Facility/Ancillary Application for Land of Lincoln Health
(Complete for each Facility)
Corporate Information (33):
Facility Name:
DBA Name:
Corporation Name:
Street Address:
City:
State:
Zip:
NPI #:
Attach any available materials (i.e., Brochures) describing your services.
Mailing Address (03):
Firm Name:
Street Address:
City:
State:
Phone:
Fax:
Zip:
Email:
Service Location (01):
Firm Name:
Street Address:
City:
State:
Phone:
Fax:
Zip:
Additional Locations can be attached in a roster.
Credentialing Contact (32):
Firm Name:
Street Address:
City:
State:
Phone:
Fax:
Contact Name and Title:
Email:
1
Zip:
Billing Information (02):
Tax Identification Number:
Is this the same Tax Id for all?
☐ Yes ☐ No
Pay to Name:
Street Address:
City:
State:
Phone:
Fax:
Zip:
Email:
Does Billing Address Apply to all Service Locations?
☐ Yes ☐ No
Billing Questions
1. Please indicate on which you bill
☐ UB ☐ CMS
2. Can all claims billed under your TIN be processed under one
agreement?
☐ YES ☐ NO
3. Is a single consolidated claim used for all services rendered by provider and/or any sub
contracted providers?
☐ YES ☐ NO
4. Imaging Center and Laboratories ONLY, do you bill for:
a. Global Services Only
☐
b. Technical Services Only
☐
c. Professional Services Only
☐
d. Global and Professional Services
☐
If Technical Services is checked, indicate who bills for the Professional Services
________________________________________________________________
Facility Provider Type (As listed on License or Accreditation):
PLEASE MARK ALL THAT APPLY.
☐
☐
☐
☐
Hospital Acute Care-General
Hospital Long Term Acute Care
Hospital Rehabilitation
Hospital Behavioral Health
2
Certifications/Licensure/Accreditations
Please attach a copy – Must be current as of effective date
☐ Medicare Certification
☐ American College of Radiology (ACR)
☐ The Joint Commission (TJC)
☐ Board of Certification/Accreditation (BOC)
☐ Community Health Accreditation
☐ College of American Pathologists (CAP)
☐ Accreditation Commission for Health Care (ACHC)
☐ Health Quality Association on Accreditation (HQAA)
☐ American Board of Certification in Orthotics and Prosthetics (ABC)
☐ Det Norse Veritas
☐ Healthcare Facilities Accreditation Program (HFAP)
☐ Other:
☐ NOT ACCREDITED (please answer the following question)
Has the provider has an on-site survey by CMS or State Agency in the last 3 years?
☐Yes
☐No
If you do not have a CMS Survey within the last 3 years, Land of Lincoln staff will
conduct an onsite visit.
Liability Information
Please attach a copy – Must be current as of effective date
A. Evidence of Insurance
Please provider evidence of your professional and general comprehensive liability
insurance. This information must include the following information for each policy in
effect:
• Carrier
• Type of Insurance
• Effective Dates
• Dollar limits for professional per occurrence and aggregate (Required:
$1M/$3M)
• Dollar limits for general comprehensive per occurrence and aggregate
(Required:
$1M/$3M)
• or State required minimum
Ancillary Services Provider Types:
Please supply additional information as needed
Ancillary Services in addition to main Facility?
(If yes, need roster)
Are there multiple locations for Ancillary Services?
(If yes, need roster)
Do all entities bill under one Tax ID Number?
(If yes, need roster)
Is Billing Centralized for all Ancillary and Facility Services?
Are all Ancillary services accredited?
3
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ No
☐ No
QUESTIONNAIRE
(Please answer all questions and provide explanation for affirmative answers)
Applications that do not include all requested responses and explanations will not be able to be
processed.
1. Has the license to do business for Facility or covered entities in any applicable
jurisdiction ever been denied, restricted, suspended, reduced or not renewed?
☐ Yes ☐ No
2. Has Facility or covered entities ever had its professional liability coverage cancelled but
not renewed?
☐ Yes ☐ No
3. Has the Facility or covered entities been denied accreditation by its selected accrediting
body (e.g. TJC), or had its accreditation status reduced, suspended, revoked or in any
way revised by the accrediting body? ☐ Yes ☐ No ☐ N/A
4. Have there been or are there currently pending any malpractice claims, suits,
settlements or proceedings involving your Facility or covered entities?
☐ Yes ☐ No
5. Has the Facility or covered entities ever been disciplined, fined, excluded from,
debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise
restricted in regard to participation in the Medicare or Medicaid program, or in regard
to other federal or state governmental health care plans or programs? ☐ Yes ☐ No
6. Has the Facility or covered entities ever been subjected to sanctions by a Professional
Review Organization (PSRO or PRO), a Third Party Payor, or a Regulatory Agency (CLIA,
OSHA, etc.)? ☐ Yes
☐ No
ATTACHMENTS NEEDED
Please include the following with your completed application:
□ W-9 Form completed, signed and dated
□ Copy of current State License/Approval (as applicable)
□ Copy of current CLIA License/Approval (as applicable)
□ Copy of current Radiology License/Approval (as applicable)
□ Copy of Medicare/Medicaid Participation Certification (as applicable)
□ Copy of Certifications and/or Accreditation Certificates (e.g. TJC, Medicare, etc.)
