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{"sheet":"Welcome","index":0,"n_rows":15,"n_cols":2,"rows_kept":15,"cut":false,"hidden":false,"merged":[[1,1,1,11],[3,1,10,11],[12,1,12,11],[14,1,14,11],[11,1,11,11],[13,1,13,11]]}
[]
[null,"Hospital Data Form"]
[]
[null,"Thank you for your interest in contracting with the Closed Network of Vaya Health and/or Partners Behavioral Health Management (Partners).  Vaya Health is the Credentialing Delegate (“Delegate”) responsible for processing all applications for credentialing submitted by Applicants seeking to become a member of the Closed Network of Partners Behavioral Health Management (“PBHM”) and/or Vaya Health.  Each individual LME/MCO is responsible for making its own independent decisions about credentialing approval, enrollment, network membership and contracting.  The delegate’s responsibility is limited to processing the application."]
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[null,"All completed applications and required attachments must be submitted via secure electronic transmission to:  CredentialingTeam@vayahealth.com\n\nAs an alternative, paper applications and attachments may be submitted to:\nCredentialing Team\nVaya Health\n200 Ridgefield Court, Suite 206\nAsheville, NC 28806\n"]
[null,"To get started, click here for instructions"]
[null,"IMPORTANT!\nDO NOT submit claims to the LME/MCO until your contract has been executed or you have been notified that you can submit claims.\nClaims must be submitted within ninety (90) days from the date of rendered service. The LME/MCO does not reimburse for non-ancillary services or non-behavioral health related services. \nAll claims for dates of service for the current fiscal year (7/1 – 6/30) are required to be submitted NO LATER than 7/31 of the following fiscal year.\n"]

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[null,"This data form can be used by Hospitals and physician practice groups owned and operated under ownership of a Hospital/Health System.\nPhysician Groups not owned or operating under the ownership of a Hospital/Health System need to be enrolled and credentialed under a different process.\nUse this link for details on how to enroll as an independent agency  http://vayahealth.com/providers/credentialing/\n"]
[null,"Instructions"]
[null,"Step 1:","Complete Corporate Information ",null,null,null,"Step 1 -> Corp Info tab"]
[null,"Step 2: ","Complete Facility Information",null,null,null,"Step 2 -> Facility Info tab"]
[null,"Step 3:","Complete Practitioner Information",null,null,null,"Step 3 -> Prac Info tab"]
[null,"Step 4: ","Print and sign the Letter of Attestation for False Claims Act Education",null,null,null,"Step 4 -> False Claims Act tab"]
[null,"Step 5:","Print and sign the Attestation and Release",null,null,null,"Step 5 -> Attest & Release tab"]
[null,"Step 6:","Submit the Hospital Based Contract Data Form with all required attachments to",null,null,null,"credentialingteam@vayahealth.com"]
[]
[null,"Required Attachments"]
[null,null,"• W-9"]
[null,null,"• Letter of Attestation for False Claims Act Education"]
[null,null,"•Attestation and Release"]
[]
[null,"One Hospital Data Form must be submitted for each tax ID."]
[null,"Upon receipt, the Hospital Data Form will be reviewed for completeness and accuracy."]
[null,"If the Hospital Data Form is incomplete the Vaya Health Credentialing Team will send notice to the hospital's primary contact person via email."]
[null,"A Hospital Data Form is considered to be invalid and must be returned to the provider for correction and/or for additional information if:"]
[null,"• The version date on any of the documents that comprise the provider enrollment packet is prior to September 14, 2016."]
[null,"• The contact person’s name and title is not completed."]
[null,"• The signatures, where required, are not original."]
[null,"• The signatures are not by the individual applicant or, where applicable, an authorized agent for the group or entity."]
[null,"• The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids."]
[null,"• The responses are illegible."]
[null,"• The National Provider Identifier is not a valid number."]
[null,"• Any of the requested information in any of the documents that comprise the Hospital Data Form are missing, with the exception of the fax number and e-mail address."]
[null,"• The provider name entered on the Hospital Data Form does not match the required IRS Form W-9, the NC Secretary of State, or NCTracks."]
[]
[null,"Important Points to Remember"]
[null,"• If services are being provided at multiple sites, you are required to list each site in this application and will be assigned a separate site ID number for each location."]
[null,"•  Retain a copy of your completed application and all documentation submitted for your records."]
[null,"• Providers are requested to include on their application the name, e-mail address, and fax number of the contact person at their organization who is responsible for receiving information."]
[]
[null,"Once the Hospital Data Form is complete, reviewed, and approved the contracting process will be initiated. "]
[]
[null,"If you have questions or need additional information, please contact the Vaya Health Credentialing Team at credentialingteam@vayahealth.com or at 855-432-9139."]

