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Instructions for Completing a Credentialing Registration Form Thank you for your interest in enrolling as a Licensed Independent Practitioner (LIP) in the Cardinal Innovations Healthcare (Cardinal Innovations) provider network. Enrollment requires that you be credentialed and either contracted with Cardinal Innovations or employed by a contracted provider.

Each of these items must be addressed in full before initiation of the credentialing process. Any applications sent without completing these requirements in full will be returned.

NCTracks North Carolina Medicaid maintains a claims system named NCTracks and requires Cardinal Innovations to submit claims data through the NCTracks system. For claims data to be accepted by the NCTracks system, all clinicians seeking to be credentialed by Cardinal Innovations must be enrolled in North Carolina Medicaid and the NCTracks system. Clinicians also must be affiliated in NCTracks with the contracted provider that intends to submit claims for the clinician’s services, along with the respective provider sites where the practitioner intends to deliver services.

a. If a practitioner is not enrolled in NCTracks: the CRF must be accompanied by the full NCTracks enrollment application. *Please note: Board Certified Behavior Analysts (BCBA) do not need to be enrolled in NCTracks*

b. If the clinician is enrolled in NCTracks, but not affiliated with your agency or all requested service sites: a copy of the full Managed Change Request (MCR) submitted to NCTracks requesting affiliation must accompany the Credentialing Registration Form (CRF).

c. To enroll and/or affiliate, visit www.nctracks.nc.gov. From there, click on the “Providers” tab and select "Provider Enrollment" from the menu on the left.

Address/Summary Locator in NCTracks If not already completed, please make sure the main address written on the CRF and any additional site addresses, appear in the Primary Service Location or Additional Service Location address section in NCTracks. If the address(es) are not in that section in NCTracks, please submit an MCR to make these changes. We cannot move forward with a credentialing application without this information in that section.

NCTracks Quick Tips:

First time enrollment: You must SAVE/PRINT the provider enrollment form from NCTracks. It will not allow you to go back and retrieve it, and it will result in an inability to save a copy of the forms until after it has been approved at a much later date. This will delay your credentialing application submission until your NCTracks is complete.

How to save: Review when you have reached the end of the application, select the option to save/print. While you are reviewing the document, either print the document or print the document to a PDF, which you can save.

How to submit an MCR: https://www.nctracks.nc.gov/content/public/providers/provider-user-guides-and-training/fact-sheets.html

Click on: “How to Affiliate an Individual Provider Record to a Group-Organization in NCTracks”

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CAQH

The Council for Affordable Quality Healthcare (CAQH) provides a streamlined, secure method for electronic data collection at no cost to you and is the portal for the North Carolina uniform credentialing application used by Managed Care Organizations. CAQH houses your clinical history (licensure, education, employment history, self-disclosed sanctions, etc.). Revisions made by you are available instantly to authorized organizations. *Clinicians maintain total control of their data at CAQH, authorizing access only to the participating Managed Care Organizations of their choice. Additional information can be found at: https://proview.caqh.org/Login/Index?ReturnUrl=%2fpo

We will not accept a Credentialing Registration Form (CRF) without a CAQH ID number. You may begin the self-registration process by accessing CAQH ProView at: https://proview.caqh.org/pr and clicking on “Register.” The “Getting Started” page will provide you with additional tips on how to get started.

How Cardinal Innovations accesses your CAQH:

Using the eight-digit CAQH number located on your CRF, we will access your CAQH profile and add you to our roster. Then, within your profile, the opportunity to designate Cardinal Innovations as an authorized entity within your CAQH will become available. Please give authorization to Cardinal Innovations.

The Cardinal Innovations Attestation:

You can find the attestation statement on our website in the Resource Library and within the CAQH profile once we have added you to our roster. The Cardinal-Innovations-specific attestation statement/form attests to the accuracy and completeness of the information within the CAQH profile and may determine your effective billing date.

• The form must be signed and dated as of the last date of your CAQH application update/re-attestation. If the signature predates the last CAQH re-attestation date, it will not be valid.

• You must upload the attestation statement into your CAQH application.

