KAISER PERMANENTE HEALTHCARE DELIVERY ORGANIZATION (HDO)

Facility Administrator: Kaiser Foundation Health Plan of Washington (“Kaiser Permanente”) evaluates the quality of the healthcare delivery organizations with which it contracts. Below you will find a facility credentialing application to complete and submit along with the required documents within 10 business days. Hereafter we will collect this same information at least every three years or until your facility’s contract ends with Kaiser Permanente. PLEASE NOTE: There are multiple documents required which are listed at the end of this form under "Attachments". If any field is not applicable, please enter N/A or zeros if it's a numerical field.

REQUESTOR INFO

Requestor Name

Requestor Email

Requestor Phone

Phone

ORGANIZATION

Tax ID

Is this Tax ID Currently Contracted?

Yes

Tax ID Type

If using a social security number, enter 000000000 and we will reach out to you for this number.

EIN

SSN

Contract Name on W9

Doing Business As

Tax ID Street Address

Tax ID City

Tax ID State

Tax ID Zip

Tax ID Phone

Phone

Tax ID Fax

Phone

Specialty

Secondary Specialty

INSTRUCTIONS

If more space is needed, please attach additional sheets and reference the question being answered.

Care Site Name

Main Care Site Street Address

Main Care Site City

Main Care Site State

Main Care Site Zip

Main Care Site County

Main Care Site NPI #

Main Care Site Phone #

Phone

Main Care Site Fax #

Phone

Secondary Care Site Name

Secondary Care Site Street Address

Secondary Care Site City

Secondary Care Site State

Secondary Care Site Zip

Secondary Care Site County

Secondary Care Site Phone #

Phone

Secondary Care Site Fax #

Phone

Type of Addition

Location Addition

Service Addition

Effective Date

Contract Mailing Address

Contract City

Contract State

Contract Zip Code

Contract Contact Name

Contract Signatory Name

Contract Signatory Title

Contract Contact Email

Contract Contact Phone #

Phone

Claim Form Type Billed

CMS-1450 (UB-04) form is the industry standard for submitting institutional claims for inpatient and outpatient services (Facility)

CMS-1500 (HICFA)form is the standard claim form used by a non-institutional provider or supplier (Professional)

CMS 1500

CMS 1450 (UB-04)

Both

Billing / Pay to Name

Billing / Pay To Street Address

Billing / Pay To City

Billing / Pay To State

Billing / Pay To Zip

Billing / Pay To NPI #

Billing / Pay To Phone #

Phone

Billing Contact Name

Billing Contact Email

Billing Taxonomy Code

Credentialing Contact Name

Credentialing Contact Email

Taxonomy (if applicable)

Enter N/A is not applicable

Unified Business Identifier

Geographical Area Serving, by Counties

ORGANIZATIONAL PROVIDER TYPES

Alcohol/Drug Treatment Facility

Yes

If inpatient Alcohol/Drug Treatment Facility; how many beds?

Outpatient

Yes

Ambulatory Surgery Center

Yes

Autism Treatment Center

Yes

Behavioral Health Agency

Attach a roster of all licensed practitioners

Yes

Birth Center

Yes

Clinical Laboratory

Yes

Comprehensive Outpatient Rehab Facility (CORF)

Yes

Dialysis Center/End Stage Renal Disease Services

Yes

Federally Qualified Health Center

Yes

Home Health Agency

Yes

If Inpatient Home Health Agency; # of beds

Outpatient (Home Health Agency)

Yes

Hospice

Yes

If Inpatient Hospice; # of beds

Outpatient (Hospice)

Yes

Hospital

Yes

If Inpatient Hospital; # of beds

Outpatient (Hospital)

Yes

Outpatient Diabetes Self-Mgmt Education

Yes

Outpatient Physical Therapy/Occupational Therapy

Yes

Portable X-ray Supplier/Imaging/Radiology

Yes

Rural Health Clinic

Yes

Skilled Nursing Facility

Yes

If Inpatient Skilled Nursing Facility; # of beds

Outpatient (Skilled Nursing)

Yes

LICENSURE, REGISTRATIONS AND CERTIFICATIONS

State Business License #

State Business License Expiration Date

State Facility License #

State Facility License Expiration Date

DOH License and/or DSHS Cert

DOH License and/or DSHS Cert Expiration Date

Medicare Certification #

Medicare Certification Expiration Date

Medicaid Certification #

Medicaid Certification Expiration Date

Accreditation Body

Accreditation Body Previous Survey Date

Accreditation Body Current Survey Date

Accreditation Body Expiration Date

Malpractice Liability Carrier

Malpractice Liability Policy Number

Malpractice Liability Carrier Start Date

Malpractice Liability Carrier End Date

General Liability Company Name

General Liability Policy #

Please attach a copy of the face sheet below

SANCTIONS

If the answer to questions 1, 2, 3, 4 or 5 below is “yes” or if “no” to question 7 below please attach a written, dated, and signed explanation.

Has your organization ever applied for accreditation or certification and were denied?

Yes

Has the Facility been sanctioned, placed on probation or stop placement, lost accreditation, licensure or certification status or been on stop payment within the last three years?

If yes, please attach a written explanation

Yes

Has your organization ever been disciplined by any state licensing or other authorizing agency, or by any professional conduct board, or has it been reprimanded or fined by a state agency that disciplines your specific provider type?

If yes, please attach a written explanation

Yes

Has your organization ever been sanctioned, censured, excluded, suspended, or disqualified by the Medicare or Medicaid programs?

If yes, please attach a written explanation

Yes

Are you currently under a corrective action plan?

If yes, please attach a written explanation

Yes

Hospitals Only: Are you a participant in the National Disaster Medical System?

Yes

Does your facility comply with State and Federal handicap access requirements?

If no, please attach a written explanation

Yes

Helpful Notes

Electronic Funds Transfer (EFT)

Kaiser Permanente is working toward full enrollment in Electronic Funds Transfer (EFT). If you are not already enrolled, click here to enroll: EFT Enrollment Electronic Funds Transfer Enrollment or go to: https://register.instamed.com

Attachments

Current copies of the following documents must be submitted with this application (an application for each type of facility). If you cannot upload the documents with this form, email them to KPWA.provider-services@kp.org and reference this HDO application.

Please submit the completed application and required documents within 10 business days to avoid denial or termination of your Kaiser Permanente contract.

- Current W9.

- Washington State Master License, Registrations and Licenses certificate (State Business License)

- DOH License and DSHS Certification, if applicable. - Accreditation letter or report (including survey results and action plans, if applicable).

- Medicare certification or State Department of Health or Department of Social and Health Services survey letter or report (including survey results and action plans, if applicable).

- Current copy of the facility’s state business license or license issued by the State Department of Health or Department of Social and Health Services.

- Current accreditation letter or certificate from a recognized agency, e.g., TJC, AAAHC, CARF, CLIA, etc. If applicable, include recommendations for improvement and corrective action accepted by the agency within the past three years.

- Current CMS certification and/or State Department of Health or Department of Social and Health Services survey letter or report. If the report(s) reflect a statement of deficiencies and plan of correction, provide recommendations for improvement and corrective action accepted by the agency within the past three years.

- Include a copy of the facilities current malpractice liability insurance face sheet. All information submitted and collected for review during the credentialing process will be kept confidential to the extent provided by law. You will be notified in writing as soon as the credentialing process has been completed.

- For behavioral health facilities we require a roster of all licensed practitioners,

You may upload up to 10 documents. If you cannot upload the documents with this form, email them to KPWA.provider-services@kp.org and reference this HDO application.

Drop your files here

Send me a copy of my responses

Report Abuse