Attachment B.7 MP CR 400 – Facility Provider Initial Credentialing & Re-Cred Checklist Facility Name: Provider Type: Cred Specialist: Auditor: Audit Date: Application Received Date: Refer to Policies CR 7 & CR 4 Place a Copy of the Application Loose in Chart Document Title Date of Verified by: √ or NA Date Audit NA Medi-Cal Verification (primary source or DHCS approval letter) Source: ________________ Application W-9 (required for Initial Credentialing only) Business License or DHCS License Source: DHCS Liability Insurance Coverage of at least 1m & 3m Y or N – Accreditation Accrediting agency/Source: ________________ Facility Site Review (if not accredited) Date of FSR: _______________ NA Sanctions Medi-Cal S&I OIG □ □ Date: Date: Reports □ Data.CMS.gov □ SAM Date: Date: With Sources NPI Verification NA (NPPES Printout) Source: NPPES CCS Status Verification - Qualified Provider? Y or N QI Facility Performance Monitoring (Re-Cred Only) Performance Monitoring/QI form capture dates since previous cred-cycle. – End date range no older than 120 days. Directory Verification NA (Re-Cred Only) Facility Grid PHC # Facility & TIN# Medi-Cal & NPI# JCAHO Insurance Facility Directories Corporate matches Medicare# Matches Cert Policy # & Type updated Address W-9 or Matches App App Status & Limits Matches Match App Exp Date App App App Match App Post Audit Supervisor Signature: Date: Revised 7/30/2018
Attachment B.7 – MP CR 400 Facility Provider Initial Credentialing & Re-Cred Checklist Facility Name: Provider Type: Cred Specialist: Auditor: Audit Date: Application Received Date: Place a Copy of the Application Loose in Chart Refer to Policies CR 7 & CR 4 Document Title Date of or NA Verified by: Date Audit √ Medi-Cal Verification (primary source or DHCS approval letter) Source: ________________ NA Application W-9 (required for Initial Credentialing only) Business License or DHCS License Source: DHCS Liability Insurance Coverage of at least 1m & 3m – Y or N Accreditation Accrediting agency/Source: ________________ Facility Site Review (if not accredited) Date of FSR: _______________ Sanctions Reports With Sources □ Medi-Cal S&I Date: □ OIG Date: NA □ Data.CMS.gov Date: □ SAM Date: NPI Verification (NPPES Printout) Source: NPPES NA CCS Status Verification - Qualified Provider? Y or N QI Facility Performance Monitoring (Re-Cred Only) Performance Monitoring/QI form – capture dates since previous cred-cycle. End date range no older than 120 days. Directory Verification (Re-Cred Only) NA Facility Grid PHC # Facility & Corporate Address Match App TIN# matches W-9 or App Medi-Cal & Medicare# Matches App NPI# Matches App JCAHO Cert Status & Exp Date Match App Insurance Policy # & Limits App Facility Type Matches App Directories updated Post Audit Supervisor Signature: Date: Revised 7/30/2018
MPCR400-B.7.docx