HMSA Provider Enrollment and Credentialing Application · 2019-09-23 · HMSA PROVIDER ENROLLMENT AND CREDENTIALING APPLICATION FORM. PLEASE RETURN THIS CHECKLIST WITH YOUR APPLICATION

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HMSA PROVIDER ENROLLMENT AND CREDENTIALING APPLICATION FORM PLEASE RETURN THIS CHECKLIST WITH YOUR APPLICATION Use this checklist to make sure you have all of the documents required to complete your application. Before sending us your application packet, confirm that you’ve included eveything on this checklist. We can’t begin this enrollment and credentialing process until we receive all required forms and documentation. _____________________________________________________________________________________________________ REQUIRED FORMS – Submit one copy of each form, all with original signatures HMSA Provider Enrollment and Credentialing Application Form Authorization to Release Documents and Information and Dispute Resolution Agreement If applying to be participating with HMSA QUEST Integration, complete the QUEST Integration Additional

Contracting Requirements Forms (pages Q-1 to Q-3) o Medicaid Provider Application/Change Request form (DHS 1139) Attestation

As of January 1, 2018, providers must complete and submit the Medicaid Provider Application/Change Request Form, also called the DHS 1139 form to the State Medicaid Agency, Department of Human Services (DHS) Med-QUEST Division (MQD). You can download the 1139 application and instructions from MQD’s website at: https://medquest.hawaii.gov/en/plans-providers/become-a-medicaid-provider.html. Please attest if this requirement has been completed.

o Cultural Competency Plan For QUEST Integration, providers need to attest that they’re aware of and will follow and incorporate into their practice the HMSA QUEST Integration Cultural Competency Plan. The link to the Cultural Competency Plan: hmsa.com/portal/provider/zav_qi.02.cul.50.htm

o Disclosure of Ownership Form (N/A if joining a Medical Group, the group will submit this form) HMSA QUEST Integration will ensure that contracted providers submit full disclosures as specified in 42 CRF§ 455 Subpart B prior to execution of the provider agreement. The disclosure is to confirm that no excluded persons are working as managing employees or have an ownership or controlling interest in the provider business entity.

REQUIRED DOCUMENTS – Submit one copy of each document, if applicable W-9 Form: Request for Taxpayer Identification Number and Certification or Copy of IRS Letter 147C Copy of Professional Liability Insurance Certificate

The coverage amount we require depends on your provider type. Coverage minimums start at $1 million per incident, with an aggregate of at least $1 million. Certificate must show the effective date, expiration date and coverage amounts. If the certificate doesn’t have a Hawaii address, attach a letter from the insurance carrier stating that you’re covered in the state of Hawaii.

Copy of Current Hawaii State License Copy of Controlled Substances Registrations (if applicable)

o Hawaii Controlled Substance Certification (CSC) o Federal Drug Enforcement Association (DEA) Certificate with Hawaii address

Copy of specialty American Board certification(s) or completion of training (e.g. Internship, Residency, Fellowship, etc.)

Copy of National Provider Identifier (NPI) Confirmation (required for all providers who would like to submit electronic claims)

CV or Resume (five year work history, education, training, etc.) CMS Medicare status – Medicare acknowledgement letter indicating your effective date and Medicare contracting

status. If you’ve opted out of the Medicare program, please submit a copy of your Opt-Out Affidavit. The Medicare acknowledgment letter is required for for enrollment in the Medicare Advantage line of business for Occupational Therapists (OT), Physical Therapists (PT), Speech Therapists (SP), Medical Nutrition Therapists (MNT) and Registered Dieticians (RD).

HMSA PROVIDER ENROLLMENT AND CREDENTIALING APPLICATION

PLEASE PRINT USING BALLPOINT PEN OR TYPE. (Write “N/A” in non-applicable sections.)

I. PERSONAL INFORMATION Legal Name: 1. First: 2. Middle: 3. Last: 4. Suffix: 5. Title:

6. Gender: Male Female

7. Date of Birth: 8. Social Security Number: 9. Individual NPI:

Other Names Known As: 10. First: 11. Middle: 12. Last: 13. Suffix: 14. Title:

15. Languages Spoken by the Provider (please check appropriate box or boxes):

Cantonese Japanese Tagalog Other Languages (List)

French Korean Thai _____________________________

German Mandarin Tongan _____________________________

Hawaiian Samoan Vietnamese _____________________________

Ilocano Spanish American Sign Language Access to Interpreter Services

Application Contact Information: (Person we can contact if we have questions about this application. If no one is listed, we’ll contact you directly.)

