Eastpointe Hospital Basedinpatient and Outpatient Psychiatricservices Application

Thankyou foryour interest in becoming aHospital providerwith Eastpointe. Inorder for us to completethe enrollment processfor contractingor “out-of-network”status, pleasesubmit the following:

GroupApplicant

Eastpointe Hospital BasedInpatient and Outpatient PsychiatricServices Application.

National ProviderIdentifier (NPI).CopyofyourNational Plan and Provider

Enumeration System (NPPES) letter.Copyof current license from the N.C.

Division of Health Services Regulation.

Copyof currentapprovalletter from CenterforMedicare and Medicaid Services (CMS).

Note:Thenameand address on theCMSlettermustmatch the name andaddress onyour agreement.

Copyof current CertifiedArticles ofIncorporation orArticles ofOrganization, ifapplicable.

Internal RevenueServices (IRS)Form W-9.

Note: A valid and complete W-9 must be submitted by the applicant to certify the applicant’s Taxpayer Identification Number (TIN) and Name. Applicant is defined as the entity completing the application for enrollment. Please reference the specific instructions on pages 2 and 3 of the Form W-9 for enteringyourcorrect TINand name.

Criminal Background Check Release Form – one each to be completed by CEO, CFO, anyone owning over 0.5% interest, and all LIPs that have not been credentialed by the hospital, but the hospital bills for services they provide.

Attachment-LetterofAttestationforFalseClaimsActEducation. Out-of-NetworkandOut-ofStateHospitalsmustsubmittheLetterofAttestationatthetimeofapplication. Hospitalseeking to contractwith Eastpointe shallexecute aLetterofAttestation forFalseClaimsActEducation for submission with theirsigned Contract.

NorthCarolinaMedicaidProviders(in-Stateorout-of-State): Copyofyourmostcurrent “RateNotificationfor DRG,Rehabilitation,Psychiatric,InpatientDRG Specific RCCLetter from the North CarolinaDepartment of Health and Human Services Division ofMedical Assistance

Out-of-State/Border-area Providers: Copyofacurrentapproval letter toparticipate inyour state’s Medicaid Program.

Note: DONOT submitclaims to Eastpointe untilyourcontract has been executed oryou havebeen notified thatyou can submit claims as an out-of-state orout-of-networkHospital.

Thankyou again foryourinterest.Ifyou have anyquestions or need additional information,pleasefeel freetocontactthe Network Operations Department at and 1(888) 977-2160.

InstructionsforEastpointe Enrollment of HospitalProviders

AprospectiveHospitalmustapply forand beenrolledasaproviderwithEastpointetoqualify for reimbursementforHospitalservicesunderEastpointe’sMedicaidWaiver. HospitalsmusthaveasignedcontractwithEastpointetoqualify forreimbursementfor Hospital services with State (North Carolina) funds.

Please submit it se note that you may have to hold down the ctrl key on your keyboard as you click this link.

Forinquiriesregardingtheapplicationprocess,pleasecontact us at our email address at orby telephone at1 (888) 977-2160.

2. Aproviderenrollmentpacketisconsideredtobeinvalidif:

Theversiondateonanyofthedocumentsthatcomprisetheproviderenrollmentpacketisprior to April 2, 2012.

TheContactperson’sName and Title is not completed.

TheSignatures, whererequired, arenot original.

TheSignaturesarenotbytheindividualapplicantor,whereapplicable,anauthorizedagentfor the groupor entity.

The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.

The responsesareillegible.

TheNational ProviderIdentifier is not a valid number.

Anyof thedocuments orpages that comprise theprovider enrollment packetaremissing.

Anyoftherequestedinformationinanyof the documentsthat comprise the provider enrollment packet is missing, with the exception of the faxnumber and e-mailaddress.

Any of the required accreditation documentation is missing (including license, permit, certification, endorsement,Articles ofIncorporation, NPPES letter, etc.).

TheprovidernameenteredontheMedicaidParticipationAgreement(forout-of-stateand/or out-of-network providers)doesnotmatchtherequiredaccreditationdocumentation,theIRS Form W-9, and the NPPES letter (where required).

