INTEGRIS Medical Group ATTN: INTEGRIS Insurance Credentialing 5300 North Independence, Suite 280 Oklahoma City, Oklahoma 73112-5556 Dear Provider: Welcome to INTEGRIS Health. Enclosed is the necessary paperwork to begin the insurance enrollment and/or clinic and hospital privileging process. Please find the following packets attached: Checklist of Required Items Uniform Credentialing Application Code of Conduct (if applicable) INTEGRIS Medical Group Packet (if applicable) Hospital Privileging Packet (if applicable) Insurance Signature Packet Self-addressed envelopes for packet return Please return all applications to one of the specialists below along with the documents listed on the check list. Each packet must be complete in its entirety. If the information is not complete, your packet will be returned to you, which could delay your privileging process and/or employment. We look forward to working with you in the service of our community! Practitioner rights: Please note you have the right to review, request status, and correct erroneous information anytime during the credentialing process or when you feel the need. Please do not remove any pages out of this packet. Respectfully, Christy Aquino Manager of Provider Credentialing 5300 N. Independence, Suite 280 Oklahoma City, OK 73112-5556 Phone: (405) 552-0155 Fax: (405) 713-7690 christy.aquino@integrisok.com Heather Maloy Clinic Credentialing Specialist 5300 N. Independence, Suite 280 Oklahoma City, OK 73112-5556 Phone: (405) 945-4521 Fax: (405) 815-6914 heather.maloy@integrisok.com
Document Checklist Current CV that includes all education and work history in month/year format A completed UCA (Uniform Credentialing Application). Please make sure that this application includes full names, addresses, and phone numbers for each facility or institution. Please include explanation(s) of any time gaps of 30 days or more in education or work history. Please ensure dates include month, day, and year. NPI Meaningful Use Form, see enclosed. (If you do not have your logon information, please call (800) 465-3203 to obtain your user ID and rest your password.) NPI Username: Password: CAQH (Council for Affordable Quality HealthCare) This is an online application that all major insurance companies access for credentialing. If claims are filed to insurance companies on your behalf, you should have a CAQH record. If you do not have your logon information, please call 888-599-1771 to obtain your user name and reset your password. CAQH Username: Password: Oklahoma Medicaid (if applicable) Medicaid Username: Password: ECFMG Certificate (if applicable) Oklahoma State Medical License Number: - If you need to apply for your license, you may do so at http://www.okmedicalboard.org All Active Out-of-state Licenses Current DEA Number: - If you need to apply for a DEA, you can do so at: http:/www.deadiversion.usdoj.gov Current OBNDD (Oklahoma Bureau of Narcotics & Dangerous Drugs) Number: to apply for an OBNDD, you can do so at: https://www.ok.gov/obndd/_app/search/index.php If you need ACLS, BLS, CPR training certificates Board Certification or Board Eligible Letter/Email List of all CME s taken in the past year Malpractice insurance certificate for the last 5 years Malpractice case explanations of any suits in which you have been named. We need details of all pending, settled or dismissed cases. Malpractice claim form is attached. Driver s license or passport for photo ID Procedure log from past facilities demonstrating proficiency for privileges requested on the Delineation of Privileges form. The log must be on facility letterhead or other identifiable form from the facility named. Diploma (allied health only)
Insurance Credentialing Packet (Signatures only, please do not date anything)
Questions for Onboarding Physicians for the EHR Incentive Program ( Meaningful Use) Providers at INTEGRIS Health are required to participate in the EHR Incentive Program established by the Centers for Medicare and Medicaid Services. In order to assist our providers in their participation, we request the following information: Please provide the following: Provider Name: NPI Number: NPI User Name: NPI Password: 1 Have you ever participated in the EHR Incentive Program ( Meaningful Use)? Yes: No: 2 If Yes, for what years? 2011 2012 2013 2014 2015 2016 (Please circle) 3 4 5 6 In what program did you participate? Medicare: Medicaid: No: N/A: (Please check) If No, were you classified as hospital-based for Medicare purposes in the last year? Yes: No: Place of service code (21) hospital inpatient or (23) emergency department: Service Code: Please provide contact information from your previous employer who can validate Meaningful Use Participation: Name: Phone: Address: What is the EHR Product name and Vendor you used in the previous year? Product Name: Vendor Name: 7 8 9 10 If attestation for the EHR Incentive Program was successful, who was the recipient of the funds? Have you received notice from CMS of an Audit for the EHR Incentive Program? Yes: No: If yes, did you successfully defend your audit? Yes: No: Do you have copies of your attestation documents submitted to CMS for the EHR Incentive Program? Yes: No: For additional information or assistance, please contact Jan Ellingson, Meaningful Use Coordinator, at: Office: 405.951.8542 Mobile: 405.628.7741 Fax: 405.951.8817 *Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information *Ultimately, it is hoped that the meaningful use compliance will result in: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems * Source: Bullets from the ONC Website, 2014