16. Name: 17. Phone No.: 18. Email Address:

19. HMSA Marketing Specialty: Additional qualifications: Diagnosing Autism Spectrum Disorder Autism Behavior Analysis Treatment

20. You’re Practicing as a: ☐ PCP ☐ Specialist

21. For Naturopathic Physicians: Please Indicate the Payment Transformation Organization (PTM) Physician Organization (PO) you Plan to Affiliate with: ________________________________________________________________________________________________ Note: You must also complete the HMSA Naturopathic Physician Primary Care Capability Attestation Form.

22. Please Select the HMSA Programs You’d Like to Participate In Below. Note: HMSA will do its best to control enrollment to avoid exceeding your reasonably agreed-upon capacity. However, you acknowledge that enrollment isn’t entirely within the control of HMSA.

Preferred Provider Plan: Yes

No

Maximum number of members:

HMO: Yes

No


Special Vision:

Yes

No

TPA Certified

Yes

No

QUEST Integration:

Yes

No


Complete pages Q-1 to Q-3.

Veterans Affairs Patient Centered Community Care:

Yes

No

Medicare Plans*:

Yes

No


Current Medicare CMS Status OR In Process for: Participating Nonparticipating Not enrolled

Opt-out Effective Date of Opt-out:

Please provide a copy of your opt-out affidavit

*Please include a letter from the Centers for Medicare & Medicaid Services (CMS) that describes your participation status with Medicare or this may delay your request.

1115-7773 1 Rev. 08/2019

II. MAILING/CORRESPONDENCE ADDRESS INFORMATION 1. Entity Name:

2. Building Name (if applicable):

3. Street (or P.O. Box): 4. City: 5. State: 6. ZIP:

7. Send Contracts to the Following Address: Same as Mailing above Other (complete #9-14 below)

8. Entity Name:



III. PRIMARY LOCATION INFORMATION NOTE: If you have additional locations, please complete the Additional Location Information form for each location.

1. At this location are you: Hospitalist Hospital Based N/A

2. Date you’ll start seeing patients at this location: 3. You’re: The Owner Employed Contracted

Office Address: Do not list this location in HMSA directories


5. Street: 6. City: 7. State: 8. ZIP:

9. Appointment Telephone (will be published in the directory):

10. Contact Telephone: 11. Office Fax: 12. Referral Fax:

13. Practice Website URL (if applicable):

14. Physician Assistants — Please provide the name of your supervising physician at this location:

15. Clinical Lab Inspection Approval (CLIA) No.: 16. CLIA Start/End Dates: Start: End:

17. Languages Spoken by the Office Staff at this Location (please check appropriate box or boxes): Cantonese Japanese Tagalog Other Languages (List)

French Korean Thai __________________________________

German Mandarin Tongan __________________________________

Hawaiian Samoan Vietnamese __________________________________


18. Does your facility/office have Americans with Disabilities Act (ADA) Accommodations? Yes No

IV. PAYMENT INFORMATION

1. Payment Checks Should be Made Out to: Provider (proceed to #5 below) Clinic or Group (complete #2-5 below)

2. Clinic or Group Name (legal name): 3. Clinic or Group NPI: 4. Federal Tax ID No.:

5. Mail Payment Checks to: Location Address Mailing Address Payment Address, Specify Below (complete #6-10 below)



1115-7773 2 Rev. 08/2019

V. BOARD CERTIFICATION – (Please indicate N/A if not applicable) Board Specialty: Primary Sub

Board:

Year Certified: Expiration Date: Recertification Date:

Board Specialty: Primary Sub

Board:


Board Specialty: Primary Sub

Board:


VI. PROFESSIONAL EDUCATION AND TRAINING ECFMG Number (if applicable):

Name of Medical/Professional School:

Address of Medical/Professional School:

Degree Earned: From (mm/yy): Through (mm/yy): Date of Completion:

Specialty: Name of Medical/Professional School:


Internship Residency Fellowship From (mm/yy): Through (mm/yy): Date of Completion:










1115-7773 3 Rev. 08/2019

HOSPITAL AFFILIATIONS AND PRIVILEGES (If applicable)

If you don’t have admitting privileges or your admitting privileges are pending approval, please leave this section blank. Facility: From (mm/yy): To (mm/yy):

Facility Address:

If currently affiliated, what’s your affiliation category? If not currently affiliated, what’s the reason for leaving?

