1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.800.472.2363 or 715.221.9555 TTY: 1.877.727.2232 or 715.221.9898 Provider Credentialing Application Security Health Plan s Expectations of Providers Security Health Plan expects affiliated providers to: act in the best interest of our members communicate fully with members regarding their illness, as well as diagnostic and therapeutic options available to them refer members for specialty care or second opinions within the Security Health Plan provider network and obtain approval from the Security Health Plan medical director when it is felt that care is necessary outside of the health plan network maintain awareness of Security Health Plan Technology Assessment and Drug Evaluation Committee decisions to the extent possible participate in Security Health Plan utilization management and quality improvement initiatives, including allowing Security Health Plan reasonable access to member medical records recognize that there are multiple, well accepted means of diagnosis and treatment for many given conditions inform the Medical Director when Security Health Plan procedures or actions are perceived as threatening the health or well-being of the member recognize that conflict occasionally occurs between providers and Security Health Plan, or members and Security Health Plan, and that these should be resolved within the appeals process outlined in Security Health Plan documents understand that Security Health Plan does not deny patient care, but simply makes payment decisions based on member s coverage through Security Health Plan communicate with members and Security Health Plan in a way that assumes that all parties are acting in good faith with the goal being good care for the member recognize that Security Health Plan is obligated to develop policies and procedures on benefit administration and to administer these in a fair and consistent manner even though this occasionally results in denial of payment for individual members understand that Security Health Plan s goal is to improve access to, and quality of, health care refrain from making comments or offering advice on payment or insurance coverage issues refer patients with payment or insurance coverage issues to Security Health Plan Customer Service Department at 1-800-472-2363 identify advance directive status in the medical record and implement advance directives per member s request HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc.
1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.800.472.2363 or 715.221.9555 TTY: 1.877.727.2232 or 715.221.9898 Provider Credentialing Application Provider s Expectations of Security Health Plan Providers of care can expect Security Health Plan to: assist the provider in meeting the expectations of Security Health Plan pay claims fairly and efficiently not make credentialing decisions based on applicant s race, ethnic/national identity, gender, age or sexual orientation or on type of procedure or patient in which the provider specializes provide due process to the provider when complaints or grievances are lodged against him or her, or when a provider wishes to appeal Security Health Plan decisions strive to interfere as little as possible with the process of care, unless there are significant issues related to quality, cost or coverage support the provider in practice by identifying opportunities to improve care when information is available on a practice basis or an individual member basis maintain an appeals process that can respond quickly and appropriately to members and providers educate and encourage members to be seen for appropriate preventive services inform providers of initiatives that may affect them or our members before such interventions occur, and before members are aware of them (i.e. educational programs which may result in questions being asked of the provider) maintain internal processes to improve service to our members and providers review clinical information when making decisions about coverage; staff do not receive financial compensation for denying benefits for health care services, nor is Security Health Plan performance measured on such denials inform providers of changes in benefit administration policies that may affect them or our members awareness provide a written copy of Security Health Plan s QI evaluation upon request HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc.