Address Information Please provide practice information for each office in which you see patients under this contract. Attach additional sheets if necessary. Address I (Please provide your payment address first. Note: If this is also a practice address, it cannot be a P.O. Box.) Payment Address Practice Address Mailing Address Street City State Zip Suite - Phone Numbers Appointments E xt. Billing Ext. ADDRESSES I Fax Is This Office Contact Name: Your primary practice location? Yes No Accessible to handicapped patients? Yes No Open to new patients? Yes No Office Hours (Required for certain states) MONDAY From - To TUESDAY From - To WEDNESDAY From - To THURSDAY From - To FRIDAY From - To SATURDAY From - To SUNDAY From - To Average Appointment Scheduling Time (Required for certain states) New patient Hours / Days / Weeks Routine Visit Hours / Days / Weeks Urgent Visit Hours / Days / Weeks Tax ID Information I Address I All information must match the W-9 Form submitted to the IRS. Tax ID Number Tax ID Name Address Information II Payment Address Practice Address Mailing Address Street Suite City State Zip Phone Numbers Appointments E xt. Billing Ext. - ADDRESSES II Fax Contact Name: Is This Office Your primary practice location? Yes No Accessible to handicapped patients? Yes No Open to new patients? Yes No Office Hours (Required for certain states) MONDAY From - To TUESDAY From - To WEDNESDAY From - To THURSDAY From - To FRIDAY From - To SATURDAY From - To SUNDAY From - To Average Appointment Scheduling Time (Required for certain states) New patient Hours / Days / Weeks Routine Visit Hours / Days / Weeks Urgent Visit Hours / Days / Weeks Tax ID Information II Address II All information must match the W-9 Form submitted to the IRS. Tax ID Number Tax ID Name ATTESTATION / RELEASE I hereby submit this application for participation with MultiPlan, Inc. through the PHCS Network and the MultiPlan Network. I understand that this application will be reviewed based on the information I have provided herein. I hereby certify that the information contained and enclosed with this form is complete, accurate and true, and that information found to be false could result in denial or subsequent termination of my participation in the PHCS Network and the MultiPlan Network. To assist MultiPlan and/or its Credentials Verification Organization (CVO) in evaluating my application, I authorize any hospital, group practice, other clinical employer, professional society, malpractice carrier or other agency or organization with information regarding my professional credentials to release, furnish copies, or give details of my professional credentials, qualifications and hospital records related to my privileges, qualifications, type of clinical practice and competence, including my moral and ethical qualifications. I hereby release from liability any and all individuals and organizations who, in good faith and without malice, provide information to MultiPlan for the purposes of evaluating this application, and release MultiPlan from liability for its use of the information it gathers in the application process. A photocopy of this permission will be as valid as the original. X Signature of Provider (Must be participating provider s signature) Name (please type or print) Date (mm/dd/yyyy) NOTE: Signature and date on this application MUST be within 30 days of submission to MultiPlan. Send your completed application and all supporting materials to MultiPlan via mail to the address below, email to registrar@multiplan.com, or fax to 781-487-8273. MultiPlan Attention: Registrar 1100 Winter Street, Suite 3800 Waltham, MA 02451-9367 Page 2 of 2