Facility: From (mm/yy): To (mm/yy):

Facility Address:


Facility: From (mm/yy): To (mm/yy):

Facility Address:


VII. WORK HISTORY (List relevant work history for the past five years. If there are any gaps longer than six months, please explain.)

Office Practice Name: From (mm/yy): To (mm/yy):

Have you had a break in service for more than six months? If yes, please explain:









VIII. PROFESSIONAL LICENSURE (List ALL active and inactive professional licenses.)

Number: State: Date Issued: Expiration:



1115-7773 4 Rev. 08/2019

IX. CONTROLLED SUBSTANCES REGISTRATIONS (If not applicable, leave this section blank.)

Hawaii Controlled Substance Certification (CSC):

CSC No.: Effective Date: Expiration: Restrictions:

Federal Drug Enforcement Association (DEA) Certificate — Must have a Hawaii address:

DEA No.: Effective Date: Expiration: Restrictions:

X. PROFESSIONAL LIABILITY COVERAGE INFORMATION Please list the names and complete addresses of each professional malpractice insurer. Attach additional sheets if necessary. Company: Policy Number:

Address: Issued: Expiration:

Amount per Incident: Aggregate Amount: Exclusions or Limitations:

Company: Policy Number:



Company: Policy Number:



1115-7773 5 Rev. 08/2019

XI. HEALTH STATUS – If you answer “Yes” to questions “b” and “c” below, please complete the Health Status Additional Information Form (included) for each occurrence. Provide all documentation related to your treatment.

Health status is defined as the physical and mental conditions of the applicant as they relate to the individual’s ability to exercise those clinical privileges requested.

a. Can you perform the functions of the privileges that you’re requesting and/or the contractual arrangement for which you’re applying, with or without accommodations? If no, please explain.

Yes No

b. Are you presently using illegal drugs? Yes No

c. Have you in the past five years used and/or been treated for substance abuse (i.e., drugs, prescription medications, or alcohol)? If yes, please explain.

Yes No

XII. RESTRICTIVE ACTIONS – If you answer “Yes” to any of the questions below, please complete the Restrictive Action Additional Information Form (included) for each occurrence.

a. Are you currently a named defendant to any pending malpractice claim or suit? Yes No

b. Have you ever been a named as a defendant in any malpractice claim or suit where judgment was made against you or where you settled out of court with the plaintiff?

Yes No

c. Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?

Yes No

d. Is there any current or pending due-process action relating to denial, revocation, suspension, or restriction for any of your clinical privileges, appointment, membership, employment, and/or contractual arrangement at any health care organization?

Yes No

e. Have any of your applications for clinical privileges, appointment, membership, employment, and/or contractual arrangement at any health care organization ever been denied, revoked, suspended, restricted, limited, reduced, or terminated voluntarily or involuntarily?

Yes No

f. Have any of your clinical privileges, appointment, membership, employment, and/or contractual arrangement at any health care organization ever been subject to any type of monitoring that’s not routinely applied to other practitioners of your specialty?

Yes No

g. Is there any current or pending due-process action relating to denial, revocation, suspension, or restriction for any of your professional licenses or applications for professional license in any jurisdiction?

Yes No

h. Have any of your professional licenses or applications for professional licenses ever been challenged, denied, revoked, suspended, restricted, limited, conditioned, or voluntarily or involuntarily relinquished?

Yes No

i. Have any of your controlled substance certificates or federal drug enforcement agency certificate ever been challenged, denied, revoked, suspended, restricted, limited, conditioned, or voluntarily or involuntarily relinquished?

Yes No

j. Are there any current or pending investigations or actions being taken against you or have there ever been any restrictive actions taken against you by the Medicare program, Medicaid program, Regulated Industries Complaints Office, Medical Complaint Conciliation Panel (MCCP), the Hawaii Department of Commerce and Consumer Affairs, and/or the Hawaii Board of Medical Examiners?

