KAISER PERMANENTE Health Choice Practitioner Ancillary Application for Participation Instructions

KAISER PERMANENTE Health Choice Practitioner Ancillary Application for

Participation

Product Information

Specifications

• Product Name: Provider Application for Participation
• Target Audience: Providers located in MD, VA, and DC
• Usage: Application for consideration into Kaiser Permanente’s network

Product Usage Instructions

1. Ensure you are a provider located in MD, VA, or DC.
2. Complete the application form in its entirety.
3. Submit the application via email to interested.providers@kp.org in PDF format.

Important Notes

• This application is for new providers seeking inclusion in the Kaiser Permanente network.
• Existing network providers should not use this application for demographic changes.
• Submission of the application does not guarantee entry into the network.

Additional Resources

• CAQH (Council for Affordable
  Quality Healthcare) for credentialing application standardization.

• EPSDT (Maryland
  Healthy Kids/ Early Periodic Screening, Diagnosis, and TreatmentProgram) information.

FAQ

• Q: Who can use this application?
• A: This application is for providers such as physicians, therapists, and other professionals located in MD, VA, and seeking inclusion in Kaiser Permanente’s network.
• Q: Is submission of the application a guarantee of entry into the network?
• A: No, submission of the application does not guarantee entry. All applications are assessed against Kaiser Permanente’s network needs.

Introduction

• This is a PRACTITIONER APPLICATION for providers located in MD, VA, and DC only. Please use this application for consideration in Kaiser Permanente’s network.
• This application is only for providers, such as physicians, physical, occupational, and speech therapists, and other professionals. For consideration for inclusion into our network of providers, please complete this application in its entirety and submit it as indicated below. This application should not be used by existing network providers to make demographic changes or add providers to your practice.
• Important Disclaimer: All Information provided will be assessed against Kaiser Permanente’s network needs. Submission of an application does not constitute any obligation on the part of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., the
• Mid-Atlantic Permanente Medical Group, P.C. or any other or related Kaiser Permanente entity to enter into a contractual obligation.
• It is important that you clearly describe the services you offer so that we can best assess our need for your offered services. Your completed application must also include the attached Disclosure of Ownership and Control Information form. Additional pages are provided to list additional providers.
• Please complete this application electronically. Do not complete it by hand. We welcome any attachments, brochures, or descriptions you may choose to include to support your application.
• Incomplete applications will be automatically denied and returned to you at the contact email address within ten (10) days of receipt. We will process complete applications and provide notice of our decision in writing within thirty (30) days.
• For questions regarding the process and/or application please email interested.providers@kp.org

Return completed applications using one of the following options

• Email-only VA, MD, and DC applications in PDFs to: interested.providers@kp.org

Provider Application for Participation

Practitioner/Ancillary Information
General Information

The group/Practice Name should be exactly as it is on your W-9, please enclose a copy of your W-9

Practice Setting

• Does this group practice exclusively in a hospital setting? ☐ Yes ☐ No
• If YES, please name the hospital(s) where providers have admitting/staffing privileges.

Provider Specialty (Including Subspecialties)

Languages Spoken

• Medicare Certified: ☐ Yes ☐ No Accepting Medicare Patients: ☐ Yes ☐ No
• VA Medicaid Certified:☐ Yes ☐ No Accepting Medicaid Patients: ☐ Yes ☐ No
• MD Medicaid Certified:☐ Yes☐ No Accepting Medicaid Patients: ☐ Yes ☐ No
• Do you maintain general liability insurance of at least $1,000,000/$3,000,000? ☐ Yes ☐ No
• Do you maintain professional liability insurance of at least $1,000,000/$3,000,000? ☐ Yes ☐ No
• Do you agree to facilitate all necessary credentialing activities? ☐ Yes ☐ No

**Lines of Business***
Check off all lines of business you want to be contacted for:

• Commercial ☐ (HMO, PPO, POS, etc.)
• Medicare ☐ provide licensure #: ____
• Virginia Medicaid ☐, provide licensure #: __
• Maryland Medicaid ☐, provide licensure #: _____

Contracting will be done for each line of business as needed by Kaiser Permanente, requesting the line of business does not guarantee a contract will be made for that line of business.

• CAQH (Council for Affordable Quality Healthcare) is a universal national data source for standardizing the provider credentialing application process. Visit www.caqh.org. Please ensure that all provider information is updated and current on CAQH.
• EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.

Disclosure of Ownership & Control Information

This section must be completed by an authorized representative of the participating provider practitioner, group, or facility. An authorized representative is defined as an individual with designated authority to act on behalf of the individual, group of practitioners, or disclosing entity. If not a solo practitioner, then the authorized representative must be a partner, president, or secretary of the group of practitioners.

Ownership and Control Information for Disclosing Entity, 42 C.F.R. §455.104

• List any individual who has any ownership or controlling interest in this provider entity or any subcontractor.
• List the name, title, (e.g., CEO, President), address, and Tax ID Number of any organization, corporation, or entity having any ownership or controlling interest in this provider entity.
• The ownership or controlling interest is an ownership interest of 5% or more in this provider entity.