Professional History and Attestation Supplement Please complete all items on this form. Incomplete forms will delay the credentialing process. Items marked with an asterisk (*) will be kept confidential to the extent permitted by law. If you need assistance completing this form, please call our Service Operations Department at 800-950-7040. HISTORY History Please describe the last five (5) years of your employment/professional history. Please include with your application a brief explanation of any gap of six months or greater.* Please note that your application cannot be processed if month and year specific detail is not provided. Activity / Position Activity / Position Activity / Position Activity / Position Facility / Program Facility / Program Facility / Program Facility / Program Be sure to complete all questions. (please provide a detailed description of all positive responses.) City, State City, State City, State City, State From-To (mm/yy) A. Have you ever had any negative action taken in connection with your license, including, but not limited, to refusal, suspension, Yes No revocation, probation reprimand, censure or restriction in any way by any state or jurisdictional board? / Present From-To (mm/yy) / / From-To (mm/yy) / / From-To (mm/yy) / / B. Have you ever been censured by a medical society or other professional society or other professional board or association? Yes No PROFESSIONAL QUESTIONS * C. Have you ever had your Drug Enforcement Administration number (DEA #) restricted, suspended, revoked or otherwise limited or Yes No DEA license application refused? NA D. Have you ever had an agreement with Medicare or Medicaid that was restricted, probational, suspended, excluded or terminated? Yes No E. Have you ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid? Yes No F. Have you ever been convicted of a criminal offense other than a minor traffic violation? Yes No G. Has any hospital or facility ever taken any action regarding your privileges, including, but not limited, to suspension, restriction, denial or revocation? Yes No H. Have you ever voluntarily resigned privileges in lieu of disciplinary action? Yes No I. Has there been, within the last five years, more than one malpractice judgment found against you or malpractice settlement made, Yes No with or without prejudice, in excess of five hundred thousand ($500,000) dollars? J. Do you have an impairment, which even with reasonable accommodation would interfere with your ability to provide care according to accepted standards of professional performance, or would pose a threat to patient health and safety? Yes No K. Are you now or have you ever been an active or habitual user of any mind or mood altering substance, including, but not limited, to alcohol, Yes No narcotics, barbiturates, hypnotics, amphetamines, cocaine, benzodiazepines, or other controlled or illegal substances? L. Has your participation in any insurance carrier sponsored program been suspended or revoked? Yes No ATTESTATION / RELEASE I hereby submit this application for participation in MultiPlan, Inc. s networks as indicated in my MultiPlan contract. I understand that this application will be reviewed based on the information I have provided herein. I hereby certify that the information contained in the submitted state credentialing application and the Professional History and Attestation Supplement is complete, accurate and true, and that information found to be false could result in denial or subsequent termination of my participation in any or all of the MultiPlan networks. To assist MultiPlan and/or its Credentials Verification Organization (CVO) in evaluating my application, I authorize any hospital, group practice, other clinical employer, professional society, malpractice carrier or other agency or organization with information regarding my professional credentials to release, furnish copies, or give details of my professional credentials, qualifications and hospital records related to my privileges, qualifications, type of clinical practice and competence, including my moral and ethical qualifications. I hereby release from liability any and all individuals and organizations who, in good faith and without malice, provide information to MultiPlan for the purposes of evaluating this application, and release MultiPlan from liability for its use of the information it gathers in the application process. A photocopy of this permission will be as valid as the original. X Signature of Provider (Must be participating provider s signature) Name (please type or print) Date (mm/dd/yyyy) NOTE: Signature and date on this application MUST be within 30 days of submission to MultiPlan. APPLICATION CHECKLIST Copy of current DEA and license certificate(s). Copy of current insurance certificate which includes Professional and Comprehensive General Liability. Copy of Curriculum Vitae. Detailed explanation and documentation for any affirmative responses to Professional Questions or Employment History Gaps six (6) months or greater. Send your completed application and all supporting materials to MultiPlan via mail to the address below, email to registrar@multiplan.com or fax to 781-487-8273. MultiPlan Attention: Registrar 1100 Winter Street, Suite 3800 Waltham, MA 02451-9367 PRVP099 (8/2011) Page 1 of 1 Questions? Call 800-950-7040 1100 Winter St. Waltham, MA 02451-9370