1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.800.472.2363 or 715.221.9555 TTY: 1.877.727.2232 or 715.221.9898 SHP Use Only Provider Credentialing Application l Security Health Plan l Family Health Center l Medicaid HMO Date credentialed Provider number Please: Type or print legibly. Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Checklist (please complete) (If your application for your DEA certificate, Wisconsin license and/or malpractice insurance are pending, please forward application and send those documents as soon as possible.) l Copy of Wisconsin license l Copy of Board Certification l Copy of Nurse Practitioner, Nurse Midwife, or Physician Assistant certification l Copy of DEA certificate l Copy of CMS letter of approval l Copy of liability face sheet with effective/expiration dates and coverage limitations (only if the professionaiability carrier section in this application is not completed in its entirety) l Copy of curriculum vitae or resumé including month and year time frame l Malpractice Litigation and Professional Complaints form, if applicable l Signed and dated Agreement Relating to Credentialing Process l Explained all gaps greater than six months in chronology l Answered all of the Disclosure Questions and enclosed explanations for affirmative answers l Signed and dated Authorization for Release of Information form Keep a copy for your records. NOTE If this application was completed more than 180 days prior to the date of your signature, information on the application must be updated and a new Authorization for Release of Information must be completed. Please review carefully and provide any current information you may have. Incomplete applications will be returned for completion. Upon advance notification, you have the right to review (in person at the Security Health Plan office during normal business hours) your credentials file. You will not be allowed to review references, recommendations, or other information that is peer-review protected or information obtained from NPDB, HIPDB or similar restricted services. You have the right to correct erroneous information. You may contact Security Health Plan Network Management Department at 1-800-548-1224 during normal business hours to be informed of the status of your credentialing application. HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 1
Fulegal name (last, first, MI) Personal information Maiden/Former name (used for primary source verification e.g. license verification) Full professional credentials (used for Security Health Plan Provider Directory): l M.D. l D.O. l D.D.S. l Other (specify) Social Security number Date of birth Gender: Languages fluently spoken in addition to English: l Spanish l French l German l Italian l Hmong l Other Wisconsin license number Professional information l Male l Female Expiration date DEA number Federal tax ID number Will you be accepting Wisconsin Medicaid patients: l Yes l No Expiration date NPI number Wisconsin Medicaid provider number Will you be accepting Wisconsin Medicare patients: l Yes l No If yes, Security Health Plan requires a copy of your CMS letter of approval of Medicare certification for each practice location, as applicable. If yes and have applied for Medicare certification but have not received your CMS letter of approval, Security Health Plan requires a copy of page 6 of CMS-855I with your personal information and correspondence address information completed for each practice location, as applicable. Note: Failure to provide a copy of one of the above forms will result in Medicare claim rejection. Primary practice location (within Security Health Plan s service area) Office name Medicare/PTAN number Address (street, city, state, ZIP) Office manager l Medicare provider number applied for Telephone number Fax number Credentialing contact Start date at this location Additional practice location Office name Medicare/PTAN number Address (street, city, state, ZIP) l Medicare provider number applied for Telephone number Start date at this location HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 2
Additional practice location Office name Professional information (continued) Medicare/PTAN number Address (street, city, state, ZIP) l Medicare provider number applied for Telephone number Start date at this location Indicate your after-hours coverage procedure(s): l Answering service and page l Nurse triage system l On-call physician/dentist via answering service l Answering machine l On-call physician/dentist via answering machine/ l Other recorded message Patients are informed of your after-hours coverage: l Yes l No IMPORTANT: After-hours coverage must be provided by a Security Health Plan affiliated provider. Medical/Graduate/Professional education From Institution name Degree received: l M.D. l D.O. l D.D.S. l D.C. l D.P.M. l Ph.D. l Other Address Telephone number From Institution name Degree received: l M.D. l D.O. l D.D.S. l D.C. l D.P.M. l Ph.D. l Other Address Telephone number ECFMG applicable to international medical graduates ECFMG number Date issued (mo/yr) Valid through (mo/yr) Internship/Post-graduate/Professional training If additional space is required, attach a separate sheet. From Institution name Type of program/specialty (transitional, rotating, 5th pathway, etc.) Completed training: l Yes l No If no, expected completion date If not successfully completed, explain and provide the following information: Program director Address Telephone number HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 3