Yes No

k. Has your membership to local, state, or national medical societies ever been placed on probation, revoked, suspended, or terminated?

Yes No

l. Have you ever been convicted of a crime, pled guilty or “no contest” to a crime (other than a traffic offense), or are you currently under indictment for an alleged crime?

Yes No

m. Do you currently employ anyone who has been excluded from the Medicare or Medicaid program? Yes No

XIII. ATTESTATION I hereby affirm that the above information is complete, accurate, and true to the best of my information, knowledge, and belief. If I have signed this form electronically, it means that I acknowledge and agree to the terms of this form and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this form just as a handwritten signature would on a traditional paper form.

Signature: Date:

Printed Name: Social Security Number (last four digits only):

Please return application and attachments to: Hawai‘i Medical Service Association Attn: Provider Operations, KLCR-PDA P.O. Box 860 Honolulu, HI 96808-0860

Phone 952-7847 (Oahu) or 1 (800) 603-4672 ext. 7847 toll-free (Neighbor Islands) Fax: 948-8210 on Oahu Email: [email protected]

1115-7773 6 Rev. 08/2019

HAWAI‘I MEDICAL SERVICE ASSOCIATION

Authorization to Release Documents and Information and Dispute Resolution Agreement Notice: Hawaii law and HMSA's Participating Provider Agreements require that HMSA perform certain peer review, quality assurance, accreditation, and compliance reviews regarding its participating providers. This Authorization permits HMSA to obtain information relevant to these functions and provides dispute resolution procedures regarding this process. Your application will not be processed without your signed consent to this Authorization. Information obtained pursuant to this Authorization will be used only for purposes of credentialing, peer review, quality assurance, and to determine compliance with applicable laws, contract terms, and professional standards. HMSA will comply with all applicable state and federal laws regarding the confidentiality of information obtained pursuant to this Authorization.

1. I HEREBY AUTHORIZE representatives and agents of Hawai‘i Medical Service Association (HMSA) to

consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a bearing on my satisfaction of the criteria for initial and continued credentialing as a Participating Provider with HMSA, including but not limited to representatives of hospitals, institutions, government agencies including licensing agencies, professional liability insurance companies, professional associations, accreditation agencies, managed health care plans, physicians, and other providers and other persons or entities (hereafter collectively referred to as "persons or entities") to obtain and verify information concerning my professional qualifications, credentials, clinical competence, employment experience, licensing, and conduct (hereafter collectively referred to as "professional qualifications and conduct").

2. I HEREBY CONSENT TO RELEASE by any and all persons or entities to HMSA all information and

documents, except as provided in Paragraph 4 below, that may be relevant to an evaluation of my professional qualifications and conduct, including but not limited to any information or materials relating to any disciplinary action, suspension or curtailment of clinical privileges, employment actions, complaints or incidents, and information from professional liability insurance carriers or others relating to insurance coverage or claims information, including the amount of any settlement or judgment against me.

3. I FURTHER CONSENT to the inspection by representatives and agents of HMSA of all records held by

persons and entities that may be material to an evaluation of my professional qualifications and conduct. This Authorization shall be deemed sufficient to effectuate the release to HMSA of all information and documents described above and shall include the right to inspect, obtain, and act upon any and all such information and documents.

4. Should HMSA have reason to believe that information about my physical and/or mental condition is

necessary for purposes of credentialing, peer review, quality assurance, or to determine compliance with applicable laws, contract terms, or professional standards, then HMSA will request an additional HIPAA- compliant authorization signed by me for release of such information and documents. I understand that any failure by me to sign and return such additional request for written authorization for those purposes will result in denial of my application and/or action to terminate any participating provider agreement I have with HMSA.

5. To the fullest extent permitted by law, I HEREBY RELEASE from any and all liability, extend absolute

immunity to, and agree not to sue HMSA, all representatives and agents of HMSA, and all such persons or entities from any and all liability for their acts in giving, obtaining, and verifying such information in connection with evaluating my professional qualifications and conduct, and participating in the credentialing review and determination process including but not limited to any actions, recommendations, reports, statements, communications, or disclosures involving me or my application that are made, taken, or received by HMSA or its authorized representatives and agents.