CommunityCare HMO Preferred CommunityChoice PPO Senior Health Plan Employee Assistance Program WorkNet of Oklahoma ExcelCare CommunityCare Life and Health Plan HOSPITAL PRIVILEGES BUSINESS NEEDS WAIVER CommunityCare Managed Healthcare Plans of Oklahoma (CCMHPO) is committed to credentialing providers at the level established by the URAC. One of the requirements for participation is having hospital admitting privileges at a minimum of one (1) contracted hospital. This requirement may be waived when deemed appropriate to further the business needs of CCMHPO s HMO, PPO or Certified Workplace plans. Please complete the following information and return to the address below: CommunityCare Managed HealthCare Plans of Oklahoma 218 West 6 th, 6 th Floor Tulsa, OK 74119 Attn: Credentialing, Provider Services Personal & Confidential I,, hereby apply for a waiver of the requirement for hospital (applicants name) admitting privileges at a contracted hospital based on the following circumstances: Since I (the applicant) do not hospitalize patients at a CCMHPO participating network hospital or other contracted health care institution I have a formal written transfer arrangement with a CCMHPO participating physician for the hospital referral arrangement. I (the applicant), also understand that sending patients to the Emergency Department of a participating hospital is not an acceptable alternative. I also understand that CCMHPO is under no obligation to grant this waiver. It shall be granted at the sole discretion of CCMHPO, and if not granted, there is no appeal of the decision. Applicants Signature: Date: ************************************************************************************************************************ For CommunityCare Managed Healthcare Plans of Oklahoma Use Only HMO and CCL&H Administrator s: Date: Signature PCC Administrator s Signature: Date: WorkNet Administrator s Signature: Date: Chief Medical Officer or Credentials Committee Chairman Signature: Date: WaiverHosp 02/2014
Network Provider Physician Assistant Contract Signature Page The Employees Group Insurance Division (EGID), a Division of the Office of Management and Enterprise Services, and the Provider, incorporate by reference the terms and conditions of the Network Provider Contract (Contract) into this Signature Page. The EGID and Provider further agree that the effective date of the Contract is the effective date denoted on the copy of the executed Signature Page returned to the Provider. The original of the signed document will remain on file in the office of the EGID. FOR THE PROVIDER: FOR THE DIVISION: Signature Date: Name (typed or printed): Diana O Neal Deputy Administrator, Finance/CFO Employees Group Insurance Division Signature: SSN: Federal Tax ID Number: Primary Service Address: Please return the completed Application, Signature Page, and required attachments to: EGID ATTN: Network Management 3545 N.W. 58 th St, Ste 110 Oklahoma City, OK 73112 Phone: 405-717-8790 or 1-800-543-6044 Fax: 405-717-8977 EGID.NetworkManagement@omes.ok.gov HCPACv1.5
TRICARE South Region Provider Data Management P.O. Box 7039 Camden, SC 29021-7039 Fax 803-462-3986 Toll-Free: 1-800-403-3950 www.mytricare.com by PGBA Physician Assistant Provider Application Package PROVIDER S NOTARIZED SIGNATURE AUTHORIZATION STATE OF COUNTY OF Know all persons by these presents: That I, have made, constituted and appointed and by these presents do make, constitute and appoint (Please attach a list of any other authorized representatives) my true and lawful attorney-in-fact for me and in my name, place and stead to sign my name on claims, for payment for services provided by me submitted to Defense Health Agency (DHA). My signature by my said attorney-in-fact includes my agreement to abide by the TRICARE payment system concept and the remainder of the certification appearing on all TRICARE claim forms. I hereby ratify and confirm all that my said attorney-in-fact shall lawfully do or cause to be done by virtue of the power granted herein. In witness whereof I have hereunto set my hand this day of, 20. SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF, 20 NOTARY PUBLIC IN AND FOR COUNTY OF (SEAL) STATE OF MY COMMISSION EXPIRES / / Per Defense Health Agency (DHA) guidelines, we may accept, in lieu of a provider s actual signature on a TRICARE claim form, a facsimile signature or signature of a representative if the FI has on file a notarized authorization from the provider for use of a facsimile signature or a notarized authorization of power of attorney for another person to sign on his or her behalf. The authorized representative may sign using the provider s name followed by the representative s initials or using the representative s own signature followed by POA (Power of Attorney), or similar indication of the type of authorization granted by the provider. 3
