Organizational Provider Credentialing Application

Instructions:

Please complete the following application. Additionally, the following documents, where applicable, will be required:

Facility license
Facility administrator’s license
Director of nursing’s license
Current copy of your Professional Liability Insurance Face Sheet (limit at a minimum of $1M / $3M)
Copy of W-9 for each Tax ID number with which you bill.
Recredentialing Facility profile corrected and initialed (please initial even if no change is made)
Certified Laboratory Improvement Amendments (CLIA) certification
Most recent CMS survey, including corrective action plan if deficiencies were cited and evidence from CMS that all deficiencies are remedied.
Most recent Department of Health Facility Regulation on-site survey, including corrective action plan if deficiencies were cited and evidence that all deficiencies have been remedied.
Copy of Accreditation certification (Neighborhood will conduct a site visit at facilities not accredited by an accrediting agency accepted by Neighborhood)

If you have any questions regarding this application, please call Neighborhood’s Credentialing Department at (401) 459-6000.

Please complete each section. Clearly state if information requested is not applicable.

Type of Facility*

Facility Demographics

Legal Business Name*

Doing Business As (DBA) Name

If applicable

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Credentialing Contact

Name*

First Last

Credentialing Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Billing Information

Contact Name*

First Last

Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Agencies providing skilled services

Director of Nursing: Name

First Last

Director of Nursing: State License #*

Please attach a copy of the Director of Nursing’s license.

Accepted file types: pdf, Max. file size: 2 MB.

Medical Director: Name

First Last

Medical Director: State License #*

Please attach a copy of the Medical Director’s license.

Accepted file types: pdf, Max. file size: 2 MB.

Laboratory Director: Name

First Last

A Medical Director who is not currently credentialed with Neighborhood Health Plan must submit an individual credentialing application to request plan participation

Laboratory Director: State License #*

Facility Questionnaire

1. Is this facility participating in the Medicare/Medicaid program (CMS)*

1. Is this facility participating in the Medicare/Medicaid program (CMS) *

Yes
No

2. Has this facility had an initial on-site survey by CMS?*

2. Has this facility had an initial on-site survey by CMS? *

Yes
No

2a. If yes, date of most recent full onsite survey by CMS*

2b. Were any deficiencies identified during the on-site survey?*

2b. Were any deficiencies identified during the on-site survey? *

Yes
No

(Please provide letter received following your site visit which states that there were either no deficiencies or that your plan of corrective action has been accepted )

If yes, provide evidence of acceptance of the Corrective Action Plan*

Accepted file types: docx, pdf, Max. file size: 2 MB.

3. Has this facility had an initial on-site survey by the Department of Health Facility Regulation (DOH)?*

3. Has this facility had an initial on-site survey by the Department of Health Facility Regulation (DOH)? *

Yes
No

3a. If yes, date of most recent full onsite survey by DOH*

3b. Were any deficiencies identified during the on-site survey?*

3b. Were any deficiencies identified during the on-site survey? *

Yes
No

(Please provide letter received following your site visit which states that there were either no deficiencies or that your plan of corrective action has been accepted)

If yes, provide evidence of acceptance of the Corrective Action Plan*

Accepted file types: docx, pdf, Max. file size: 2 MB.

4. Has any formal complaint been filed with CMS?*

4. Has any formal complaint been filed with CMS? *

Yes
No

5. Has any formal complaint been filed with DOH?*

5. Has any formal complaint been filed with DOH? *

Yes
No

6. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization?*

6. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization? *

Yes
No

7. Has any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility?*

7. Has any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility? *

Yes
No

8. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied?*

8. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied? *

Yes
No

9. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS?*

9. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS? *

Yes
No

10. Has any Federal or State agency ever taken any action which limited this facility?*

10. Has any Federal or State agency ever taken any action which limited this facility? *

Yes
No

11. Has the facility’ ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state?*

11. Has the facility’ ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state? *

Yes
No

12. Is criminal background check performed for all personnel employed by the facility?*

12. Is criminal background check performed for all personnel employed by the facility? *

Yes
No

13. Does the facility conduct ongoing screening and monitoring to ensure all personnel employed and vendors the provider contracts with are not excluded from Medicare and/or Medicaid program?*

13. Does the facility conduct ongoing screening and monitoring to ensure all personnel employed and vendors the provider contracts with are not excluded from Medicare and/or Medicaid program? *

Yes
No

14. Are there any formal or written claims alleging malpractice against the agency that have been resolved or are currently pending ?*

14. Are there any formal or written claims alleging malpractice against the agency that have been resolved or are currently pending ? *

Yes
No

Detailed Summary*

Carrier at Time of Incident*

Date of Alleged Incident*

Date of Lawsuit Filed*

Name of Court*

Case Number*

Date of Settlement

Status of Case (with reference to you specifically)*

Notice of Claim Filed
Pending Before Malpractice Panel
Pending in Court
Closed Without Payment
Pre-Trial Settlement
Verdict for Defendant
Verdict for Plaintiff

Pre-Trial Settlement - Dollar Amount*

Verdict for Plaintiff - Dollar Amount*

What was/is your status?*

Sole-defendant
Co-Defendant
Other

Co-Defendant: Further Explanation*

Other: Further Explanation*

I certify that I am the duly authorized representative of the Facility, that all information provided herein, including attachments, represents full and truthful disclosures of the matters to which they pertain.

Name of person who completed the questionnaire*

First Last

Title*

Signature*

Date*

Facility License*

Accepted file types: pdf, Max. file size: 2 MB.

W-9*

Accepted file types: pdf, Max. file size: 2 MB.

Current Professional Liability Insurance Face Sheet*

Accepted file types: pdf, Max. file size: 2 MB.

Certified Laboratory Improvement Amendments (CLIA) certification

Accepted file types: pdf, Max. file size: 2 MB.

Most recent CMS survey, including corrective action plan if deficiencies were cited and evidence from CMS that all deficiencies are remedied

Accepted file types: pdf, Max. file size: 2 MB.

Most recent Department of Health Facility Regulation on-site survey, including corrective action plan if deficiencies were cited and evidence that all deficiencies have been remedied

Accepted file types: pdf, Max. file size: 2 MB.

Copy of Accreditation certification (Neighborhood will conduct a site visit at facilities not accredited by an accrediting agency accepted by Neighborhood)

Accepted file types: pdf, Max. file size: 2 MB.

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