Hawai'i Medical Service Association Authorization to Release Documents and Information (rev. 11/15) Page 1

6. I UNDERSTAND AND AGREE that I, as an applicant, have the burden of producing adequate information to demonstrate to the satisfaction of HMSA, my professional qualifications and conduct and for resolving doubts thereto. I FURTHER UNDERSTAND AND AGREE that it is my responsibility to inform HMSA of any changes in the information provided in connection with my application during the application period or at any subsequent time.

7. I HEREBY AGREE to the following dispute resolution procedures:

A. Except as provided in paragraph 9 below, if I disagree with any decision or action by HMSA arising out

of or relating to this Authorization or HMSA's credentialing process, I shall submit a written request for arbitration to HMSA's Legal Services in Honolulu, Hawaii, within 30 calendar days following my receipt of the credentialing committee's decision. It will be assumed that I received the decision within three days of the date it is mailed.

HMSA and I agree that any and all claims, disputes, or causes of action arising out of or related to this Authorization or its performance, or arising out of or related to HMSA’s credentialing process, including but not limited to any and all claims, disputes, or causes of action based upon contract, tort, statutory law, or actions in equity, shall be resolved by binding arbitration as set forth in this document.

The arbitration of disputes shall be conducted in Honolulu, Hawaii or by telephone if I have an office on an island other than Oahu, by an independent arbitration service mutually selected by HMSA and me. If HMSA and I are unable to agree upon an arbitration service within 30 calendar days of HMSA's receipt of my request for arbitration, Dispute Prevention and Resolution, Inc. ("DPR") will conduct the arbitration. If HMSA and I are unable to agree upon an arbitrator within 30 calendar days following the submission of the claim to the arbitration service, then the two parties shall select an arbitrator in accordance with DPR's arbitration selection procedures. The arbitration will be conducted pursuant to the Hawaii Uniform Arbitration Act, HRS ch. 658A and the arbitration service’s arbitration rules (or such other arbitration rules as the parties may mutually agree on) to the extent not inconsistent with the arbitration provisions in this Agreement. In the arbitration, both parties shall have the right to be represented by an attorney or other person of their choice; to have a record made of the proceeding, copies of which may be obtained upon payment of any reasonable charges associated with their preparation; to call, examine, and cross-examine witnesses; to present evidence determined to be relevant by the arbitrator regardless of its admissibility in a court of law; and to submit a written statement at the close of the hearing. Upon completion of the arbitration hearing, the arbitrator shall issue his or her written decision in the form of a recommendation to HMSA including a statement of the basis for the recommendation. HMSA will issue a written decision consistent with the arbitrator's recommendation including a statement of the basis for the decision. The arbitrator may hear and determine motions for summary disposition pursuant to HRS 658A-15(b). The arbitrator shall also hear and determine any challenges to the arbitration agreement and any disputes regarding whether a controversy is subject to an agreement to arbitrate. To make the arbitration hearing fair, expeditious and cost-effective, discovery by both parties shall be limited to requests for production of documents material to the claims or defenses in the arbitration. Limited depositions for use as evidence at the arbitration hearing may occur as authorized by HRS §658A-17(b). Each party will pay its own attorney and witness fees, provided that the arbitrator may award attorney fees and costs in an amount authorized by law to a prevailing party related to any claim or contention of a nonprevailing party, that the arbitrator determines was frivolous or wholly without merit. Fees and costs of the arbitrator and the arbitration service may be awarded by the arbitrator as the arbitrator determines is appropriate. If no award is made, fees and costs of the arbitrator and the arbitration service shall be shared equally by both parties. The decision of the arbitrator shall be final and binding on HMSA and me, and judgment shall be entered thereon upon a timely motion by either party in a court of competent jurisdiction. No action may be brought in any court in connection with the dispute or award, except as provided under the Hawaii Uniform Arbitration Act. There shall be no consolidation of parties in the arbitration proceeding. The arbitrator may award any remedy that can by law be granted by a court in like circumstances, provided that no award of punitive damages or exemplary damages shall be made. The parties shall take appropriate measures to protect the confidentiality of any credentialing, peer review, quality assurance, and personal health information related to the dispute and arbitration proceeding.


B. If I become an HMSA Participating Provider, then the Dispute Resolution terms of HMSA’s Participating Provider Agreement shall supercede this paragraph 7 and shall govern any disputes arising out of or related to that Agreement.

