Organizational Credentialing Application

Organizational Credentialing Application

Things to note!

1. Type or print clearly in black ink
2. If the requested Credential does not apply to the submitted provider, denote with N/A
3. A separate Organizational Credentialing Application must be completed for each NPI.
4. Cenpatico Integrated Care is the Credentialing Verification Organization (CVO) for Bridgeway Health Solutions (BW) Behavioral Health line of business only
5. Are you contracting with Cenpatico only Yes No N/A
6. Are you contracting with Bridgeway only Yes No N/A
7. Are you contracting with Both Cenpatico and Bridgeway Yes No N/A

1. Contracts with both healthplans are needed to be considered in network with both Health Plan’s
2. Credentialing approval does not guarantee a contract approval or claims payment

Please ensure the following documents are included with your application

• Initial and Re-Credentialing: A copy of your JCAHO/CARF/COA/or AOA accreditation letter with dates of accreditation.
• If not accredited please include a copy of your Centers for Medicare and Medicaid Services (CMS) certification review/audit. The audit cannot be more than 3 years old from the time of credentialing cycle inception.
• If a CMS survey has not been completed and the provider is not accredited, the provider can supply the most current review conducted by the Arizona Department of Health Services (ADHS) denoting the summary and audit findings. The survey cannot be more than 3 years old from the time of credentialing cycle inception.
• Initial and Re-Credentialing: A copy of the state or local license(s) and/or certificate(s) under which your facility operates.
• Initial and Re-Credentialing: A copy of your CLIA license. (If applicable)
• Initial and Re-Credentialing: A copy of your Pharmacy license. (If applicable)
• Initial and Re-Credentialing: A copy of your professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate, name of liability carrier, and insurance effective date and expiration date (Month/Day/Year). If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement.
• Initial and Re-Credentialing: If applicable or requested a copy of W-9 for each TaXID

Mail, fax or email the signed application with all necessary documents to:

Cenpatico Integrated Care

Attention: Credentialing Department

1501 W Fountainhead Pkwy

Ste360

Tempe, AZ 85282

FAX: 866-912-3611

EMAIL:

Are you providing transportation services? Yes No N/A

If Yes, (the following information is to be included in the credentialing packet)

1. Include a maintenance schedule for all vehicles used to transport AHCCCS members.
2. Attestation statement to be signed (included on last page of application); to confirm that your group is using age appropriate car seats when transporting children.
3. Transportation group would also have to meet Automobile Liability coverage “Combined Single Limit - $1,000,000.00”

Note for internal processing: Credentialing Specialist must check for transportation COS’s in PMMIS (31 or 14 or both)

1. The billing address should link to the name and address noted on the W9.
2. We can only process one payment address per TaxID.

Is your facility affiliated with any other health care organization(s) through corporate linkage or other formal arrangement? If so, please provide the following information: (List additional affiliations on a separate page.)

Please provide a copy of these documents as applicable, including the results of the survey and a report that shows the effective date of accreditation or certification, deficiencies and approved plan for corrective action.

The face sheet must indicate applicant as the insured, the policy period, and the following coverage amounts;

• Each Occurrence - $1,000,000.00
• Damage to Rented Premises - $50.000.00
• Personal and Advertising Injury $1,000,000.00
• General Aggregate - $2,000,000.00
• Products completed operations aggregates - $1,000,000.00
• Sexual Abuse/Molestation - $500,000.00
• Professional Liability
• Each Claim $1,000,000.00
• Annual Aggregate $2,000,000.00
• If applicable
• Automobile Liability: Combined Single Limit - $1,000,000.00
• Workers Compensation & Employers Liability
• E.L. Each Accident $500,000.00
• E.L. Disease each employee $500,000.00
• E.L. Disease – Policy Limit $1,000,000.00

1. Provide the name and address of all persons with an ownership or control interest in each subcontractor named in question #2. NOTE: Designate relationship to subcontractor listed above by using A., B., C., etc.