TRICARE South Region Provider Data Management P.O. Box 7039 Camden, SC 29021-7039 Fax 803-462-3986 Toll-Free: 1-800-403-3950 www.mytricare.com by PGBA Physician Assistant Provider Application Package PRACTITIONER AUTHORIZATION FOR REASSIGNMENT OF BENEFITS TO CLINIC TRICARE PGBA, LLC It is agreed that (Name of Clinic, Group or Professional Association) will bill for and receive any charges or fees for the services of (Name of Practitioner) (Office Address) Signature: Authorized Individual for Clinic Employer Identification Number NPI # for Employer Identification Number Date Signature of Practitioner Social Security Number NPI # for Social Security Number Date Date Individual joined group practice: / / Please return to the address indicated at the top of this form. 5
FOR OFFICE USE ONLY: Oklahoma Health Network Provider Demographics Form Please complete the below demographics form, and return to Oklahoma Health Network with the signed agreement and a completed W-9 form. All information is required unless otherwise noted. Note: Additional locations and providers require separate demographic form for each. In lieu of this demographics form, you may submit a provider roster as long as it contains the minimum data requirements listed below: Last Name: First Name: Middle Degree: OK License #: Specialty: Tax Identification Number: Individual NPI Number: Date of Birth: Group NPI Number: Group Name: Primary Office Address: Office Telephone Number: Office Fax Number CAQH Number (If Applicable): Billing Office Address: Billing Telephone Number: Billing Fax Number: Contact Name: Email: Please select the preferred method for receiving the countersigned Agreement: Fax Number: Email Address: Mailing Address: By completing this form, you agree that Oklahoma Health Network s credentialing agent, MultiPlan,Inc., may access your CAQH profile if applicable. Otherwise, MultiPlan s credentialing department will be contacting you to procure your Oklahoma State Credentialing Application. Provider Signature Date Oklahoma Health Network 4013 Northwest Expressway, Ste. 575 Oklahoma City, OK 73116 800-816-5356 contactohn@healthcarehighways.com
PROVIDER APPLICATION Please complete ONE application for each Practitioner DIRECTORY/BILLING INFORMATION Last Name First Name M.I. Professional Degree Date of Birth Specialty Tax I.D. or Social Security Number for billing purposes Clinical Name or d/b/a Name Directory Address City, State, Zip Phone: Fax: E-mail : ( ) ( ) Billing Address (if different from directory address) Billing Phone: ( ) City, State, Zip Fax: ( ) Repricing Statement E-mail : LICENSURE/INSURANCE INFORMATION License Number State Effective Date Expiration Date Federal DEA Registration Number State Date Issued Expiration Date CLIA Certification Number State Effective Date Expiration Date Medicaid Number Medicare Number NPI Malpractice/Professional Liability Insurance Company Name: (Attach Insurance Face sheet) Policy Number: Expiration Date: Facility Address HOSPITAL/SURGICENTER STAFF PRIVILEGES Telephone City ( ) State ZIP Type of Privileges: Facility Address City State ZIP Telephone ( ) Type of Privileges: CONSENT/REPRESENTATIONS AND WARRANTIES I authorize USA to consult with hospital administrators, members of medical staffs, malpractice carriers and other persons to obtain and verify my credentials and qualifications as a provider. I release USA and its employees and agents from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application. Applicant s Signature: Date: Applicant s Printed Name: LOA_AMS 1 01/16/2009 S:\Mast_con\Provider Please return this form to: USA Managed Care Organization, Inc., Attn: Network Development 916 Capital of Texas Highway South, Austin, Texas 78746 Initials
SECTION 12: COPIES OF REQUIRED DOCUl\iENTS Please mclude a copy of the followmg with this application. Practitioner should check off needed items that are bemg attached to this application. l\.ttached Oklahoma Bureau ofnarcotics and Dangerous Drugs Registration (BNDD) Current Federal DEA Registration Certificate Emergency Care Training Certificates (CPR, etc., if certified) Phmo Idemiticanon Cumculum Vitae Tax Identification Information Form \V -9 SF,CTION 13: ATTFSTATION All intfjrmation and documentation contained in this application is true, correct and complete to my best knowledge and belief. I further acknowledge that any matenal misstatements m or omissions tl-om this application may constitute cause for denial of my application for staff membership, privileges, or participation. Name (printed)--------------------------------------------------- Signature Date---------------- NO IIi,: Practitioners arc reminded that each organization will require submission of additional information. :S~CTlUN 14: AUUlTlUNAL lnj1uk1vlatlun This page is furnished for your convenience in completing questions or providing additional information. Please make as mcmy copies of this pc1ge c1s you require to fully cmswer c11l questions. As appropnme, nme secnon number and quesnon number rhm you are addressmg.
