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Managed Care Contract Assessment and Credentialing
Healthcare Management Consulting |
- Practice Start Up & Development
- Managed Care Contract Negotiations
- Credentialing
- Marketing
- Compliance and Risk Assessment
- Other Services
Practice Assessment Form
LIST
OF ITEMS NEEDED FOR EACH PROVIDER Provider Name/Title: ________
Specialty: ______________________ - 1. Copy of C.V. for each provider with Month/Year for education & work
history
- A. Date of Birth __________________
- B.
Place of Birth _________________________________
- 2. Copy of each providers:
A.
Occupational LicenseB. DEA License
# ________________ Expiration Date: ______ - C.
Medical License #__________________Expiration Date_____
- D. Board Certification # __________________
- E. Diplomas (medical
school/residencies)
- F. NPI Notification on national pin number: Individual and roup
- G. FCFMG # ____________________
- H. CME Listing
- 3. Numbers for each provider:
A.
Medicare # _____________ Group #_________________B. Medicaid # _____________
Group # ________________ - A. UPIN # ___________________National Pin # _________
- Group _________________
- B.
BS # __________________ Group # __________________
- C. SS # __________________
- D. CAQH Prov # ______User
Name__________Pswd:________
- 4. Home Address for each provider and home phone number for each provider____________________________________________________
- 5. New Corporation Information: Effective Date: _____________
- A. Name
__________________________________________
- B. Tax ID Number _________________________________________
- C. Copy of tax deposit slip for new corporation or IRS CP575 (letter).
- D. Copy of Articles of Inc.
- E.
Copy Occupational
License
- F.
Copy Bank Letter
- G. Office Location Address (include County)_________________________________________________ _________________________________________________
_________________________________________________
- H. Office Phone____________________Fax________________
- I.
Email Address: __________________________________
J. Billing Address __________________________________________ __________________________________________
Page 2 of 2
- 6. List of hospitals, phone,
and Addresses where each provider has privileges:___________________
___________________ __________________ ___________________ ____________________ ___________________
- 7. Previous information
– used for filings before new corporation
A. Corporation Name _________________________________ B. Tax ID # _______________________________________________- C.
Corporation address ______________________________________
- D.
Corporation Phone # ______________________________________
- 8.
Completed W9 Form
- 9.
Completed sample
HCFA 1500 Form
- 10. Copy of Malpractice Insurance Face Sheet and info on any claims.
- 11. Copies of any Malpractice Suit Information.
- 12. Copy of General Liability Insurance Face Sheet
- 13. CLIA Information:
- A.
License copy and number ________________________________
- B.
Type of tests performed ___________________________________________________________________________________________________________________________________________14. List
of Managed Care Plans each provider participates in as well as products they participate in and reimbursement and provider numbers for each. (Attach to
this form)
- 15.Copies of all managed care contracts or have available for review.
- 15. Office Hours: Mon
Thurs.
Tues
Fri
Wed
Sat/Sun
- 16. Age Limits: ____________________________________________
- 17. References and Call Group Names, phone and Address: _______________________________________________________18. _________________________________________________________ _________________________________________________________
_________________________________________________________NOTE:
Make additional copies for each provider as needed. AMN Consulting – P. O. Box 20545 – Tampa, FL 33615-0545
PRACTICE ASSESSMENT
QUESTIONNAIRE
LIST OF ATTACHMENTS
| Doctors' Cvs | | | | | | | | Monthly Breakdown of number of patients seen Current Year
and Previous Year | | List of Patient Mix by Payor | | Referral Tracking Report - 2 years | | Active Patient Report | | System Summary - Current and Previous Year | | Current Fee Schedule | | Insurance Aging Summary - Current | | List of Managed Care Plans
and copies of contracts | | Current Aging Report (AR) | | Copy of Encounter
Form (Charge slip) | | Sample copies of current insurance rejections | | Billing Service Agreement - if applicable | | | | | | | | Mission Statement
& Goals and Objectives | | | | | | | Marketing Materials,
e.g., patient satisfaction questionnaires, brochures, newsletters letterhead, business cards, logo, etc. |
Please
check material and check off to confirm attachments. P.O. Box 20545 Tampa, FL 33622-0545 813-690-5551 bnorwood23@yahoo.com
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