3. ImportantPoints to Remember

Ifservices arebeingprovidedat multiplesites, you arerequired to list each site in thisapplication and willbe assigned aseparatesiteIDnumber foreach location.

Copiesoftheapplicableaccreditationdocumentationmustaccompany theapplication. Ifthese documents aremissing, the application willbe returned to theprovider.

Retainacopyofyourcompletedenrollmentpacketandalldocumentationsubmittedwiththe enrollment packet for your records.

Providers are assigned a provider number and are notified by mail once the enrollment process has been completed. Please do not submit claims for any services until you have received notification of your provider number and effective date.

Billing information and clinical coverage polices will be made available on Eastpointe’s website at

Providersarerequestedtoincludeontheirapplicationthename,e-mailaddress,andfax number oftheindividual(contactperson)attheirsite whoisresponsiblefor receivingEastpointe information.

4. Important Points to Remember regarding hospital staff:

Any hospital who credentials its staff may complete a hospital enrollment application and provide the required information for each licensed professional (as indicated on the Hospital Registration Worksheet and provided on our website for you to complete), as long as the hospital allows the LME-MCO to complete a survey of the hospitals credentialing application.
This process suffices for all hospital billing for the identified licensed professionals.

EASTPOINTEHOSPITAL BASED INPATIENT ANDOUTPATIENT PSYCHIATRICSERVICES APPLICATION

ApplicationDate:

Provider is completingapplication for thepurposeof:

Contract Out-of-NetworkStatus Out-of-State

SECTIONI:CORPORATEINFORMATION

1. OrganizationName:

(Your organization name must match the organization name onyourcurrent accreditation documentation andyourcurrent letter of approvalfrom theCenters for Medicare and Medicaid Services)

2. Legal NameofOrganization:

(Name usedfortaxreportingpurposes ifdifferent from Organization Name)

Doing Business as (DBA)

Ifapplicable, enteryourDBA name:

Federal TaxID #:

Federal Tax Status: For Profit Non-Profit

NationalProviderIdentifier#:

[YouMUSTattachacopyofyourNationalPlanandProviderEnumerationsSystem(NPPES)Certification Letterwiththisapplication. PleaseprovidetheNPI#sandNPPESCertificationLetterforeachsiteyouare applyingforonthisapplication.]

Medicaid #:

[Please provide a list ofMedicaid#s for eachsite youareapplying foronthis application.]

Physical Address:(P.O.Boxaddress is not acceptable as a physical address)

Street:

City: State: Zip Code(+4):

County: Phone: Fax:

Email Address:

Number ofyears doingbusiness under this name:

WebsiteAddress(if applicable):

Has this Organization ever been in business underadifferent name? Yes No

Ifyes, what name?

Isyour Hospital/Programan approvedNorth Carolina Medicaid serviceprovider? Yes No

Ifyes,pleaseattachthemostrecentcopy ofyour“RateNotificationforDRG,Rehabilitation, Psychiatric,and InpatientDRGSpecificRCCLetter”fromtheNorthCarolinaDepartmentofHealth and Human Services Division ofMedical Assistance

PrimaryContact:

PrimaryContact’s Title:

PrimaryContact’s E-mail Address:

Telephone:

Office: / Fax:
Mobile: / Pager:

ExecutiveDirector/CEO:

FinanceDirector:

Assistant Director/COO:

Clinical/Medical Director:

Behavioral Health Unit Director (if applicable):

EmergencyDepartment Director:

Board Chairman:

Pleaselist names andtitles of peopleauthorized to sign contracts and other legal documents

Pleaseattacha list of all currentboardmemberswithaddresses.

3. Background checks have been completed on the owner(s), Board Members, director(s), officers,administratorsandstaff. Documentationof backgroundchecksismaintainedbythe hospital. Yes No

(Ifyes, pleaseattach an explanation and anysupportingdocumentation.)