Resident/Post-graduate/Professional training If additional space is required, attach a separate sheet. From Institution name Address Telephone number Type of program/specialty Completed training: l Yes l No If no, expected completion date If not successfully completed, explain and provide the following information: Program director From Institution name Address Telephone number Type of program/specialty Completed training: l Yes l No If no, expected completion date If not successfully completed, explain and provide the following information: Program director Fellowship/Post-graduate/Professional training If additional space is required, attach a separate sheet. From Institution name Address Telephone number Type of program/specialty Completed training: l Yes l No If no, expected completion date If not successfully completed, explain and provide the following information: Program director HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 4
Medical specialty Certifying Board Specialty/Subspecialty Date Certified Date Recertified Expiration Date Security Health Plan provider directory designation All credentialed providers will appear in the Security Health Plan Provider Directory as applicable. direct our members to the appropriate provider, the following questions must be answered: Are you willing to serve as a primary care provider. (Primary care providers are M.D.s, D.O.s, N.P.s and P.A.s) in general practice, internal medicine, family medicine, general pediatrics and geriatric medicine): l Yes l No Do you provide services to children: l Yes l No Security Health Plan Provider Directory designation is based on education/training/board certification. Please list your provider specialty designation Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet. This information may be used for referral purposes.) Hospital privileges List all hospitals within Security Health Plan s service area where you currently have, OR have applied for, hospital staff privileges. Primary hospital name City Additional hospital name City Additional hospital name I have hospital privileges and they are in good standing. l Admitting l Other l N/A l Applied for: I have applied for hospital privileges and have made arrangements for admitting privileges with another Security Health Plan affiliated provider until I receive active privileges (*please explain arrangement below) l No: I do not have admitting privileges but have made a formal arrangement with another Security Health Plan affiliated provider (*please explain arrangement below) City *Explanation for formal hospital admitting arrangement HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 5
Chronological employment/practice history (include military service) Chronologicaisting (month/year) of employment/practice history since completion of your postgraduate training. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOLOGY. From Organization name/activity Address Telephone number From Organization name/activity Address Telephone number From Organization name/activity Address Telephone number From Organization name/activity Address Telephone number Explain gaps/interruptions of greater than six (6) months to practice of medicine/professional practice (if additional space is required, attach a separate sheet): From Explain From Explain From Explain From Explain HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 6
Professionaiability carrier If this section is not completed in its entirety you must submit a copy of the declaration page of your present malpractice liability policy showing the effective/expiration dates and coverage limitations. Coverage dates From l Certificate pending Insurance carrier name Address Name in which policy issued Policy number Expiration date Amount of coverage (per occurrence/aggregate) Security Health Plan requires that all physicians and nurse anesthetists participate in the Injured Patients and Families Compensation Fund in accordance with the Wisconsin Statutes. Please provide a complete explanation if any of the following questions are answered in the affirmative. Use a separate sheet to continue, if necessary. Yes No Disclosure questions Licensure 1. Has your professionaicense or registration ever been, or is it in the process of being reprimanded, placed on probation, terminated, stipulated, restricted, limited, conditioned, suspended, revoked, refused, voluntarily relinquished or not renewed by any licensing board or any health-related agency organization, or is there a review pending? 2. Has your professionaicense or registration ever been investigated or is it currently being investigated and, if so, what is the status or what were the results? DEA or State controlled substance registration 3. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) Certificate(s) or Authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished, or is there a review pending? Hospital privileges and other affililations 4. Has your membership, participation, clinical privileges, or employment ever been denied, reprimanded, placed on probation, terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer reviewer organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending? HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 7
Disclosure questions (continued) Yes No 5. Have you ever voluntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professionaicense, or registration in lieu of disciplinary action, or prior to or during an investigation into your professional conduct or competency? 6. As a medical provider, has your employment ever been terminated by an employer for quality of care or professional conduct reasons? 7. Have you ever involuntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professionaicense or registration? Medicare, Medicaid or other govermental program participation 8. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Other sanctions or investigations 9. Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? Professionaiabilty insurance information and claims history 10. Have you ever had any professionaiability claims or lawsuits brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or final judgements? If yes, please complete the enclosed Malpractice Litigation and Professional Complaints Addendum. 11. Have you ever been found negligent in any malpractice suit or action? If yes, please complete the enclosed Malpractice Litigation and Professional Complaints Addendum. HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 8