CRF

Credentialing Registration Form (CRF) – After you have completed your NCTracks information, and CAQH, you can initiate the LIP credentialing process. Review the attached checklist on pages 4and 5 of this document to assure all information forms and fields are complete and that all required documentation and supporting documents are collected before submitting the CRF.

How to submit the CRF and Supporting documentation:

• Subject Line when submitting by fax/email: New Credentialing Application

• Via Email: NetworkMgt@cardinalinnovations.org

• Via Fax to the Credentialing Department at 704-939-7513. (Make sure email is legible).

• Via Mail to Cardinal Innovations Healthcare, Network Management Department, 550 South Caldwell St., Suite 1500; Charlotte, NC 28202.

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Once we receive your application:

• Cardinal Innovations will complete the required background checks and verify information supplied in the Credentialing Registration Form and CAQH application.

• Once the verification process is complete, your file will be submitted to the Cardinal Innovations Medical Director for review. If there are no questions or concerns, the Medical Director will approve the file and you will be credentialed by Cardinal Innovations. If there are questions or concerns, the file will be submitted to the Cardinal Innovations Credentialing Committee for review. You will be contacted at this time for any additional information or explanation required for the Credentialing Committee review. You will be notified of the committee’s decision within 30 days.

As part of the Cardinal Innovations credentialing process, each clinician has the right:

• To review information collected during the credentialing process except the references and

• To Review National Clinician Data Bank (NPDB) query, upon request

• To be informed of the status of their credentialing application, upon request

• To be notified of information that is significantly different than reported by you and to have the opportunity to correct erroneous information in writing

• To be notified about the Credentialing Committee’s decision within 30 days of the committee’s decision or Medical Director’s approval

Thank you for your interest in Cardinal Innovations Healthcare.

If you have any questions, contact the Network Provider Line at 855-270-3327.

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Cardinal Innovations Healthcare Credentialing Application Checklist Required Document Specifications Special Attention

Required for all Applications NCT Enrollment Form (Send only if not already enrolled/affiliated to

requested site listed on CRF). Site address(es) must match with practice address on CRF

CAQH Application Should have complete CAQH application before initiating Credentialing Process via CRF.

Education, background/disclosure questions, work history

Cardinal CAQH State Release/Attestation

Will only be available as a missed item in CAQH after CRF is submitted to us and we've added clinician to the roster.

Must be dated on or after the last re-attestation date in CAQH.

Acknowledgement, Consent and Authorization Form for Required Background Screening

First two lines are signed and dated

Credentialing Registration Form (CRF)

Completed entirely SS# + DOB should match CAQH, NPI should have 10 digits, CAQH numbers should have 8 digits

Provider Eval 1 - Licensed At least one reference must come from a like-licensed peer.

All questions filled, dated no older than 6 months, signed, name of applicant on top of form

Provider Eval 2 - Licensed If provisional, associate, or under CPA, must be from supervisor who signed contract

All questions filled, dated no older than 6 months, signed, name of applicant on top of form

Copy of Current Professional License

Supervision Contract All supervision contracts must be consistent with respective licensing board requirements

See below for additional supervision requirements

Proof of Professional Liability Coverage (COI)

Name of applicant must either be on the company policy certificate, on a cover sheet (with company letterhead) attached to the insurance or must have their own personal certificate.

Coverage must be at least $1,000,000/$3,000,000 aggregate

Resume/5-Years Employment History

Send Resume or fill in CAQH; if graduated less than 5 years ago, only provide employment since graduation

If gaps of 6 months or longer occur, provide brief written explanation.

Additional Requirements by License Type

BCBA and Associate Licensure Supervision Agreements BCBA Supervision contract required Supervision must come from a NC

LP or LPA LCAS-A Supervision contract required via Learning

Builder See NCASPPB website

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LCMHC-A LCMHC Board approved supervision contract required. In addition, evidence of approval is also required.

