Service Provider Application

Please complete the Service Provider Application by:

  • completing the online form below in its entirety
  • downloading the Service Provider Application (PDF), completing it in its entirety and either:
    • email to: providerrelations@477home.org
    • fax to: 315.671.5129
    • mail to:
       Nascentia Health Options
       Attn: Provider Relations Department
       1050 West Genesee Street
       Syracuse, NY 13204-221

If a field/section does not apply, write “N/A”.

Questions: Call 315.477.9820

    General Information:

    Phone (include area code): (required)

    Fax (include area code): (required)

    Billing Phone (include area code): (required)

    Fax for Authorizations (include area code): (required)

    Medicare Certification:


    If your facility has more than 1 NPI# please list the NPI# and the facility name below:

    2.

    3.

    4.


    Parent Company Name and Contact Information (if applicable):

    Primary Contact Person Phone (include area code):


    Location Information

    Address and Phone Number of Branch or Satellite Offices (with counties serviced):






    Operating Hours: Please list hours (a.m. and p.m.):


    Contact Information (Include Name, Title, Phone Number and Email):



     

    Please check all items applicable to your location:











    ****THE FULLY EXECUTED CONTRACT WILL BE MAILED BACK TO THE PERSON WHO SIGNED IT. IF YOU WISH FOR IT TO BE MAILED TO A DIFFERENT PERSON/ADDRESS PLEASE LIST BELOW****




    Service Provider Applications

    Please select what type of service provider(s) you are applying for:










    Complete the required sections for each service provider you are applying for. After completing the General Information, Location Information and the necessary Service Provider Applications REMEMBER TO COMPLETE the Attestation, Credentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.


    Adult Day Care:

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Business Associates Agreement (BAA) (Social adult day only):

      • Nascentia will send for review and signature along with finalized contract.

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)





    Note: Before contract may be executed, an in-person site inspection visit must be completed. Your regional Provider Relations Representative will request to schedule one upon receipt of all necessary credentialing documentation listed above.

    Adult Day Care Services Offered (Check all that apply):








    Certified Home Care Agency (CHHA) / Licensed Home Care Services Agency (LHCSA):

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx




    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)



    • FLSA Attestation Form (complete form(s) below and sign)


    • JCAHO Accreditation:




      CARF Accreditation:




      Certified Home Health Care Agency Services offered (Check all that apply):
























      Licensed Home Care Agency Services offered (Check all that apply):
























      NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - CERTIFIED HOME HEALTH AGENCY

      Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

      I hereby certify that funding for all Medicaid home care services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the home care worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including required licensed home care service agency attestations and information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

      In addition, I will provide the managed care organization, if applicable, and/or the Department (when applicable) with all information to verify my compliance with the terms of this directive (including this attestation) and that such information shall be made available to the Department upon request.

      Check the appropriate box:




      Please note that in accordance with Parts 86-1.2 of Title 10 of the Commissioner’s Administrative Rules and Regulation, only the following individuals may sign this attestation:

      • Proprietary Sponsorship – Operator/ Owner
      • Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive officer, Chief Financial Officer or Chairperson, Public Sponsorship – Public Official Responsible for the Operation of the Facility

      Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.


      NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - LICENSED HOME CARE AGENCY

      Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

      I hereby certify that funding for all Medicaid home care services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the home care worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including this attestation and related information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

      In addition, I will provide the managed care organization, if applicable, and/or the Department (when applicable) with all information to verify my compliance with the terms of this directive (including this attestation) and that such information shall be made available to the Department upon request.

      Check the appropriate box:




      Please note that in accordance with Parts 86-1.2 of Title 10 of the Commissioner’s Administrative Rules and Regulation, only the following individuals may sign this attestation:

      • Proprietary Sponsorship – Operator/ Owner
      • Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors, Public Sponsorship – Public Official Responsible for the Operation of the Facility

      Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.


    Consumer-Directed Personal Aid (FI):

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)



    NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - CONSUMER DIRECTED FISCAL INTERMEDIARY

    Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

    I hereby attest that funding for all Medicaid consumer directed personal assistance services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the consumer directed worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including this attestation and related information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

    In addition, I will provide the managed care organization, if applicable, and/or the Department (when applicable) with all information to verify my compliance with the terms of this directive (including this attestation) and that such information shall be made available to the Department upon request.

    Check the appropriate box:




    The following individuals may sign this attestation:

    • Proprietary Sponsorship – Operator/ Owner
    • Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors

    Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.


    Durable Medical Equipment / Personal Emergency Response System:

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Business Associates Agreement (BAA):

      • Nascentia will send for review and signature along with finalized contract.