Disclosure questions (continued) Yes No 12. Has your professionaiability carrier ever refused or canceled your coverage or excluded you from performing any specific privileges within your specialty? Criminal/Civil history 13. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? 14. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? Ability to perform job 15. Are you currently engaged in the illegal use of drugs? ( Currently means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one s ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act. 21 U.S.C. S 812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federaaw. The term does include, however, the unlawful use of prescription controlled substances.) 16. Do you use any substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? 17. Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions? HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 9
Malpractice litigation and professional complaints addendum CONFIDENTIAL INFORMATION Please complete the following form. For each lawsuit or complaint, please furnish the following and attach a copy of the complaint including your response to the complaint and level of participation. It is your responsibility to provide external verification (i.e., statement from an attorney, court records, etc.) of your response. You may choose to have your attorney complete this form. Please make additional copies of this form if needed. Month/Year of incident: Where incident occurred: Describe the nature of incident (complaint, allegation) do not include patient name or identifiers: Provide a narrative description of your participation/level of care: Outcome of incident: l Pending l Dropped/Settled/Closed no payment l Verdict for you no payment l Settled/closed with payment, amount l Verdict for plaintiff, amount l Date closed Represented by legal counsel for this claim/malpractice lawsuit: l Yes If yes, give the name and address of counsel. Name l Dismissed with prejudice l Dismissed without prejudice l No Address (street, city, state, ZIP) Telephone number Insurance company that provided coverage for this claim Name Address (street, city, state, ZIP) Telephone number Policy number Signature Date Name (print) Telephone number HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 10
Agreements relating to credentialing I am submitting an application for credentialing with Security Health Plan of Wisconsin, Inc. In submitting my application to Security Health Plan, I agree to the following: I certify that all information in my application is accurate and complete. I understand that falsification of any information on this application may result in denial or termination of affiliation. During the application process and during any period in which I am an affiliated provider, I agree to immediately update Security Health Plan on any changes in the information submitted in my application and agree to provide such additional information and execute such additional forms as may be requested by Security Health Plan in order to evaluate my professional qualifications and competence and conduct. As an applicant for credentialing with Security Health Plan, I have the right to review the information submitted in support of my credentialing application. I acknowledge that Security Health Plan will notify me if there are discrepancies in the information received during the credentialing process, and I will be allowed an opportunity to add information to my application. All policies of Security Health Plan are administered without regard to race, color, national origin, ancestry, handicap, sex, marital status, age or sexual orientation. Signature and professional credentials Date Name (print) Authorization for release of information I have applied to be an affiliated provider with Security Health Plan of Wisconsin, Inc. In order for Security Health Plan to evaluate my qualifications, I authorize Security Health Plan and its authorized representatives and agents to consult with any third party who may have information (including information that otherwise may be privileged or confidential) relating to my professional qualifications and competence and conduct. I also authorize any such third party to release such information and related reports and documents to Security Health Plan and its authorized representatives and agents upon request and receipt of a copy of this Authorization for Release of Information. I understand Security Health Plan will use this information solely in conjunction with my application for affiliation, and that the information is not subject to redisclosure except as permitted by Federal or State Law. I hereby release from aliability Security Health Plan and its directors, officers, employees and authorized representatives and agents and third parties for any acts performed in good faith in providing or receiving information, reports or other documents relating to, or in evaluating, my professional qualifications or competence or conduct. This release from liability shall include, but not be limited to, actions relating to the following: My application to be an affiliated provider with Security Health Plan Periodic appraisals undertaken for recredentialing, utilization review or otherwise for quality management Proceedings for termination, suspension or restriction of my status as a participating provider with Security Health Plan or any other disciplinary action This authorization is valid for 180 days and, if I become a Security Health Plan affiliated provider, for the time that I participate as a Security Health Plan provider. Signature and professional credentials Date Name (print) Email address HP-00019 (10/13) 2000 2013 Security Health Plan of Wisconsin, Inc. page 11