1) The approval letter or email confirmation approving the contract from the board - OR - 2) The approved supervision contract – there is a box near the top right that the board fills out

LP-A Supervision contract required From NC Psychology Board LCSW-A Supervision contract required Include employment verification

and emergency crisis plan LMFT-A Supervision contract required

MD/DO ABPN or other

Board Certification If applicable, provide copy of certificate

Admitting Privileges If none, hospital admission plan required CAQH Question #17 Copy of DEA Certification

Copy of ECFMG Certificate If foreign MD graduate

MD/DO Supplemental Questions

Required if no psychiatry specialty or board certification

Documents will be given by Credentialing Coordinator

NP Collaborative Practice

Agreement (CPA) Ensure agreement is dated within the last year per North Carolina Board of Nursing.

Copy of DEA Certification

PMHNP Certification If applicable, provide copy of certificate NP Supplemental

Questions If not PMHNP-BC Documents will be given by

Credentialing Coordinator

PA Collaborative Practice

Agreement (CPA)

Copy of DEA Certification NCCPA CAQ in Psychiatry If applicable, provide copy of certificate

PA Supplemental Questions If PA does not have CAQ in Psychiatry Documents will be given by Credentialing Coordinator. Enhanced supervision may be required

CADC, LPN, RN (Only the below items are required) Credentialing Registration

Form (CRF)

NPI Copy of License

Check off all documents for missing information, signatures, dates.

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Credentialing Registration Form (CRF) The Credentialing Registration Form is intended only to initiate the credentialing process. The credentialing process will begin once Cardinal Innovations is able to download a completed North Carolina Uniform Credentialing application from CAQH. If any section with a red asterisk (*) in the below application is left blank, the application will be returned.

NCTracks Enrollment Verification We will not move forward with an application that does not have all required NCTracks forms. We cannot accept any other forms of documentation besides the Provider Enrollment Application or Managed Change Request documents.

*Question 1: Has the clinician applying for Credentialing had their NCTracks Provider Enrollment application completed and approved by NCTracks? You will know this step is complete if you are able to log in to NCTracks and make changes

Please note: BCBA’s do not need to be enrolled in NCTracks. Skip the NCTracks section and proceed to Clinician Information section below.

Yes | Proceed to Question 2

No | DO NOT PROCEED UNLESS you can provide the Provider Enrollment Application. If you do not have this form, do not send in your application until the clinician is fully enrolled/enrollment in NCTracks is complete. If enrollment is not completed at NCTracks, we will send the application back to you.

*Question 2: Are you affiliated to the agency and the practice address(es) in NCT that you will list below? (Is the practice and address(es) listed within your MCR or NCT Enrollment Application below completed in NCT?)

Yes | Complete the rest of the credentialing application

No | DO NOT PROCEED: See “NCTracks Quick Tips box” on page 1 of the instructions

Note: In addition to affiliating to the agency and practice address, the sites address(es) must also appear as either a Primary or Additional Service Location in your NCTracks record or in any MCR or Enrollment Application furnished with this form.

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Clinician Information

*Clinician Name:

First Middle (No Initial) Last Maiden

*Name of Agency/Practice:

*Clinician Practice Location:

Street City State ZIP

Clinician Additional Practice Locations (Attach additional sheet if necessary)

If the clinician is not affiliated to the site listed below, Cardinal Innovations cannot add the site to their profile in Cardinal Innovations’ system unless it is included on the Enrollment Application or Managed Change Request Form forwarded with this registration form. If not included, you will have to request the site following approval.

Street City State ZIP

*Clinician License Type:

e.g., MD, DO, Neuropsychologist, Clinical Psychologist, LCHMHC, LCMHC (A), LCSW (A), LMFT(A), LCAS, LCAS (A), PA, BCBA

Specialty Privilege (if applicable): ☐ TF-CBT/PCIT ☐ Sexual Harm

If applying for one of these services, please also fill out and submit the application for that specific privilege. The applications can be found on our website within the Resource Library at https://www.cardinalinnovations.org/ Resources/Resource-Library. Search for the applications in the search box above the “Resource Type” filter on the left side of the page by typing “TF-CBT/PCIT” or “Sexual Harm.”