4. OrganizationLegal Entity Type

C-Corporation / General Partnership / Cooperative
S-Corporation / Sole Proprietorship / Not forProfit
LimitedLiabilityCorporation / LimitedLiabilityPartnership / Government
PublicAuthority(LME,Hospital or HealthcareAuthority)

5. FACILITIES/PROGRAMS:

Pleaselist all PsychiatricFacilities Operated by theHospital andcovered by theHospitals accreditation(inpatient, PRTF, Intensive Outpatient, Partial Hospitalization, Outpatient):

NameofFacility
orProgram / Address
(include zip+4code) / Numberof
beds
(ifapplicable) / Child,
Adolescentor
Adult / NPINumber
(pleaselist each facility/program
NPInumber) / Program
Specific Medicaid Number
(ifapplicable) / Medicaid
Rate/Billing
Code
Facility/Program
Name / SupportingPsychiatrist(s)
Name/Address / Hospitalemployeeor
otherpractice? / If Hospitalemployee,pleaselist
theirNPI#

6. ACCREDITATION

Facility/Program
Name / Dateoflast
JCAHOReview / YearsAccredited / ExpirationDate / DHSRLicense
Number
(ifapplicable) / ExpirationDate

7. PROVIDERDISCLOSURE

a. Providers must disclose the following information to Eastpointe. List all information requested for each person, including yourself, who has direct or indirect ownership or control interest of 5% or more in the organization/entity. If any of the persons named are related to each other as parent, spouse, child or sibling, indicate the relationship. Failure to provide sufficient information, including complete Social Security Numbers, to allow for the verification of the disclosed information may result in a denial for participation with the N.C. Medicaid Program

Name(FirstName,MILastName)
andCompleteAddress
(Street,City,StateZipCode) / Title
(ifapplicable) / SocialSecurity
Number / License#
(ifapplicable) / %Ownership
DateofBirth:
Checkbusinessrelationshipthatapplies:
Owner Shareholder Partner
Officer ManagingEmployee
Director BoardMember
Other:
ElectronicFundsTransfer(EFT)authorizedindividual
Check relationship to other persons named:SpouseParentChildSiblingNone
(Check all that apply)Other:
Name(FirstName,MILastName)
andCompleteAddress
(Street,City,StateZipCode) / Title
(ifapplicable) / SocialSecurity
Number / License#
(ifapplicable) / %Ownership
DateofBirth:
Checkbusinessrelationshipthatapplies:
Owner Shareholder Partner
Officer ManagingEmployee
Director BoardMember
Other:
ElectronicFundsTransfer(EFT)authorizedindividual
Check relationship to other persons named:SpouseParentChildSiblingNone
(Check all that apply)Other:
Name(FirstName,MILastName)
andCompleteAddress
(Street,City,StateZipCode) / Title
(ifapplicable) / SocialSecurity
Number / License#
(ifapplicable) / %Ownership
DateofBirth:
Checkbusinessrelationshipthatapplies:
Owner Shareholder Partner
Officer ManagingEmployee
Director BoardMember
Other:
ElectronicFundsTransfer(EFT)authorizedindividual
Check relationship to other persons named:SpouseParentChildSiblingNone
(Check all that apply)Other:

b. ProvidersmustdisclosethefollowinginformationtoEastpointe.Listallinformationrequestedfor eachagent oftheorganization/entity includingindividualofficers, directors,managing employees(generalmanager, businessmanager,administrator), andElectronicFunds Transfer(EFT)authorizedindividuals.Ifany ofthepersonsnamedarerelatedtoeachother asparent,spouse,childor sibling,indicate the relationship. Failure toprovide sufficient information,including completeSocialSecurity Numbers,toallowfortheverificationofthe disclosed information mayresultin a denial forparticipation withEastpointe

8. Disciplinary Actions(You must answer allsections of this question):

Have you, or anyoftheindividualsorentitieslistedinsections 8.Aor 8.B, or anyindividual employed ina clinical roleever:

a. Beenconvictedofafelony,hadadjudicationwithheldonafelony,plednocontesttoafelony or enterinto apre-trialagreement for afelony? Yes No

IfYes,listthename(s) oftheindividual(s)andyoumustattachacompletecopyofthecriminal complaintandfinaldisposition. Submitting only awrittenexplanationinresponseto this question is not sufficient.You must attach the applicable documentation.

b. Hadanydisciplinaryactiontakenagainstanybusinessorprofessionallicenseheldinthisor anyother state? Yes No

Or;

Hadyour licenseto practice restricted,reduced orrevoked in this or anyother state?