8. I UNDERSTAND AND AGREE that this Authorization shall remain in effect during the term of any

Participating Provider Agreement extended to me by HMSA and during the pendency of any dispute or claim related to my actions under any Participating Provider Agreement with HMSA.

9. I UNDERSTAND AND AGREE that if my application for credentialing is denied, I am not eligible to re-apply

for credentialing for one year after the date of either my receipt of HMSA's decision to deny my application or if I appeal HMSA’s decision, the date of the Arbitration Award, whichever is later. HMSA's decision not to consider an application that is submitted within the one year waiting period is final and cannot be challenged in arbitration or litigation.

10. I FURTHER UNDERSTAND AND AGREE that, if I submit an application for credentialing after the one

year waiting period has expired, HMSA will not be required to consider my application unless the Credentialing Committee, in its discretion, determines that the basis for the earlier adverse decision no longer exists.

If I have signed this document electronically, it means that I acknowledge and agree to the terms of this document and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this document just as a handwritten signature would on a traditional paper application.

Typed or Printed Name Date

Signature


HMSA PROVIDER ENROLLMENT AND

CREDENTIALING APPLICATION

SUPPLEMENTAL FORMS

HEALTH STATUS ADDITIONAL INFORMATION FORM

Please complete this form if you answered “no” to Health Status question “a” and/or “yes” to Health Status questions “b” and “c.” All questions must be answered completely. If additional sheets are required, photocopy this sheet prior to completing. Provider Name: What is the nature of your health condition?

Please list any accommodations that you require to practice medicine safely as an HMSA-credentialed provider:

If you’re currently using illegal drugs or have a history of a substance use disorder, please provide details of your drug use, a summary of treatment, and all evidence that supports you’re in full sustained remission and are safe to practice medicine as an HMSA-credentialed provider:

Please provide the name of a treating provider or monitoring program that can attest to your ability to practice medicine safely:

Please provide any additional documents you have about your treatment (e.g., Certificate of Completion from monitoring program, letter of compliance from your monitoring program stating that you’re fit to practice medicine, etc.). If you don’t have additional documents to submit, please explain why.

Provider signature: Date:

RESTRICTIVE ACTION ADDITIONAL INFORMATION FORM

Please complete this form if you answered “yes” to any Restrictive Actions question. Complete a separate form for each pending or closed professional adverse action whether or not any payment was made on your behalf. All questions must be answered completely. If additional sheets are required, photocopy this sheet prior to completing. Provider Name: Date of Incident:

Description of occurrence: Outcome: Resolved

Pending

Please provide details about the circumstances related to this occurrence:

Please describe the extent of your involvement and actions related to the occurrence:

Please articulate any professional insights from your perspective about the occurrence. What process improvements, if any, have you made in your professional practice to prevent a similar incident from occurring in the future?

If you believe that your actions were appropriate despite any adverse occurrence/actions, please provide an explanation and supporting documents. (E.g., MCCP decision documents, Stipulation for Dismissal without a settlement, independent expert professional opinions, etc.):

Provider Signature: Date:

ADDITIONAL LOCATION INFORMATION - NOTE: If you have additional locations, please complete this form; one page for each location.

1. At this location are you: Hospitalist Hospital Based N/A

2. Date you’ll start seeing patients at this location: 3. You’re: The Owner Employed Contracted

Office Address: ☐ Do not list this location in HMSA directories.


5. Street: 6. City: 7. State: 8. ZIP:

9. Appointment Telephone (will be published in the directory):

10. Contact Telephone: 11. Office Fax: 12. Referral Fax:

13. Practice Website URL (if applicable):

14. Physician Assistants — Please provide the name of your supervising physician at this location:

15. Clinical Lab Inspection Approval (CLIA) No.: 16. CLIA Start/End Dates: Start: End:

17. Languages Spoken by the Office Staff at this Location (please check appropriate box or boxes): Cantonese Japanese Tagalog Other languages (list)

French Korean Thai _______________________________

German Mandarin Tongan _______________________________

Hawaiian Samoan Vietnamese _______________________________


18. Does your facility/office have Americans with Disabilities Act (ADA) Accommodations? Yes No

PAYMENT INFORMATION

Payment Information for This Location is the Same as What’s Listed in Section IV, Page 2.