□ Copy of Declaration Sheet and/or Certificate of Insurance:
BOTH ARE REQUIRED and must name covered entities
□ Current Professional Malpractice
□ Comprehensive General Liability Insurance Policies
□ Completed Application
□ Roster of Service Addresses in format sent from LLH
4
Facility Services
Additional Hospital Services
☐250 NICU
☐255 PICU
☐256 Burn Unit
☐257 CCU
☐258 Trauma
☐75 ER
☐259 Inpatient medical/surgical-adult
☐260 Inpatient medical/surgical -child
☐261 Cyberknife
☐262 Gamma Knife
71 Behavioral Health
☐72 Dual Diagnosis- Behavioral Health
☐73 Eating Disorder Unit
☐74 Elective Admissions Only- Mental Health
☐275 Emergency Admits
☐76 Inpatient Rehab Mental Health
☐95 Intensive Outpat Rehab Mental Health
☐78 Observation Unit
☐79 Outpatient Medication
☐80 Outpatient Rehab Mental Health
☐81 Partial Hospitalization/Mental Health
227 Women’s Center
☐100 Bone Mineralization Imaging
☐101 Breast Cancer/Screening/Mammograms
☐230 Breast Exams
☐231 Endocrine Studies
☐84 Genetic Counseling
☐233 High Risk Pregnancy
☐167 Pap Smear
☐109 Percutaneous Bx (Sterotactic)
☐110 Percutaneous Bx (U/S)
☐274 Pregnancy and Child Birth Education
☐113 Ultrasound
88 Chemical Dependency Treatment Center
☐95 Adolescent Teen
☐89 Detoxification Drug/Alcohol
☐90 Dual Diagnosis-Chem. Dependency
☐91 Elective Adm Only- Chem. Dependency
☐92 Emergency Admits Chemical Dep
☐94 Intensive Outpat-Chemical Dependency
☐95 Intensive Outpat- Rehab Mental Health
☐96 Outpatient Rehab Chemical Dependency
☐97 Partial Hospitalization Chem Dep
☐98 Residential Program
99 Diagnostic Radiology
☐100 Bone Mineralization Imaging
☐101 Breast Cancer/Screening/Mammograms
☐102 CT Scanner
☐103 General Radiology
☐104 Invasive Testing
☐105 MRI Services
☐106 Neuroradiology
☐107 Non-Invasive Testing
☐108 Nuclear Medicine
☐109 Percutaneous Bx/Stereotactic
☐110 Percutaneous Bx (U/S)
☐111 Pet Scan
☐112 Plain Film Radiography
☐113 Ultrasound
☐114 Vascular Services
67 Audiology/Hearing
☐68 Brain Stem Auditory Response Testing
☐69 Hearing Aid/Aural Rehab
☐70 Hearing Testing
11 Durable Medical Equipment
☐270 CPAP
☐118 Diabetic Supplies
☐ 115 DME- Furniture
☐ 280 DME- Other Medical supplies
☐271 Wheel Chair
120 Home Care Agency
☐121 Aids/Arc Outpatient Services
☐118 Diabetic Supplies
☐ 37 Dialysis Center
☐115 Durable Medical Equipment
☐124 Geriatric Programs
☐57 Hemodialysis
☐33 Hospice
☐127 Ng Feeding Tubes
☐66 Nursing
☐43 Occupational Therapy
☐45 Pain Management
☐86 Perinatal Care
☐132 Peritoneal Dialysis
☐133 Peripheral IV Administration
☐41 Physical Therapy
☐32 Speech Therapy
☐136 Tpn
☐137 Ventilator Adult
☐58 Infusion Therapy
☐264 Ostomy Care
☐151 Ventilator Pediatrics
162 Laboratory
☐163 Amino/Genetic Counseling
☐164 Blood Chemistry
☐231 Endocrine Testing
☐166 Isotopes
☐167 Pap Smear
☐168 Pathology
☐169 Pregnancy Testing
☐170 Routine Hematology
☐171 Surgical Biopsies
☐172 Toxicology
☐173 Urine Analysis
152 Orthotic/Prosthetic
☐117 Adult Orthotics/Prosthesis
☐116 Customized Prosthesis
☐119 Pediatric Orthotics/Prosthesis
272 Arthroscopy/ S/B Transportation
☐223 Air Transportation
☐224 Ground Transportation
☐225 Staff Ccrn Certified
☐226 Staff Cen Certified
208 Surgicenter
☐272 Arthroscopy
☐252 Breast Surgery/Needle Localization
☐210 Endoscopic Procedures
☐211 Ent Surgery
☐212 General Surgery
☐263 Gynecology
☐59 Kidney stone “Crusher”- Lithotripsy
☐215 Laser Surgery
☐216 Minor Vascular Surgery
☐217 Ophthalmologic Surgery
5
☐218 Orthopedic Surgery
☐219 Plastic Surgery
☐220 Podiatric Surgery
☐221 Urologic Surgery
138 Nursing Facility/Long-Term Care &
Rehabilitation Facility
☐139 Aids
☐121 Aids/Arc Outpatient Services
☐141 Alzheimer/Dementia Care Unit
☐176 Amputee Rehab
☐177 Arthritis Program
☐142 Brain Injury Program
☐143 Caregiver Support Program
☐179 Cardiac Rehab
☐180 Central Line IV Admin
☐181 Chemotherapy Admin
☐33 Hospice Services
☐183 Iv Vasopressor Admin
☐184 Neuromuscular Disorder
☐127 Ng Feeding Tubes
☐185 Orthopedic Rehab
☐186 Peripheral IV Admin
☐187 Pulmonary Rehab
☐147 Respite Program
☐188 Spinal Injury Rehab
☐189 Stroke Rehab
☐39 Sub-Acute Care
☐136 Tpn
☐150 Tracheotomy
☐278 Ventilator Rehab
☐151 Ventilator Pediatrics
☐182 Wound Care Management
33 Hospice
☐139 Aids/Arc Services
☐194 Caregiver Program
☐145 Ng Feeding Tubes
☐196 Nonsectarian-Hospice