YesNo

Or;

Beenpreviously foundbyalicensing,certifyingorprofessionalstandardsboardoragency to haveviolatedthestandardsorconditionsrelatingtolicensureorcertificationorthequality of services provided?

YesNo

Or;

EnteredintoaConsentOrderissuedbyalicensing,certifyingorprofessionalstandardsboard oragency? Yes No

Ifany oftheQuestionsinSectionBwereansweredyes,pleaseprovidethefollowing information:

Against Whom?

Action Taken?

Who Took Action?

Date ofAction?

IfYes,youmustattachacompletecopyoftheConsentOrderandorfinaldisposition.You mustalsoattachdocumentationfromtheproperauthoritiesapproving thereinstatementofthe license.

c. Had anyaction or investigation againstyou or anyowner orqualified professional inyour Organization relatingto: (Ifyes, please attach explanation.)

Yes / No / Yes / No
License / Privileges
Certification / BillingOrganizations
Registration / Sanctions

d. Have anyadverseactions been filed againstyou by:(Ifyes, pleaseattach explanation.)

Yes / No
Medicaid
Medicare
OtherInsurance

e. Beendeniedenrollment,suspended,excluded,terminated or involuntarilywithdrawnfrom Medicare, Medicaid or anyother government or private health careorhealth insuranceprogram in any state,or been employed bya corporation,business,orprofessional associationthathas ever beensuspended, excluded, terminatedorinvoluntarilywithdrawnfromMedicare, Medicaidor anyothergovernmentorprivatehealth careorhealthinsurance programin any state? Yes No

IfYes,youmustlistthename(s)andprovidernumber(s)oftheindividual(s)orentity (ies)and attach acomplete copyof applicable documentation.

Name / ProviderNumber

Hasyour organizationbeen excluded from participation in Federal Health CarePrograms under either Sections 1128 or 1128A ofthe Social SecurityAct? Yes No

f. Had suspended paymentsfrom Medicareor Medicaid in anystate, or been employed bya corporation, business, orprofessional association that ever had suspended payments from Medicareor Medicaid in anystate? Yes No

If Yes, you must list the name(s) and provider number(s) of the individual(s) or entity(ies) and attach a complete copy of applicable documentation.

Name / ProviderNumber

g. Had civil monetarypenalties levied againstthis organization/entityoranyindividuals or entities listed in Questions 1 and 2 byMedicare,Medicaid or otherStateor FederalAgencyor Program, includingthe Division of Health ServiceRegulation (DHSR), even ifthe fine(s) have been paid in full? Yes No

IfYes,you must attachan explanation and supportingdocumentation from the agencyor program which levied the penalties as to thereason.

h. Owemoneyto Medicare orMedicaid that has notbeen paid? YesNo

i.Beenconvictedunderfederalorstatelawofacriminaloffenserelatedtotheneglectorabuse ofapatient in connection with thedeliveryof anyhealth caregoods or services? Yes No

j.Been convicted under federal or state law of a criminal offense relating to the unlawful manufacture, distribution, prescription, ordispensingofa controlled substance? Yes No

k. Been convicted of any criminal offense relating to fraud, theft, embezzlement, breach of fiduciaryresponsibility,financial misconduct, ormoral turpitude?

l.Been found to have violated federal or state laws, rules or regulations governing North Carolina’sMedicaidprogramorany otherstate’sMedicaidprogramoranyotherpublicly funded federal or state health care or health insurance program and been sanctioned accordingly?Yes No

IfYes,youmustlistthename(s)andprovidernumber(s)oftheindividual(s)orentity(ies)and attach acomplete copyof applicable documentation.

