The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with:

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1 Provider Networks Provider Applicant Process University of Utah Health Plans (UUHP) contracts with physicians and other health care professionals and facilities to offer provider networks essential to the delivery of health care and services to our members. UUHP is committed to the triple aim of improving experience and quality of care, improving the health of populations, and reducing the per capita cost of care. We recognize the importance of population health and payment reform and have developed extensive care management and value-based payment programs that improve health and align provider reimbursement with value and positive outcomes. Provider applications to participate in any UUHP network are considered based on 1) network adequacy, 2) business needs and 3) the credentialing process. All providers must be approved through our credentialing process before they may participate in any network. The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with: Healthy U: A Medicaid Accountable Care Organization (ACO) plan and network available to eligible Medicaid members in Box Elder, Cache, Davis, Morgan, Salt Lake, Summit, Tooele, Utah, Wasatch and Weber counties. Healthy Advantage: A Medicare Special Needs plan and network for individuals who qualify for Medicare and Medicaid in Salt Lake, Davis, Weber and Utah counties. H.O.M.E.: A Coordinated Healthcare Model, in partnership with the University Neuropsychiatric Institute, to meet the medical and mental health needs of people with developmental disabilities. Healthy Advantage Plus: A Medicare Advantage HMO plan and network available for eligible Utah Seniors in Salt Lake, Davis, Weber and Utah counties. Healthy Premier: A statewide commercial network offered to employer groups and individuals. Healthy Preferred: A commercial narrow network along the Wasatch Front available to employer groups. For consideration in any UUHP network, please fill out the attached application form and return to UUHP via , or fax, , and include the following: Page 1

2 1. A copy of your W-9 IRS Tax form. A copy of your current Utah Business License. 3. A copy of your Utah State Medicaid approval letter. 4. A copy of your Medicare acceptance letter, or certificate. 5. A copy of your current Certificate of Insurance Liability. 6. An Electronic Data Interchange (EDI) number or EDI clearing house. If you do not furnish these 6 requested documents, your application may be withdrawn. University of Utah Health Plans evaluates provider network applications in accordance with its credentialing policy and criteria, as well as business needs for the particular network. Business needs may include and are not limited to: Network adequacy requirements based on state and/or federal guidelines Network adequacy requirements based on the current or expected population of a given geographic area (usually defined by county or zip code) Network adequacy requirements based on provider type and/or specialty Network composition based on scope of services required by payer such as employer, health plan, union/trust, government entity, etc. Network performance requirements in terms of cost/utilization, quality measures, outcomes, access, and/or patient or physician satisfaction. Demographic needs including but not limited to languages spoken Existing, non-compensated, referral patterns with current network providers and/or UUHP members Benefits of participating with a UUHP network include: Claim payments made to you directly on a weekly basis. Provider Relations representatives are available to help you and your staff. Inclusion in UUHP s on-line and printed provider directories made available to brokers, employers and members for the applicable products. Member benefits are designed to encourage use of network providers. Participation with U Link an online tool to verify eligibility, check claims status, submit inquiries, etc. Completion of this application does not guarantee a contract or participation with the University of Utah Health Plans. The University is a governmental entity and thus subject to the Utah Government Records Access and Management Act, Utah Code Ann., Sec et seq., as may be amended ( GRAMA ); that certain records within University s possession or control, including without limitation may be subject to public disclosure; and that University s confidentiality obligations shall be subject in all respects to compliance with GRAMA. Pursuant to Section 63G of GRAMA, University hereby informs that any person or entity that provides University with records that such person or entity believes should be protected from disclosure must be accompanied by a written claim of confidentiality and a concise statement of reasons supporting such claims. Page 2

3 Application Form Please give a brief description of your services or scope of practice, in the space below: (You may attach your marketing material.) Office / Business Information (Group & Individual NPI numbers must be registered with Utah Medicaid) Group Name Specialty(s) Group NPI Group Tax ID Clinic # 1 Billing (Please include a copy of your W-9) Clinic Phone Number Billing Phone Number Clinic Billing Clinic Facsimile Name of Clinic Administrator Clinic Administrator Phone Number Billing Facsimile Electronic Data Interchange Number (EDI) EDI Billing Service or Clearing House Page 3

4 Provider Information Provider # 1 5. Provider # 2 5 Provider # 3 5. Provider # 4 5. (If more than 2 clinics and /or more than 4 providers, please copy this page and submit) Please to: or fax to: (801) Page 4

5 Provider Information Each applicant must complete questionnaire (please make copies if necessary) NAME: Minimum Requirement for all Applicants Do you have any current Medicare or Medicaid sanction(s)? Have you ever had a license to practice revoked, suspended or placed on probation by any state licensing agency? Have you ever been convicted of any felony, or of any misdemeanor relating to the practice of medicine? Yes No If you have answered YES to any of the above questions, you may be ineligible to be a participating provider. Please contact UUHP Provider Relations at (801) Do you have a current license to practice in the State of Utah? Do you have professional Liability Insurance? Physicians Only. Have you successfully completed an internship and residency program approved by the American College of Graduate Medical Education or the American Osteopathic Association? Physicians Only. Have you successfully graduated from an accredited School of Medicine, Osteopathy, Podiatry or Dentistry? Physicians Only. Do you have a current DEA license and State Controlled Substance license? Physicians Only. Have you ever had medical staff appointments denied, revoked, resigned, relinquished or terminated by any health care facility or health plan, for reasons related to clinical competence or professional conduct? Physicians Only. Are you board admissible, board certified, completing the last six months of an approved residency program of at least three (3) year s duration, or in the process of becoming board certified? Physicians Only. Do you have malpractice insurance in the amount of $1,000,000 for each occurrence? Physicians Only. Do you have malpractice insurance in the amount of $3,000,000 in the annual aggregate or greater? Page 5

6 ATTESTATION / CONSENT / RELEASE (Per Provider) The information contained herein and the attached documents contain detailed and specific information relating to my character and professional competence. I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that any misrepresentation and/or any significant omissions in this application constitute cause for denial or for subsequent revocation of membership and privileges. By applying for appointment to the facility or health plan and for the exercise of specific clinical privileges, I hereby authorize the facility or health plan, its medical staff, and its authorized agents to investigate and evaluate my provider application, and consult with any person, organization, or entity that has, or could have any information, data, or documents regarding my background, competence, credentials, character and ethical qualifications. I further authorize the transmission of this application and all supporting documentation, and all information collected during the credentialing process, to each and every component of the participating healthcare entities in which I have sought membership, privileges or other status, and I further fully authorize the release of that documentation or information to any hospital, medical staff, medical group or other health care entity that may seek it as part of an authorized credentialing or peer review process. I hereby fully release from liability all representatives of the facility or health plan, its medical staff, and its authorized agents for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from liability any and all individuals and organizations who provide information to the facility or health plan or its medical staff, or authorized agents in good faith and without malice, concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information. If applicable for the healthcare entity that I am applying, I further consent to the obtaining of a criminal background check. During the time that this application is being processed, I agree to update the application should there be any material change in the information provided which may affect the application or its outcome, and I specifically agree to notify the specified entities to which I am applying immediately upon notification of any significant or formally recommended change in licensure status, or any actual or formally recommended denial, suspension or revocation of privileges or membership with another healthcare entity, or cancellation or interruption of my professional liability insurance coverage. I attest that all information submitted by me in this application is true, current and complete and furnished in good faith. Signature: Date: Printed Name: Page 6

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