) $ Respite Services $ Skill Building $ Speech/Language Therapy $ Supports Coordination $ Supported Integrated Employment Services $ Supported Housing $ Wraparound Services (must be approved by MDHHS and enrolled with DWMHA) $ If other, please specify Selection Service Description Usual and Customary Fees Please list all specialty areas (i.e. infant mental health, children, adolescents, geriatric, chemical dependency/substance use, dialectical behavioral therapy, cognitive behavioral therapy) Please note: The usual and customary fees submitted on your application are not an agreement to pay these amounts. CareLink will agree to pay the rates contained in the actual provider agreement. 6

7 Staff Roster for Residential only If additional pages are needed, this page may be copied. 1. Staff Name: FTE Yes No Date of Hire: Criminal Background Check Conducted: Date: Most recent dates for: Direct Care Worker Training: Recipient Rights Training: CPR Training: Medication Training: First Aid Training: Credentials, certifications or other trainings (Substance Abuse Training, Blood Borne Pathogen Trainings etc.): Location(s) staff is employed: Staff Name: FTE Yes No Date of Hire: Criminal Background Check Conducted: Date: Most recent dates for: Direct Care Worker Training: Recipient Rights Training: CPR Training: Medication Training: First Aid Training: Credentials, certifications or other trainings (Substance Abuse Training, Blood Borne Pathogen Trainings etc.): Location(s) staff is employed: Staff Name: FTE Yes No Date of Hire: Criminal Background Check Conducted: Date: Most recent dates for: Direct Care Worker Training: Recipient Rights Training: CPR Training: Medication Training: First Aid Training: Credentials, certifications or other trainings (Substance Abuse Training, Blood Borne Pathogen Trainings etc.): Location(s) staff is employed: 7

8 Provider Application for Credentialing Release Authorization and Ethical Commitment The Applicant hereby has submitted an application for appointment to the Provider Panel of CareLink Network. The Applicant certifies that the information provided is true, complete and correct. The Applicant expressly agrees that any information entered into this document that is subsequently found to be false or inaccurate are grounds for immediate contract termination and removal from the provider network. The Applicant agrees to maintain general and professional liability coverage as stated in this document and as required by the Detroit Wayne Mental Health Authority. The Applicant authorizes CareLink Network or its designee to obtain and verify information contained on the application and consents to release all persons, organizations, including other networks or other entities of liability in any respect because of having furnished information as a result of this application. The Applicant authorizes investigation of all statements contained in this application and specifically authorizes CareLink Network or its designee to investigate any and all information that may be reasonably relevant to an evaluation of, but not limited to, the organization s licensure, accreditation, absence from the Office of Inspector General s (OIG) and Excluded Parties List (EPLS) sanction list and potential exclusion from Medicare or Medicaid. The Applicant releases CareLink Network and its designees from any liability for any reports, records, recommendations, claims information and claims history, or any other information given in good faith and related to the credentialing process. The Applicant further understands that participation and continued participation as a provider for CareLink Network is dependent upon successful completion of the credentialing process and the impaneling process for the Detroit Wayne Mental Health Authority, as applicable. A photocopy of this authorization shall be deemed equivalent to the original. The Applicant understands and agrees that misrepresentation or omission of facts called for is grounds for termination from the Provider Panel. I certify that I am authorized to make the above warranties, representations and releases on behalf of this provider organization and to sign this application on behalf of this organization. Criminal background checks must be done on all new hires and annually thereafter. Signing this form confirms this process is completed by the organization. Name of Provider Organization (Print) Date Name of Authorized Representative (Print) Signature of Authorized Representative RETAIN A COPY OF THIS APPLICATION FOR YOUR FILES Return this application to: CareLink Network, Inc. Contract Management Attn: Administrative Assistant 1333 Brewery Park Blvd. Suite 300 Detroit, MI