☐197 Outpatient Services
☐186 Peripheral IV Administration
☐199 Sectarin-Hospice
200 Sleep Disorders Centers
☐201 24Hr 16Chan Ambu
Electroencephalography
☐202 24Hr 8Chan Ambu
Electroencephalography
☐203 24Hr Blood Pressure Monitoring
☐204 Adult Sleep Apnea Evaluation
☐273 Child Sleep Apnea Evaluation
☐205 Continuous Pos. Airway Pressure (Cpp)
☐206 Infant Breathing Assessment
☐207 Multiple Sleep Latency Test (Mslt)
☐83
☐84
☐85
☐86
☐87
82 Birthing Center
Family Planning
Genetic Counselling
Obstetrics
Perinatal Care
Prenatal Services
Occ/Physical/Speech Therapy Center
☐157 Chiropractic Services
☐43 Occupational Therapy
☐41 Physical Therapy
☐32 Speech Therapy
☐161 Whirlpool Services/Work Hardening
☐ 279 County Health Department
☐55 Ambulatory Care Clinic
☐60 Walk In Care Clinic
☐99 Diagnostic Radiology
☐61 Specialty Care Only (Ambu Care Clinic)
67 Audiology/Hearing
☐68 Brain Stem/ Auditory Resp Testing
☐69 Hearing Aid/Aural Rehab
☐70 Hearing Testing
STATEMENT OF APPLICATION/AUTHORIZATION FOR RELEASE OF INFORMATION
In order to evaluate this application for participation in and/or continued participation
in the Plan, the Facility hereby gives permission to the Plan to request from other entities
information regarding the Facility’s credentials and qualifications. This includes consent to
contact the Facility’s accreditation agencies, State Regulatory and Licensing Departments,
professional liability and workers compensation insurance carriers. The Facility understands that
the Plan will use this information in a confidential manner on its own behalf and, if applicable, as
an agent for one of its affiliated networks in connection with the administration of the Plan. The
Facility certifies that the information provided and the answers to the questions on this
application are accurate and complete. While this application is being evaluated, and if this
Facility/Subcontractor is selected or retained, after such selection or retention, the Facility
agrees to inform the Plan in writing within 15 days of any changes in the information provided
and the answers to questions on the application as a result of developments subsequent to the
execution of this application. The Facility agrees that submission of this application does not
constitute selection or retention by the Plan on its own behalf or, if applicable, as an agent for
one of its affiliated Plans and if the Facility is initially applying for participation, grants this
Facility no rights or privileges in any Plan programs or any program or one of its affiliated Plans
until such time as this Facility receives notice of selection.
All information submitted in this application is true and complete to the best of my/our
knowledge and belief. A photo copy of this original constitutes our written authorization and
requests to release any and all documentation relevant to this application. Said photo copy shall
have the same force and effect as the signed original.
6
TESTIMONIAL:
I hereby submit this application for participation in the Land of Lincoln Health, Inc.
Provider Network, on behalf of the above named provider/facility and understand that this
application will be reviewed based on the information I have provided herein. I hereby certify
that the information contained in this form, including any and all enclosures and/or attachments
submitted as part of this Application, is accurate and complete, that this provider/facility, and its
owners, are in full compliance with all applicable Federal and State laws, including but not
limited to anti-self referral laws including Stark I and Stark II laws. Information found to be false
could result in denial or subsequent termination of this provider’s/facility’s participation in the
LLH Provider Network.
FACILITY NAME:
______________________________________________________________________________
Signature of Individual completing Application
Date
______________________________________________________________________________
Printed name of Individual completing Application
______________________________________________________________________________
Title of Individual completing Application
LLH Use Only
Name of Network Development Contractor Evaluating and Approving
Date:
Signature of Network Development Contractor
7