QUESTIONS Please answer each of the following questions in full. If the answer to any question is yes, please provide full explanation of the details on a separate sheet, and attach. If regarding malpractice, see last page of this processing information form & copy as necessary for each case. Question Yes No 1. Have any disciplinary actions been initiated or are any pending against you by any state licensure board? 2. Has your license to practice in any state ever been or is it currently in the process of being denied, limited, suspended, revoked or terminated (whether voluntarily or involuntarily)? 3. Have you ever been or are you currently in the process of being suspended, sanctioned or otherwise restricted from participating in any private, federal or state health insurance program (for example, Medicare, Medicaid)? 4. Have you ever been or are you currently in the process of being the subject of an investigation by any private, federal or state agency concerning your participation in any private, federal or state health insurance program? 5. Has your narcotics registration certificate ever been or is it currently in the process of being limited, suspended, revoked or terminated (whether voluntarily or involuntarily)? 6. Have you ever been or are you currently in the process of being charged with or convicted of a crime (other than misdemeanor traffic violations)? 7. Has your professional liability insurance coverage ever been or is it currently in the process of being terminated by action of the insurance company? 8. Have you ever been or are you currently in the process of being denied professional liability insurance coverage? 9. Has your present professional liability insurance carrier excluded or is it currently in the process of excluding any specific procedures from your coverage? 10. Have any professional liability suits been or are there any currently in the process of being filed against you? 11. Have any professional liability suits been filed against you which are presently pending? 12. Have any judgments or settlements been or are there any currently in the process of being made against you in professional liability cases? 13. Have your employment, Medical Staff appointment or privileges ever been or are they currently in the process of being suspended, diminished, revoked, refused or terminated (whether voluntarily or involuntarily) at any hospital or other health care facility? 14. Have you ever withdrawn your application for appointment, reappointment and/or clinical privileges or resigned from the Medical Staff before a decision by a hospital's or health care facility's governing board was rendered? 15. Have you ever been or are you currently in the process of being the subject of an investigation and/or disciplinary proceedings at any hospital or health care facility?
Questions Continued Yes No 16. Have you ever been or are you currently in the process of being denied appointment or renewal thereof, or been subject to disciplinary proceedings in any professional organization? REFERENCES List at least three practitioners who have an active practice and who have had significant work experience with you, have observed your professional performance in the recent past and who can provide reliable, non-confidential information as to your training, clinical experience and ability, ethics, character, ability to work with others and other qualifications for appointment. These references must not be partners or relatives but should be peers (in the same discipline). One of these references must be your training director from your most recent training program, if completed within the past ten years. One of the other peers should be your department chairman at your most recent or current hospital affiliation, if applicable. Provide current, complete mailing addresses, including zip code and email address. 1. Name: Relationship: Address: Telephone: Fax # Email: 2. Name: Relationship: Address: Telephone: Fax #: Email: 3. Name: Relationship: Address: Telephone: Fax#: Email: Print Name Signature Date