Facility Responsibility Form

I hereby understand that as a prospective/current Cenpatico Integrated Care (Cenpatico IC)or Bridgeway Health Solutions provider, I am solely responsible for ensuring that any licensed practitioners under my employment or working in association with my clinical practice are fully qualified and have all necessary licenses required by all relevant laws to legally perform the assigned functions within my practice. Furthermore, I understand that as a prospective/current Cenpatico Integrated Care (Cenpatico IC) or Bridgeway Health Solutions contracted facility, I am responsible for ensuring that any behavioral health technicians and paraprofessionals must have appropriate training and documentation including but not limited to; Training by the agency, supervision and monitoring by licensed staff, Medicaid clearance and fingerprint clearance. A full listing of requirements can be found in the AHCCCS Medical Policy Manual, chapter 900, policy 950. Further, from time to time, such licensed practitioners may change, as my practice associates. In all such cases, I accept responsibility for notifying CENPATICO IC in a timely manner about these new arrangements and will be responsible for fully cooperating in the submission of completed application forms and providing any other information as may be required to satisfy CENPATICO IC credentialing/recredentialing requirements for all such individuals associated with my practice.

By applying for participation with CENPATICO IC, I hereby fully understand that the information submitted in this application shall be held confidential by the CENPATICO IC and provided only to individuals connected with the Plan on a need to know basis. Notwithstanding the foregoing, I agree to the following:

• Participation in the credentialing review functions of CENPATICO IC.
• Authorize CENPATICO IC and its representatives to consult with prior or current associates and others who may have information bearing on our professional competence, character, health status, ethical qualifications, ability to work cooperatively with others and other qualifications needed for verification of credentials. This includes such primary source verifications as accreditation bodies, professional liability carriers, State and Federal agencies or any other verification entities required by the Plan’s accrediting bodies, CMS, or other State or Federal regulatory agencies.
• Consent to an inspection by CENPATICO IC and its representatives of all documents that may be material to an evaluation of qualifications and competence. This is applicable if the applicant is not accredited by a nationally recognized accrediting body.
• Consent to the release of such information for credentialing purposes.
• Release from liability all representatives of CENPATICO IC for their acts performed and statements made, in good faith and without malice, in connection with evaluating the application, credentials and qualification for determination of credentialing status.
• Acknowledge that I, the Applicant, have the burden of producing adequate information for a proper evaluation of our professional, ethical and other qualifications for credentialing purpose and for resolving any doubts about such qualifications.
• Acknowledge that any material misstatement in, or omissions from, this application constitute cause for denial of credentialing status or cause for summary for revocation or suspension of privileges and/or dismissal from the participating network.

Attestation statement for Transportation providers:

I confirm that my transportation group is using age appropriate car seats when transporting children.

In order to evaluate this application for participation in and/or continued participation with CENPATICO IC, the Facility hereby given permission to CENPATICO IC to request from other entities information regarding the Facility’s credentials and qualifications. This includes consent to contact the Facility’s accreditation agencies, State Regulatory and Licensing Departments, professional liability and workers compensation insurance carriers. The Facility understands that CENPATICO ICwill use this information in a confidential manner on its own behalf and, if applicable, as an agent for one of its affiliated networks in connection with the administration of CENPATICO IC.

The Facility certifies that the information provided and the answers to the questions on this application are accurate and complete. While this application is being evaluated, and if this Facility is selected or retained, after such selection or retention, the Facility agrees to inform CENPATICO IC in writing within 10 days of any changes in the information provided and the answers to questions on the application as a result of developments subsequent to the execution of this application.

The Facility agrees that submission of this application does not constitute selection or retention by CENPATICO IC on its own behalf and if the Facility is initially applying for participation, grants this Facility no rights or privileges in any CENPATICO IC programs or any program until such time as this Facility receives notice of participation.

All information submitted in this application is true and complete to the best of my/our knowledge and belief. A photo copy of this original constitutes our written authorization and requests to release any and all documentation relevant to this application. A photo copy shall have the same force and effect as the signed original.

Revision 12:

1/19/2017