*Clinician Personal Email Address (for future correspondence):

*Provider Contact Email Address:

*Phone Number: *24 hour/7 day Coverage Phone Number

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Additional Information

*CAQH ID Number (8 digits) *Clinician NPI Number (10 digits)

*Clinician Taxonomy Code(s)

*Date of Birth *Social Security Number (all numbers required)

Month (MM) Day (DD) Year (YYYY)

Gender and Race/Ethnic Background: (Information is voluntary and may be used publicly, i.e., directories)

☐ Male ☐ Female

☐ Caucasian ☐ Asian/Pacific Islander

☐ Black/African American ☐ Hispanic/Latino

☐ American Indian/Alaskan Native American ☐ Multi-racial

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Clinician Specialty Information Help us communicate to member, staff, and others what they need to know about your specialties and areas of practice. Credentialing cannot be initiated without receipt of this form. Check below that all that apply to you.

Target Population POPS

☐ MH-Adult ☐ MH-Child

☐ SA-Adult ☐ SA-Child

☐ IDD-Adult ☐ IDD-Child

General Categories GEN Ages GEN ☐ Mental Health ☐ Intellectual/Developmental Disabilities ☐ Substance Use Disorder

☐ Young Child (3-5) ☐ Older Child (6-12) ☐ Adolescent (13-20)

☐ Adult (21-64) ☐ Geriatrics (65+)

Specialty and Applied Approaches FOCUS

☐ Amnestic Disorder ☐ Anxiety/Phobias ☐ Assessment Evolution ☐ ADHD ☐ Autistic Spectrum ☐ Bipolar Disorder ☐ Chemical Dependency/Sub. Abuse ☐ Conduct Disorders ☐ Couples/Marriage ☐ Crisis/Solution focused Brief Therapy ☐ Sexual Behavior Problems:

☐ Adult ☐ Youth ☐ Sexual Offenders ☐ Sexual Reactive

☐ Dementia Disorder ☐ Depression ☐ Eating Disorders ☐ Factitious Disorders ☐ Forensic Screening/Evaluation

(NC State Certified) ☐ Gay/Lesbian/Transgender/

Gender Specific ☐ General Psychiatry ☐ General Psychology ☐ Gero Psychiatry ☐ Grief and Loss Therapy ☐ Health Psychology-

Chronic Medical Conditions ☐ Psychological Testing

☐ HIV/AIDS ☐ Impulse Control ☐ Intellectual/Developmental Disability ☐ Neuro Psych. Psychological Testing ☐ OCD ☐ Personality Disorders ☐ Personality Psych. Testing ☐ Play Therapy ☐ PTSD ☐ Psychoanalysis ☐ Psychotherapy ☐ Sleep Disorders

Traumatic Brain Injury (TBI) ☐ Other (specify)

Culturally diverse populations that you feel competent to treat ☐ Caucasian ☐ Asian/Pacific Islander

☐ Black/African American ☐ Hispanic/Latino

☐ American Indian/Alaskan Native American ☐ Multi-Racial

Language(s) other than English in which you are able to communicate fluently LANG

☐ Spanish ☐ Other (specify)

☐ American Sign Language ☐ Available Interpreter Types (specify)

*Signature *Date: Of the practitioner for whom the application is being submitted

Please sign and date your completed application. Unsigned applications will not be accepted.

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Cardinal Innovations Healthcare Provider Evaluation Form ☐ Peer (Licensed Practitioner, not partner) ☐ Referring Physician or Practitioner ☐ Supervisor ☐ Chief of Department/Staff where practitioner has admitting privileges (Not partner)

Name of Applicant Group Name

The above provider is a Cardinal Innovations Healthcare network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence.

1. What is your specialty/credentials?

2. What is your relationship to the applicant?

3. How long have you known the applicant?

4. How would you rate the applicant’s professional abilities? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

5. How would you rate the applicant’s ability to work and communicate with physician and non-physician staff? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

6. How would you rate the applicant’s rapport with consumers/clients? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

7. What do you believe to be the applicant’s strengths and weaknesses (if any)?

a) Strengths:

b) Weaknesses:

8. To your knowledge, has the applicant had any of the following: ☐ Yes ☐ No Malpractice claim(s)? ☐ Yes ☐ No Problems with medical licensure, certification, or licensing boards? ☐ Yes ☐ No Revocation, denial, or change in hospital privileges? ☐ Yes ☐ No History of/or current impairment due to drugs and/or alcohol?