1. Payment Checks Should be Made Out to: Provider (proceed to #5 below) Clinic or Group (complete #2-5 below)

2. Clinic or Group Name (legal name): 3. Clinic or Group NPI: 4. Federal Tax ID No.:

5. Mail Payment Checks to: Location Address Mailing Address Payment Address, Specify Below (complete #6-10 below)



ATTESTATION I hereby affirm that the above information is complete, accurate, and true to the best of my information, knowledge, and belief. If I have signed this form electronically, it means that I acknowledge and agree to the terms of this form and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this form just as a handwritten signature would on a traditional paper form.

_______________________________________________________________________ _____________________________________

Signature Date _______________________________________________________________________ _____________________________________

Printed or Stamped Name Social Security Number (last four digits only)

QUEST INTEGRATION ADDITIONAL CONTRACTING REQUIREMENTS

For QUEST Integration, please indicate if you’ll be participating as a: PCP Specialist

MEDICAID PROVIDER APPLICATION/CHANGE REQUEST FORM (DHS 1139) ATTESTATION

To improve Medicaid fraud prevention, the State Medicaid Agency, Department of Human Services (DHS) Med-QUEST Division (MQD) is required to perform more comprehensive screening, credentialing and enrollment for all providers. Starting January 1, 2018, providers must complete and submit the Medicaid Application/Change Request Form, also called the DHS 1139 Form. You can download the DHS 1139 Form and instructions from the MQD’s website at: https://medquest.hawaii.gov/en/plans-providers/become-a-medicaid-provider.html. If you have any questions, contact the Department of Human Services, Med-QUEST Division via email at [email protected] or telephone at 808-692-8099.

Yes: I completed and submitted the Medicaid Provider Application/Change Request Form (DHS 1139 form). Note: You are required to renew and resubmit with the State every 5 years.

No: I have not completed and submitted the Medicaid Application/Change Request Form (DHS 1139 form). Note: Your HMSA participation is contingent upon completing and submitting the completed DHS form to the State of Hawaii Med QUEST Division.

ACCESSIBILITY

For QUEST Integration physicians, including physician assistants and advanced practice registered nurses who are primary care providers, how does your practice provide patients with 24-hour access to medical services (i.e., emergency and vacation coverage)? Please provide the name, address, and telephone number of the physician(s) covering for you.

CULTURAL COMPETENCY PLAN

Providers: Acknowledge that you’re aware of, will follow, and will incorporate into your practice HMSA’s QUEST Integration Cultural Competency Plan. The QUEST Integration Cultural Competency Plan can be found here: hmsa.com/portal/provider/zav_qi.02.cul.50.htm.

Yes No


Signature: Date:


Q-1 Rev. 08/2019

DISCLOSURE OF OWNERSHIP (REQUIRED TO PARTICIPATE IN THE HMSA QUEST INTEGRATION PROGRAM) Med-QUEST Hawaii requires disclosure information (as identified in 42 CFR § 455 Subpart B) before a provider agreement can be made. List each individual or corporation with a 5 percent or more ownership or controlling interest in the provider business entity. Also, provide the requested information for all of the applicant’s managing employees. Attach additional pages as needed.

SECTION I: OWNER (INDIVIDUAL) Name (Individual): Start Date of Ownership: End Date:

Title (Choose one): Owner/Company Owner/Individual Chief Executive Officer Chief Financial Officer Chief Information Officer Chief Operating Officer Board of Directors Managing Employee Employee Contractor

Has this individual been: convicted, debarred, suspended, or none of the above?

Date of Birth: Social Security Number:

Address:

Are you the spouse, parent, child or sibling of another person with an ownership or controlling interest in the provider?

Yes No

Do you have an ownership or controlling interest in a subcontractor of the provider? Yes No

If yes, does the provider have a 5 percent or more interest in that subcontractor? Yes No

Name any other providers (individual or group practices) in which you have an ownership or controlling interest: SECTION II: OWNER (CORPORATE) Name (corporation):

Start Date: End Date:

Primary Business Address:

Mailing Address (P.O. Box):

Other Business Address(es):

Tax Identification Number:

a. Please provide the tax identification number of any entity with an ownership or controlling interest in any subcontractor of the provider if the provider has 5 percent of more interest in that subcontractor:

Tax ID number:

b. Is the corporation the spouse, parent, child or sibling of another person with ownership or controlling interest? Yes No

c. Does the corporation have an ownership or controlling interest in a subcontractor to the provider? If yes, does the provider have a 5 percent or more interest in that subcontractor?

