Please complete the Recredentialing Form below.

Complete all applicable fields. Write “N/A” for all fields that do not apply. If you have any questions, please call 315-477-9820.

The Recredentialing Form can also be completed by:

  • downloading the Recredentialing Form (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

    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:



     

    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****




    Recredentialing

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










    Complete the required sections for each service provider you are recredentialing for. After completing the General Information, Location Information and the necessary Recredentialing forms REMEMBER TO COMPLETE the Attestation, Recredentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.
     


    Adult Day Care:
     
    Please attach the following document:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below) – applicable only to adult medical day care providers
      • Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

    Note:

    • Provider Compliance Certification not applicable to Adult Social Day Care providers
    Adult Day Care Services Offered (Check all that apply):







     


    Certified Home Care Agency (CHHA) / Licensed Home Care Services Agency (LHCSA):
     
    Please attach the following document:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.
    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):























     


    Consumer-Directed Personal Aid (FI):
     
    Please attach the following document:
    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.
     


    Durable Medical Equipment / Personal Emergency Response System:
     
    Please attach the following document:

    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.


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










     


    Home and Safety Modification:

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









     


    Licensed / Certified Professional Services:
     
    Please attach the following document:

    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.
    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.

    1.

    2.

    3.

    4.

    5.

     


    Meals Provider
     

    Services Offered (Check all that apply):


     


    Skilled Nursing Facility (SNF):
     
    Please attach the following document:

    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.



    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 document:

    Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

    • Provider Compliance Certification (provide information in the Provider Compliance Certification below)

      • Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
      • If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

    Transportation Services Offered (Check all that apply):







     


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

    Provider Compliance Certification
    I agree to submit to Nascentia annually a copy of the Certification Statement for Provider Billing Medicaid pursuant to NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance

    Please Initial:


    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.


    Recredentialing 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.