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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
Please complete the application and include the requested documentation:
1.
Completed and signed Behavioral Health Facility/Program Application form
2.
Accreditation Certificate from an accreditation body or quality
organization
3.
Hawaii License (in good standing)
4.
Liability insurance certificate policy that covers all services and staff (reflects limits of liability
and expiration date)
5.
Organization chart and staff roster (licensed and unlicensed) of those
providing services within the scope of the ABA program
6.
Name of the program’s staff member with clinical oversight of all autism services. The staff
member must be a licensed Psychologist, Psychiatrist, or Doctorate Level Behavioral Health
Professional
If your organization is not accredited, please also include the following:
7.
A copy of the organization’s ABA/Autism program description that outlines in detail how the
program is implemented and by whom
8.
Sample patient record
9.
Documentation of human resource requirements that supports the credentialing /vetting of
licensed and non-licensed staff rendering ABA services as part of the program. Documentation
must include
10.
A copy of the organization’s quality assurance program
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
HMSA
BEHAVIORIAL HEALTH
FACILITY/PROGRAM APPLICATION FORM
Facility/Program/Program Legal
Name:_________________________________________________
Business Name:______________________________________________________________
TAX ID #:____________________________________________
Mailing Address:______________________________________________________________
Location Address:____________________________________________________________
County:____________________________________________________________________
Main Phone # :_____________________________ Main Fax #:_______________________
(Attach additional sheet if more locations)
If Applicable (Please attach copy) :
Medicare #:_________________________ Medicaid #:__________________________
Setting:
x Other ____ABA ___________________________
Category:
Disorder Facility
x Other ____ABA___________________________
Administrative Contact:
Name:_______________________________________________________________
Phone #:__________________________ Fax:_______________________________
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
Corporate Owner (IF APPLICABLE):
Name:_____N/A__________________________________________________________
Corporate
Address:__________________________________________________________________
_________________________________________________________________________
Please list the key contacts at your Facility/Program: (If different from page 1)
Contact for Admissions
Name:________________________ Phone#:______________
Corporate Office Contact
Name:________________________ Phone#:______________
Medical Director (psychiatric) Name:________________________ Phone#:______________
Medical Director (substance abuse) Name:____________________ Phone#:______________
Business Office (billing)
1.
Name:_________________________ Phone#:_____________
List your geographic service area:
___________________________________________________________________________
___________________________________________________________________________
2.
How is the Facility/Program/Program licensed? (check all that apply)
3. Is your Facility/Program accessible to the handicapped?
4. Chemical Dependency services are based on:
-specify:______________________
5. Emergency Room Services
a. If no emergency room services, which acute care Facility/Program(s) provide
emergency room services?
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
______________________________________________________________
Is your relationship with them contractual?
b. Emergency psy
Specify hours:_____________________
c. Emergency substance abuse services evaluation services in ER?
Specify hours:______________________
d. Other, please specify:_______________________________________________
6. Facility/Program License and Accreditation Information.
Please list and attach current copies of each that apply:
a. State License:
Number:________________ Exp. Date:______
b. Is Facility/Program Accredited:
No
If YES
Name of accrediting organization ____________________________________
Attach copy of current certificate
If NO
Are there plans to be accredited?
No
If YES,
Date of expected accreditation ______________________________________
By whom _______________________________________________________
If NO, please explain below.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
c. Below, please list any other licenses or certifications that the Facility/Program has
acquired. Include current copies of each. If you need more space, please use a
separate sheet of paper.
License Name:______________________ Number:____________ Exp. Date:_______
License Name:______________________ Number:____________ Exp. Date:_______
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
7. Facility/Program Evaluation:
a. Does the Facility/Program conduct regular quality assurance reviews?
No
b. b. Does the Facility/Program conduct regular quality reviews for utilization
management?
No
If “yes”, how often do they occur? Quality/effectiveness:_____________________
Utilization Management:___________________
c. Please send a written sample of your guidelines for measuring quality/effectiveness
and utilization management. (Preferably, copies of policy/procedure manuals, reports
and any lists of the standards that the Facility/Program is measured against).
d. If “No”was checked, specify the criteria that is used to evaluate Facility/Program
quality/effectiveness.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
10.
Liability Information:(Please include a current copy of malpractice face sheet with this
application). The limits of liability can not be lower than 1 Million/1 Million.
a. Carrier Name:________________________________________________________
b. Policy Number:_______________________________________________________
c.
Coverage Limits:_____________________________________________________
d. Expiration Date:______________________________________________________
11. Malpractice Claim History:
1. Has the Facility/Program or any shareholders/owners/partners ever been named in
any malpractice action?
No
2. Has the Facility/Program or any shareholders/owners/partners ever had or currently
have pending any legal action?
No
3. Has the Facility/Program or any shareholders/owners/partners ever had professional
liability insurance refused, declined, canceled or accepted on special terms?
No
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
4. Has any government agency ever investigated, suspended, revoked, or taken action
against your license to conduct business?
No
5. At any time, has any license or certification been revoked, reduced, denied, or
suspended by others or voluntarily given up by the program, or are any actions which
may lead to such conclusions under way?
No
6. At any time, have any memberships in professional organizations ever been revoked,
reduced, denied, or suspended by others or voluntarily given up by the program, or are
any actions which may lead to such conclusions under way?
No
7. Has the Facility/Program or any shareholders/owners/partners ever been convicted of
a crime, excluding misdemeanors?
No
8. Has the Facility/Program ever been assessed a penalty, conviction or suspension or is
the Facility/Program currently under investigation by a Medicaid or Medicare program?
No
9. Number of Claims (check one)
0____ 1_____ 2_____ 3_____ (more)______
10. Has your facility / program ever been excluded from any Federal health programs?
No
ABA_Facility_Initial Application_10-2015
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HMSA ABA QUALIFIED PROVIDER NETWORK
CREDENTIALING DOCUMENT CHECKLIST & FACILITY/PROGRAM APPLICATION
2015
FACILITY/PROGRAM’S STATEMENT
We certify that all of the above information is true, complete and correct to the best of our
knowledge and belief and is made in good faith. We further understand that any false or
incomplete information knowingly provided by us may be ground for our dismissal. We hereby
authorize HMSA or its designees, to verify and release any and all of the information contained
herein as may be necessary to evaluate our application to become a provider with HMSA.
___________________________________________
Print Name
_____________________________________
Title
____________________________________________
Authorizing Signature
ABA_Facility_Initial Application_10-2015
____________________________
Date
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