Yes No

Yes No

d. Other providers (individual or group practices) over which the corporation has an ownership or controlling interest:

e. Has this corporation been: convicted, debarred, suspended, or none of the above?

Q-2 Rev. 08/2019

SECTION III: MANAGING EMPLOYEE INFORMATION A managing employee is a “general manager”, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly indirectly conducts the day-to-day operations of an institution, organization, or agency.” (42 CFR section 455.101). Managing employees are in a position to exert influence over the conduct of the provider’s operations. Name: Start Date: End Date:

Title (Choose one): Owner/Company Owner/Individual Chief Executive Officer Chief Financial Officer Chief Information Officer Chief Operating Officer Board of Directors Managing Employee Employee Contractor

Has this individual been: convicted, debarred, suspended, or none of the above?

Date of Birth: Social Security Number:

Address:

SECTION IV: ADDITIONAL INFORMATION a. List the names and addresses of all other Hawaii Medicaid providers with which your health service and/or facility engages in a

significant business transaction and/or a series of transactions that during any one of fiscal year exceed the less of $25,000 or 5 percent of your total operating expense. (Attach extra page if necessary.) Check here for N/A

Name:

Address:

City: State: ZIP:

b. List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5 percent or more who have been convicted of a criminal offense related to the involvement of such persons or organizations in any program established under Title XVIII (Medicare), or Title XIX (Medicaid), or Title XX (Social Services Block Grants) of the Social Security Act of any criminal offense in this state or any other state since the inception of those programs. (Attach extra page if necessary.) If individual or organization is associated with a Hawaii Medicaid provider number(s), please indicate below. (Attach extra page if necessary.) Check here for N/A

Name(a)/Hawaii Medicaid Provider Number(s), if applicable:

Name(b)/Hawaii Medicaid Provider number(s), if applicable:

I don’t have any managing employees, owners, or other Medicaid providers to report in Sections I, II, III or IV.


Signature: Date:


If the provider, any owner or managing employee is found to be on the List of Excluded Individuals and Entities (LEIE) maintained by the Office of Inspector General (OIG), HMSA will deny the application for participation in the HMSA QUEST Integration Program and Medicare programs. To see the list, go to the Department of Health and Human Services Office of Inspector General (HHS-OIG) online exclusion database at http://exclusions.oig.hhs.gov/.

Q-3 Rev. 08/2019

QUEST Integration Disclosure of Information To comply with Federal Regulations (42 CFR §455 Subpart B) and Med-QUEST Hawaii requirements, providers who’d like to participate in QUEST Integration must complete this form for each managing employee, individual, or corporation with a 5 percent or more ownership or controlling interest in your business. Definitions Managing employee is a general manager, business, manager, administrator, director or other individual

who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, or agency.

Ownership interest is the possession of equity in the capital, stock or profits of the disclosing business

entity. Indirect ownership interest is an ownership interest in a business entity that has a direct or indirect

ownership interest in the disclosing entity.

Person with an ownership or controlling interest is a person or corporation that (a) has a direct or indirect ownership interest totaling 5 percent or more in a disclosing entity; (b) has a combination of direct or indirect ownership interests equal to 5 percent or more in a disclosing entity; (c) owns an interest of 5 percent or more in any mortgage, deed, of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; (d) is an officer or director of a disclosing entity that’s organized as a corporation; ( e) is a partner in a disclosing entity that’s organized as a partnership.

If you don’t have any managing employees or owners to report, check the box next to “I do not have any managing employees, owners, or other Medicaid providers to report in Sections I, II, III or IV.” If you, a managing employee, or an owner is on the list of excluded individuals maintained by the Department of Health and Human Services Office of Inspector General (HHS-OIG), the System for Award Management (SAM), or Med-QUEST Hawaii’s excluded parties list, we must terminate your participation with HMSA QUEST Integration, Medicare and Veterans Administration (VA) programs. To verify, see the HHS-OIG online exclusion database at https://exclusions.oig.hhs.gov.

Q-4 Rev. 08/2019