Name / ProviderNumber

m.Beenconvicted of an offense againstthe law other than aminor traffic violation?

YesNo

n. Has anyoneinyourcompanywho has an ownership, managerial orclinical role ever been sanctioned byanyprofessional organization orgovernment Organization for violation of ethics, professional misconduct,unprofessional conduct, incompetenceor negligencein anystateor country? Yes No

(Ifyes,attach explanation.)

Areyou awareof anycircumstances that mayresultin such an action?

YesNo

(Ifyes,attach explanation.)

9. Is the organization/agency incorporated? YesNo

Ifyes,pleaseattachacompletecopy oftheCertifiedArticlesofIncorporationorArticlesof Organizationandany subsequentchangestothe ArticlesofIncorporationorArticlesof Organization.

10. Is the organization/agency State-owned?YesNo

11. HasyourorganizationeverhadacontractcancelledbyanotherLME/AreaAuthority/ County PrograminNorth Carolina orsimilar entity inanotherstate?

YesNo (Ifyes,attach explanation.)

12. Identify otherproviders, ifany,whichareownedoroperated by theapplicant underthe sameownername.

Name – Provider:

City:.State: Zip Code:

Relationship type (nursinghome, homehealth agency,communitybased residential facility, hospital):

13. Is the applicant a subsidiary company, either wholly or partially owned by another organizationor business? Yes No

Ifyes, providethe followinginformation

Legal BusinessName –Parent Company:

Typeof Ownership:

14. Admissions/discharge criteria forInpatient Psychiatric Services,PRTF, IOP,PH, or Outpatient Services:

(Mayattachfacilitypolicy)

15. FinancialandBilling Information

The following capacitywillbeneeded:

a. An operational computersystem to includeDigital SubscriberLine (DSL)orhigher speed connection to theInternet and hardware and/or softwarefirewall

Is this currentlyavailable? YesNo

b. Current Anti-virus Protection on alldevices that will storeor displayclientidentifiable information.

Is this currentlyavailable? YesNo

Pleasesupplythe name,phonenumber ande-mail address ofyour agency’s billingstaff:

Name:

Phone Number:

E-mail Address:

Pleaseindicate themethodyou willuse to performelectronicbilling:

Eastpointe Provider directSystem (web based system thatyou will access through ahigh speed internetconnection.

HIPAA Compliant Transaction Sets (837Pand/or 8371 electronicfiles)

DoyoucurrentlyhaveaTradingPartnerAgreement with Eastpointe? Yes No

Ifnot,oneMUST be completed at Eastpointe’s website

Ifyou plan to useHIPAA Compliant Transactionsets (837Pand/or 8371),pleaselist thename of yoursoftware and softwarevendor:

Doyoucurrentlyhave clients insured bythird partypayers? Yes No

Areyou contractedwith anythird partypayers? Yes No

Areyou interested in electronic funds transfer ofpayments from Eastpointe? Yes No

Ifyes, youmust completeanAuthorizationAgreement forAutomaticDeposits.

16. Quality Management

Pleaseindicateyouragency/hospital contact’s name, phonenumber,and e-mail addressfor follow- up on incident reports orinvestigations:

Name:

PhoneNumber:

E-mail address:

Doyou haveaClient Rights Committee?Yes No

Client Rights Contact:

Name:

PhoneNumber:

E-mail address:

Quality ManagementContact:

Name:

PhoneNumber:

E-mail address:

SignatureAuthorizationandRelatedInformationRequired

** All InformationMust BeEntered for theApplicationto beProcessed**

Icertifythattheaboveinformationistrueandcorrect.Ifurtherunderstandthatanyfalseormisleading informationmay becausefordenialorterminationofparticipationasan EastpointeMedicaidProvider. Individualapplicationsmusthavetheprovider’soriginalsignature.Authorizedagentscanonlysign foragroupapplication.

SignatureofApplicantorAuthorizedAgentDate

PrintedNameandTitle

Eastpointe 08/16/2016