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THiteRGevFEudD3oWgIJburJ3J3z2yRaRLtsJMoEMPTLcu9Vg7vQ2TNrLsDHCKRQCHJVAJkkZTnuCre8YMiGUsjbCVVrRbUuxb7o9VAj

ASHA_DCHA PRACTICE NETWORK INTEREST FORM

Thank you for your interest in joining the Ascension Seton Health Alliance.

We kindly request all applicants to provide thorough and thoughtful responses in this application to join the Ascension Seton Health Alliance network. Your responses play a significant role in our decision-making, and they will be carefully reviewed by our Membership and Credentials Committee.

In addition to this network interest form, please upload a full provider roster for your practice (full names and NPIs), and a signed/dated W-9. Please allow a minimum of 90-120 days for your application to be reviewed. We will follow up with your practice via the email or phone number submitted on this form.

Additionally; ASHA/DCHA is not a payor. When you apply to join the ACO you should simultaneously apply to be in-network with our payors Aetna, BCBS, Medicare and SmartHealth. Each payor contracts and credentials separately with your practice.

Should you have any questions please e-mail: SHAPhysicianEngagement@seton.org

***DO NOT SUBMIT THIS FORM IF YOUR PRACTICE IS ALREADY CONTRACTED WITH ASHA & DCHA.

IF YOUR GOAL IS TO ADD/TERM/CHANGE A PROVIDER IN AN EXISTING CIN GROUP, USE THIS LINK: ASHA/DCHA Roster Add/Term/Change Link

Legal Group Name:

* must provide value

Full physical address:
(street, city, state, zip)

* must provide value

Tax ID Number:

* must provide value

Organization NPI:

* must provide value

How did your practice hear about the Ascension Seton Health Alliance/Dell Children's Health Alliance?

* must provide value

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Does your practice have a website?

* must provide value

Yes

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If yes, please provide:

* must provide value

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Practice type:

* must provide value

PCP Only (Fam Med, Int Med, Pedi)

Specialist Only

Both

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Patient type:

* must provide value

Adult Only

Children Only

Both

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How many patients does your practice have?

* must provide value

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How many Providers are in your Practice?

# PCP:
# Specialist:
# APN/PA?

*DO NOT INCLUDE ADVANCED PRACTICE PROVIDERS WHO BILL UNDER A SUPERVISING PHYSICIAN*

* must provide value

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Please download the following documents to upload your Provider Roster and W-9:

ACO Roster Template.xlsx

Form W-9.pdf

Please upload and attach your practice's Provider Roster:

* must provide value

Upload file

Please upload and attach your practice's signed and dated W-9:

* must provide value

Upload file

Service Counties in Austin or Waco
(Click "Other" to type any unlisted County)

* must provide value

Bastrop

Burnet

Bell

Caldwell

Hays

McLennan

Travis

Williamson

Other

Unlisted County:

* must provide value

Does your practice use an Electronic Medical Record (EMR)?

* must provide value

Yes

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If yes, please provide which vendor your practice uses:

* must provide value

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If no, please share why your practice does not use an Electronic Medical Record (EMR):

* must provide value

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Does your practice provide Concierge Medicine Services?

* must provide value

Yes

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If yes, please discuss the fees and concierge services provided:

* must provide value

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What is your practice's business structure? (independent, partnership, owned by management company etc)

* must provide value

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Has your practice been acquired in the last year?

* must provide value

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Is your practice seeking opportunities to be acquired within the year?

* must provide value

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Does your practice currently participate in any value-base arrangements?

* must provide value

Yes

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Our practice has not participated in any value-based arrangements in the past because:

* must provide value

Please list ACO(s) & Payor(s):

* must provide value

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Which insurances does your practice accept?

* must provide value

Aetna

Blue Cross & Blue Shield

Medicare (CMS)

Medicare Advantage (MA)

Seton Health Plan/SmartHealth

Other

If other, please describe:

* must provide value

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Is your practice contracted with Seton Physician Hospital Network (SPHN)?

* must provide value

Yes

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Is your practice willing to participate in data sharing/aggregation?

* must provide value

Yes

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Our practice is not willing to participate in data sharing/aggregation because:

* must provide value

What Ascension Seton Hospital does your practice consider as primary?

* must provide value

Is your practice primarily an office based provider?

* must provide value

Yes

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What is the average time to get new patients seen by a provider in your practice?

* must provide value

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Does every provider in your practice have privileges at an Ascension Seton facility and/or Joint Venture facility?

* must provide value

Yes

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If any provider in your practice does not have Ascension Seton Hospital privileges, what is their admitting arrangement with/to Seton?

* must provide value

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What other hospital systems do your providers have privileges (admitting or consulting)?

* must provide value

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What hospital(s) does your practice send patients if they need emergency or inpatient services?

* must provide value

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The ASHA is held accountable to improving quality.

What is your practice doing to improve quality and can you provide examples of the work?

* must provide value

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The ASHA is held accountable to reducing healthcare costs.

What is your practice doing to reduce healthcare costs within the population your practice manages?

* must provide value

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Please describe your practices after hour services:

* must provide value

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How does your practice prevent avoidable ER visits?

* must provide value

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Does your practice get notified if patients have been in the ER or Hospital?

* must provide value

Yes

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If yes, please describe how your practice is notified and your process for following up with those patients:

* must provide value

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What is your practice's process to have patients complete their annual screenings/annual visit?

* must provide value

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Please share the reason(s) your practice is interested in joining the Ascension Seton Health Alliance/Dell Children's Health Alliance:

* must provide value

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Are your physician and practice leads committed to completing the annual Incentive Compensation Engagement and Quality Process Metrics?

* must provide value

Yes

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Comments:

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Name:

* must provide value

Direct Phone Number:

* must provide value

E-Mail:

* must provide value

Thank you for completing the Network Interest Form.

THIS SECTION IS FOR INTERNAL USE ONLY:

Interest Form Request Denied

Sent to Membership Committee

Date of Membership Committee meeting:

M-D-Y

CIN Network Saturation by Role/Specialty:

Percentage:

What type of request is this?

Seton Recruitment Initiative?

Yes

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Has this practice ever been contracted with the ACO?

* must provide value

Yes

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What was the reasoning for the PPA termination i.g. removed due to non-compliance?

* must provide value

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Additional Notes or Follow up:

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Denial reasoning:

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Date approval or denial letter sent:

M-D-Y

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