Relationships

• List any individuals named in Question 1 who are related to each other (e.g., spouse, parent, child, or sibling).
• List their name, state their relationship, and include their Social Security Number.

Subcontractor

• List any individual with an ownership or control interest in any subcontractor that the disclosing entity has direct or indirect ownership of 5% or more.

Other Disclosing Entity

• List the name, address, and Tax ID Number of any other disclosing entity other than a subcontractor in which a person with an ownership or controlling interest in this disclosing entity has an ownership or control interest of 5% or more.

Criminal Offenses
Has any individual or organization listed in Questions 1, 2, 3, and 4 ever been convicted or assessed fines or penalties for any health-related crimes or misconduct and/or excluded from any federal or state health care program due to fraud, obstruction of an investigation, a controlled substance violation or any other crime or misconduct? If your answer to this question is YES, please provide the name, address, Social Security Number, Tax ID Number, and percentage of ownership for these individual(s) and/or organization(s).
☐ Yes ☐ No

Criminal Offenses
Has ANY individual or contractor connected with your practice been convicted or assessed fines or penalties for any health-related crimes or misconduct, or excluded from any federal or state health care program due to fraud, obstruction of an investigation, a controlled substance violation, or any other crime or misconduct? If your answer to this question is YES please provide the name, address, and Social Security Number/Tax ID Number for individual(s) or contractor(s).
☐ Yes ☐ No

Criminal Offenses
Has the applicant ever had any adverse legal actions imposed by Medicare, Medicaid any other federal or state agency or program, or any licensing or certification agency?
☐ Yes ☐ No

If yes, please provide a copy of the relevant final disposition

Provider (Group/Facility/Individual) Information Form

Section 1: Provider Demographic Information

Legal Entity Information

Legal Entity Name:|
Legal Entity Tax ID:|
Legal Entity NPI:|
Legal Entity Medicare ID:|
Legal Entity VA Medicaid ID:|
Legal Entity MD Medicaid ID:|
Legal Entity Information

Legal Entity Name:|
Legal Entity Tax ID:|
Legal Entity NPI:|
Legal Entity Medicare ID:|
Legal Entity VA Medicaid ID:|
Legal Entity MD Medicaid ID:|
Billing Information

Billing Contact Name:|
Job Title:|
Street Address, Suite/Floor:|
City, State, Zip:|
Phone Number:|
Email:|
Claims Payment Address

Claims Payment Contact Name:|
Job Title:|
Street Address, Suite/Floor:|
City, State, Zip:|
Phone Number:|
Email:|

Section 2: Virginia and Maryland Medicaid and Medicare Enrollment

• Enrollment is required for all Groups, Facilities, and/or Individuals in the systems above to have these lines of business added to your Agreement.

Section 3: Practice Location Adds

Location 1

Practice Name:|
Street Address, Suite/Floor:|
City, State, Zip:|
Location Tax ID:|
Location Billing NPI/CCN Number:| Location Billing NPI| CCN Number (Skilled Nursing Facility Only)
|
Medicare/Medicaid Numbers:| Medicare Advantage ID#| Virginia Medicaid ID#| Maryland Medicaid ID#
| |
Practice Location Phone Numbers:| Voice| Fax
|
Contact Name/ Email:|
Email:|
Location 2

Practice Name:|
Street Address, Suite/Floor:|
City, State, Zip:|
Location Tax ID:|
Location Billing NPI/CCN Number:| Location Billing NPI| CCN Number (Skilled Nursing Facility Only)
|
Medicare/Medicaid Numbers:| Medicare Advantage ID#| Virginia Medicaid ID#| Maryland Medicaid ID#
| |
Practice Location Phone Numbers:| Voice| Fax
|
Contact Name:|
Email:|
Location 3

Practice Name:|
Street Address, Suite/Floor:|
City, State, Zip:|
Location Tax ID:|
Location Billing NPI/CCN Number:| Location Billing NPI| CCN Number (Skilled Nursing Facility Only)
|
Medicare/Medicaid Numbers:| Medicare Advantage ID#| Virginia Medicaid ID#| Maryland Medicaid ID#
| |
Practice Location Phone Numbers:| Voice| Fax
|
Contact Name:|
Email:|
Location 4

Practice Name:|
Street Address, Suite/Floor:|
City, State, Zip:|
Location Tax ID:|
Location Billing NPI/ CCN Number:| Location Billing NPI| CCN Number (Skilled Nursing Facility Only)
|
Medicare/Medicaid Numbers:| Medicare Advantage ID#| Virginia Medicaid ID#| Maryland Medicaid ID#
| |
Practice Location Phone Numbers:| Voice| Fax
|
Contact Name:|
Email:|

• For additional Location adds, please replicate this section for as many additional locations as are needed

Section 4: Provider Adds

For additional Provider adds, replicate this section for as many additional providers as needed.

I am authorized to sign for the physicians or providers listed above about the current agreement, including any amendments with the Mid-Atlantic Permanente Medical Group, P.C., and/or the Kaiser Foundation Health Plan, and to bind such providers to the terms and conditions of the agreement.

THE FORM MUST BE SIGNED AND DATED OR IT WILL BE RETURNED AS INCOMPLETE

References

• CAQH - Streamlining the Business of Healthcare

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