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)




    Durable Medical Equipment/Personal Emergency Response System Services offered (Check all that apply):












    For Durable Medical Equipment (DME) vendors who supply incontinence products:

    The Department of Health (DOH) issued an incontinence supply initiative effective September 1st, 2016. DME companies must now ensure that incontinence products that they dispense to Medicaid members meet minimum quality standards put in place by the DOH.

    The minimum standards include:

    • No plastic (Non-breathable) backed products
    • Rewet rate of <2.0g
    • Rate of Acquisition (ROA) of <6 seconds
    • Retention Capacity >250g
    • Presence of breathable zones with a minimum value of >100 cubic feet per minute (cfm)
    • Presence of closure system which allows for multiple fastening and unfastening occurrences

    Verification that your incontinence products meet minimum standards must be on file with Provider Relations at VNA Options. Verification must be in the form of test results obtained from an independent testing laboratory.

    IF your company purchases incontinence products from Twin Med, LLC, the State’s new preferred supplier, you do not have to verify incontinence product quality standards. Proof that your products are being purchased from Twin Med, LLC will suffice.

    Further, most First Quality and Covidien brands meet minimum quality standards, however, verification for these brands must also be on file.

     



    Home and Safety Modification:

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Business Associates Agreement (BAA):

      • Nascentia will send for review and signature along with finalized contract.

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)




    Environmental Modifications and Support Services offered (Check all that apply):










    Licensed / Certified Professional Services:

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Valid state licensure information (provide Licensure/Certification information in the General Information section of this form)

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)



    Services offered (Check all that apply):
















    Please list License/Certification information for all professionals employed at your facility. Applicable to all licensed staff, including but not limited to: Audiologists, Dietitians, Nutritionists, Optometrists, Opticians, Outpatient Therapists (PT, OT, ST, Respiratory) and Podiatrists.

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    5.


    Meals Provider

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Business Associates Agreement (BAA):

      • Nascentia will send for review and signature along with finalized contract.

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)



    Services Offered (Check all that apply):



    Skilled Nursing Facility (SNF):

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Valid state license(s) or operating certificate(s) (provide Licensure/Certification information in the General Information section of this form)



    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)







    JCAHO Accreditation:


    CARF Accreditation:


    Covered Services offered (Check all that apply):













    Skilled Nursing Facility Services:





    For SNFs providing OUTPATIENT THERAPY: Please list License/Certification information for all OT/PT/ST professionals employed at your outpatient facility.

    1.

    2.

    3.

    4.


    Transportation Provider:

    Please attach the following documents:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Business Associates Agreement (BAA):

      • Nascentia will send for review and signature along with finalized contract.

    • EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)



    Transportation Services Offered (Check all that apply):









    After filling out the necessary Service Provider Applications REMEMBER TO COMPLETE the Attestation, Credentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.

    ATTESTATION

    I agree to use best efforts to inform Nascentia Health Options in writing within 15 business days if there is any change in the information provided or the answers to questions on the application as a result of developments subsequent to signing this application.

    I agree that a photocopy or facsimile of this document with my signature may be accepted with the same authority as the original.


    Credentialing Attestation and Release Form

    In the past 3 years or presently, has your company or any of its representatives:

    1. Had disciplinary actions, criminal proceedings, or other adverse actions initiated against them (this includes license or certification limitations, revocations, suspensions, terminations, or voluntary relinquishment)? (required)


    2. Been subject of an investigation, or ever been suspended, sanctioned or otherwise excluded from participating in any private, state, or federal health insurance program (examples – Medicare, Medicaid, other Managed Care Organization)? (required)


    3. Been subject to (in whole or in part) professional liability or malpractice claims, suits, settlements, arbitration proceedings, or complaints? (required)


    4. Been subject to (in whole or in part) professional liability or malpractice claims, suits, settlements, arbitration proceedings, or complaints? (required)


    5. Been denied liability insurance (in whole or in part) or had your insurance canceled, involuntarily restricted, denied renewal, or rated up because of the nature volume of claims against your company? (required)


    Please Initial:


    Certification / Affirmation of Accuracy and Completeness

    I hereby affirm that all information provided in or attached to this application for credentialing/re-credentialing is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I understand that any misrepresentation or omission of any fact requested, whether intentional or not, is cause for automatic and immediate rejection and/or termination of the credentialing/re-credentialing process.

    I hereby agree to immediately notify Nascentia Health Options if such representation ever ceases to be accurate and true. I understand that this credentialing/re-credentialing review process will occur prior to approval of participation. I hereby authorize Nascentia Health to consult with any third party who may have information bearing on any services that my company provides. I hereby release any person, institution or other party from any liability in connection with the provision of such information or documentation.