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[]
[null,"Step 1 -> Corporate Information (fields highlighted in blue are required)"]
[]
[null,"1.  Legal Name of Organization: "]
[null,"Must match W-9"]
[]
[null,"2.  Doing Business As (DBA):"]
[null,"If applicable, enter your DBA name"]
[]
[null,"3.  Federal Tax ID:"]
[null,"Attach W-9"]
[]
[null,"4.  Federal Tax Status:"]
[]
[null,"5.  Administrative Mailing Address:"]
[]
[null,"Street",null,null,"City",null,"State","Zip Code (+4)"]
[]
[null,"County","Phone","Fax"]
[]
[null,"Email Address"]
[]
[null,"6.  Has this Organization ever been in business under a different name?"]
[null,"If yes, what name?"]
[]
[null,"7.  Has your Organization ever had a contract cancelled by another LME/MCO in North Carolina or a similar entity in another state?"]
[null,"If yes, attach explanation"]
[]
[null,"8. Contact Information"]
[null,null,null,null,"Name",null,null,null,null,"Title","Phone","Email Address"]
[null,"Primary Contact Person:"]
[null,null,null,null,null,null,null,null,null,"Mobile"]
[null,null,null,null,null,null,null,null,null,"Fax"]
[null,null,null,null,null,null,null,null,null,"Pager"]
[null,null,null,null,"Name",null,null,null,null,"Title","Phone","Email Address"]
[null,"Executive Director/CEO:"]
[null,"Finance Director:"]
[null,"Clinical/Medical Director:"]
[null,"Behavioral Health Unit Director:"]
[null,"Emergency Department Director:"]
[null,"Billing Contact Person(s):"]
[]
[]
[null,"Identify individuals authorized to sign contracts and other legal documents:"]
[]
[]
[]
[null,"9.  Financial & Billing Information"]
[null,"Indicate method you will use to perform electronic billing"]
[null,"If you use a clearinghouse, provide the following"]
[null,"Name of Clearinghouse:"]
[null,"Clearinghouse Contact Person:"]
[null,"Email Address:"]
[null,"Phone:"]

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[]
[null,"Step 2 ->  Facility Information (fields highlighted in blue are required)"]
[]
[null,"1.   Is the applicant a subsidiary either wholly or partially owned, operated, or managed by another hospital/ health system or organization?"]
[null,"If yes, provide the following information"]
[null,"Legal Business Name – Parent Company"]
[null,"Type of Relationship"]
[]
[null,"2.  Attach admissions/discharge policy for Inpatient Psychiatric Services, PRTF, Intensive Outpatient, Partial Hospitalization, or Outpatient Treatment Facilities for behvioral health services.   "]
[]
[null,"3.  Facilities/Programs (Information provided must match Medicaid enrollment information in NC Tracks)"]
[null,"Please enter information associated with the Billing NPI used with the same Legal Entity’s Tax ID as indicated in Section I, for each facility/site and/or category of services. "]
[null,"Use separate Hospital Data Forms for different legal entities and Tax ID numbers"]
[]
[null,"Facility Info"]
[null,"Facility Type","Facility Site or Group Practice Name","Site Street Address","City","State","Zip Code (+4)","DHSR License #","Billing Facility or Group NPI","Taxonomy","Location NPI \n(if different)","Type of Service Billed"]

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[]
[null,"Step 3-> Practitioner Information (fields highlighted in blue are required)"]
[null,"By completing this section you are expressing interest in signing a Delegated Credentialing Agreement (DCA) with the MCO.  A DCA allows the MCO to accept the Hospital's credentialing of the practitioners that bill the MCO for behavioral health services.   \n\nHospitals that choose not to sign the DCA must complete the MCO's standard credentialing process for all practitioners that will bill the MCO for behavioral health services PRIOR to the delivery of such services.  The standard credentialing process for practitioner credentialing is initiated by completing and submiting the Credentialing Initiation Form for each practitioner.  The Credentialing Initiation Form can be found at http://vayahealth.com/providers/credentialing/. \n\nHospitals that choose to sign a DCA must submit practitioner data on the form below.  Submission of practitioner information on this form serves as an attestation that all practitioners listed in this document have been credentialed by the hospital in accordance with URAC accreditation standards.  ONLY practitioners who will bill the MCO for behavioral health services should be included in the list below.\n\nPhysician group practices that are not legally owned by the hospital/health systems are not eligible to submit practitioner information in this format."]
[null,"1. Legal Name of Hospital/Health System/Physician Group:"]
[null,"2. Is this practice owned, operated, or managed by a hospital/health system?"]
[null,"3. If yes, is there a delegation agreement between the MCO and the hospital/health system that covers practitioner credentialing"]
[null,"4. Physician Group's Tax ID/EIN (associated with the billing provider NPI)"]
[null,"Tax ID:"]
[]
[null,"Practitioner Info",null,null,null,null,null,null,null,null,"Physical Address/Info"]
[null,"Last Name","First Name","Middle Name","License Type","License Number","License Issue Date","License Expiration Date","Individual NPI Number","Practitioner's Taxonomy Code","Street","City, State","Zip + 4 ","County","Billing/Group NPI","Billing/Group Taxonomy"]

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["Yes",null,"For profit",null,"Clearinghouse",null,"Acute Care/Inpatient Medical Detoxification",null,"Emergency Department Facility",null,"251S00000X"]
["No",null,"Not for profit",null,"Direct bill",null,"Emergency Department",null,"Emergency Department Facility and Physician Evaluation & Management",null,"251E00000X"]
[null,null,null,null,null,null,"Emergency Room Physician Group",null,"Emergency Department Physician",null,"251B00000X"]
[null,null,null,null,null,null,"Inpatient Psychiatric Unit",null,"Inpatient Facility and Psychiatrist  Evaluation & Management",null,"253Z00000X"]
[null,null,null,null,null,null,"Outpatient Behavioral Health",null,"Medical Floor Inpatient Detoxification",null,"261QA3000X"]
[null,null,null,null,null,null,"Psychiatric Physician Group",null,"Outpatient Behavioral Health Assessments and Treatment (NC DMA Clinical Coverage Policy 8C)",null,"261QC1500X"]
[null,null,null,null,null,null,null,null,"Psychiatric Group Services",null,"261QH0100X"]
[null,null,null,null,null,null,null,null,"Psychiatric Inpatient Facility",null,"261QP0905X"]
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