If your answer is yes to any of the above questions, please provide details.

9. Would you recommend this person as a provider for the Cardinal Innovations Healthcare network? ☐ Without reservation ☐ With reservation ☐ Would not recommend

10. Please provide any other information that would be helpful to us in evaluating this applicant.

Evaluator’s Signature Date

Printed Name Phone

Complete Address

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Cardinal Innovations Healthcare Provider Evaluation Form ☐ Peer (Licensed Practitioner, not partner) ☐ Referring Physician or Practitioner ☐ Supervisor ☐ Chief of Department/Staff where practitioner has admitting privileges (Not partner)

Name of Applicant Group Name

The above provider is a Cardinal Innovations Healthcare network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence.

1. What is your specialty/credentials?

2. What is your relationship to the applicant?

3. How long have you known the applicant?

4. How would you rate the applicant’s professional abilities? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

5. How would you rate the applicant’s ability to work and communicate with physician and non-physician staff? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

6. How would you rate the applicant’s rapport with consumers/clients? ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

7. What do you believe to be the applicant’s strengths and weaknesses (if any)?

a) Strengths:

b) Weaknesses:

8. To your knowledge, has the applicant had any of the following: ☐ Yes ☐ No Malpractice claim(s)? ☐ Yes ☐ No Problems with medical licensure, certification, or licensing boards? ☐ Yes ☐ No Revocation, denial, or change in hospital privileges? ☐ Yes ☐ No History of/or current impairment due to drugs and/or alcohol?

If your answer is yes to any of the above questions, please provide details.

9. Would you recommend this person as a provider for the Cardinal Innovations Healthcare network? ☐ Without reservation ☐ With reservation ☐ Would not recommend

10. Please provide any other information that would be helpful to us in evaluating this applicant.

Evaluator’s Signature Date

Printed Name Phone

Complete Address

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Acknowledgement, Consent and Authorization for Required Background Screening Pursuant to 42 CFR §455.450 and N.C. Gen. Stat. §108C, Cardinal Innovations Healthcare is required to conduct certain background screening of all individual practitioners and all individuals disclosed pursuant to 42 CFR § 455.100-106 as acting on behalf of an organizational agency/practice, applying to be credentialed/enrolled or re-credentialed/re-enrolled as Medicaid providers. Some of these background screenings, for instance a criminal history report obtained from FirstPoint, Inc., P.O. Box 26140 Greensboro, NC 27402, 800-449-0245, www.firstpointresources.com, could possibly be construed as a “consumer report” under the Fair Credit Reporting Act, (FCRA) 15 U.S.C § 1681 et seq.

The undersigned individual practitioner applicant or organizational agency/practice applicant, by the below signature, hereby acknowledges, consents and authorizes Cardinal Innovations Healthcare to obtain the above required background screening information necessary to properly process and assess any credentialing/enrollment or re-credentialing/re-enrollment application as the case may be. This acknowledgement, consent and authorization will be construed as continuing during the entire time of the individual practitioner’s or organizational agency/practice’s credentialing/enrollment with Cardinal Innovations Healthcare. Additionally, the applicants, by their signature below, hereby release from liability all representatives of Cardinal Innovations Healthcare for acts performed in good faith and without malice in connection with acquiring the above required background screening information and further release from liability all individuals and organizations, including FirstPoint, Inc., P.O. Box 26140 Greensboro, NC 27402, that provide such information to Cardinal Innovations Healthcare in connection with their application.

Please sign, date and legibly print the name of the signatory below.

Individual Practitioner Applicant Signature Date

Printed Name of Individual Practitioner Applicant

Organizational Agency/Practice Applicant Authorized Representative Signature Date

Printed Name and Title of Authorized Representative of Organizational Agency/Practice Applicant