• EHO360 Pharmacy Credentialing Part 1

    Thank you for choosing to be a part of EHO360's Pharmacy Network. To avoid data loss, allocate uninterrupted time to complete this form.

  • IMPORTANT NOTES - READ BEFORE STARTING

    - This form will take approximately 30-45 minutes and must be completed in one session. Progress will not be saved. 

    - Consider your computer and browser settings, such as timeouts and re-authentication after periods of inactivity. All entered data will be lost if your session times out.  

    Our credentialing process has two parts. After submitting part 1:

    - If you already have an account with us, you'll be automatically directed to part 2 (supporting documentation) the next time you log in.

    - If you do NOT have an account with us yet, don't worry. After you submit part 1, we'll email you a link to complete part 2 (supporting documentation) within 7 business days.

    Be prepared to answer questions and/or provide details regarding the following:  

    1. All certification and license #s and expiration dates, including DEA registration, Medicaid, and Medicare numbers
    2. State and Federal Tax ID#s
    3. Pharmacy's physical address, phone, hours of operation
    4. List of owners and dates of ownership for the last 5 years
    5. Previous trade names the pharmacy has used/operated under
    6. Previous NCPDP# (if changed in the last 7 years) and chain code affiliation 
    7. NCPDP dispenser class and type
    8. List of prescribers if applicable, including NPI # and DEA #
    9. Software vendor used by the pharmacy
    10. Third-party reconciliation service provider (if applicable)
    11. List of all pharmacists, including license #s
    12. Pharmacist in Charge licensing information
    13. Pharmacy Liability Insurance information, including agent, phone and fax, and aggregate values
    14. PCAB or URAC accreditation status and dates (for Mail Order, Compounding, or Specialty)
    15. §503A/B status (for compounding)
    16. VIPPS accreditation status and dates (for mail order/delivery)
    17. List of 1099 or sub-contractors
    18. 340(B) certification status
    19. Network exclusion or suspensions, for the last five years
    20. Bankruptcy or reorganization details (court, dates, etc.), if applicable and less than 4 years ago
    21. Name and email address for authorized signatory (used for pharmacy contract)

     The list above is not all-inclusive.    

    CONTACTS

    Technical issues: Bob Curb at bob@ehorx.com or Amber Steely at asteely@ehorx.com 

  • EHO360 Pharmacy Credentialing Part 1

    All information is required for processing

  • Contract cannot be implemented without first providing the following information

    Delays will occur if the form is not completed and/or required credentialing information is not supplied.

  • Section A: Pharmacy / Ownership Information


  •
  • Format: (000) 000-0000.
  • A7. Does the pharmacy have a fax number?*
  • Format: (000) 000-0000.
  • A13. Other than the current name listed above, has the pharmacy operated under any other trade or business name?*
  • A14. Does the pharmacy have a full un-restricted DEA?*
  • A17. DEA expiration date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • A20. Pharmacy State License expiration date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • A18. Date of ownership*
     - -
    2 digit month, 2 digit day, 4 digit year

  • A25. Does the pharmacy owner control pharmacy operations?*
  • A26. Has your pharmacy location provided pharmacy services under a different owner and/or NCPDP # in the past seven (7) years?*
  • A27. Are there any owners of the pharmacy that are licensed physicians/prescribers?*
  • A27. List any Physicians/Prescribers that is an owner and any other Physician/Prescriber at your pharmacy
    Rows

  • Business Types (Check all that apply):

  • A28. NCPDP Dispenser Class*
  • A29. NCPDP Dispenser Type*
  • A30. Does the staff speak English?*
  • A31. Does the staff speak any other languages? (Check all that apply)
  • A32. Does your pharmacy offer 24-hour service?*
  • A32. Enter Pharmacy Hours*
    Rows
  • A35. Does your pharmacy have Internet Access?*
  • A36. Does your pharmacy currently use a third-party reconciliation service?*
  • A38. Does your pharmacy have e-Prescribing capabilities?*
  • A39. Services and Programs (Check all that apply):*

  • Section B: Pharmacist-in-Charge (PIC) Information

  • B3. Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • B6. Expiration date - PIC State License*
     - -
    2 digit month, 2 digit day, 4 digit year
  • B8. Has the PIC worked at this pharmacy for less than 5 years?*

  • Section C: Additional Pharmacy Employees (please list ALL employees)

  • C2. Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • C3. Is Pharmacy Manager a licensed professional?*
  • C4. List Pharmacist(s) - include the following for EACH pharmacist*
    Rows
  • C5. Does your pharmacy employ technicians?*
  • C5. List Pharmacy Technician(s) - include the following for EACH technician
    Rows
  • C6. Does pharmacy use a vendor or external staffing agency to source pharmacists and/or technicians?*

  • **Pharmacy is responsible to verify the staffing agency understands and completes all required federal and state training including but not limited to; fraud, waste, and abuse, HIPAA, etc.

  • Section D: Pharmacy Liability Insurance Policy Information

  • D3. Expiration date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • D9. Are the store pharmacists covered under this policy?*
  • D10. Are the store pharmacists covered under a professional liability policy?*

  • Pharmacy Credentialing Application

    Pharmacy is responsible for notifying EHO360, LLC of any future change(s) to the information provided in this Pharmacy Credentialing Form. Additional Credentialing may be required to dispense specific compound or specialty products.

  • Section E: Compounding

  • E1. Does your pharmacy process compound drug claims?*
  • E4. Select the type(s) of compounding performed:*
  • E2. Does your pharmacy have a:*
  • E3. Is your pharmacy a member of:*
  • E5. Is your pharmacy accredited by the Pharmacy Compounding Accreditation Board (PCAB)?*
  • E6. Is your pharmacy a §503A pharmacy?*
  • E7. Is your pharmacy a §503B pharmacy?*
  • E8. Does your pharmacy have a dedicated, exclusive area for general, non-sterile compounding that meets current USP standards?*
  • E9. Are all bulk, raw, chemical ingredients used by pharmacy in Compounded Drugs purchased from FDA-registered manufacturing facilities?*
  • E10. Are all bulk, raw, chemical ingredients used by pharmacy in Compounded Drugs approved by the FDA?*
  • E11. Does pharmacy compound only patient-specific prescriptions written by a prescriber (not batch of non-patient specific medications) or does pharmacy engage in anticipatory compounding?*
  • E13. Does pharmacy perform Sterile Compounding?
  • E14. Is pharmacy accredited, certified and/or licensed for sterile compounding?*
  • E15. Does pharmacy have an area for aseptic compounding of sterile preparations that meets current USP standards?*
  • E16. Have pharmacy location facilities and Compounded Drugs been independently tested/inspected for sterility?*
  • E17. Are all sterile compounds prepared in a barrier isolator which has been certified as ISO 5 by an independent contractor?*

  • *Additional Credentialing may be required to dispense specific compound products.

  • Section F: Long Term Care (LTC)

  • F1. Do you dispense to Long Term Care facilities?*
  • F2. Which types of LTC facilities do you service?*
  • F5. Your pharmacy services*
  • F6. Is your pharmacy contracted for Medicaid?*
  • F8. Does your pharmacy belong to a GPO?*
  • F9. Part D LTC Pharmacy Network: Is your pharmacy in compliance with the LTC Pharmacy requirements listed on the Long Term Care Pharmacy Network Exhibit and Compensation Exhibit?*

  • Section G: Home Infusion (HI)

  • G1. Is your pharmacy a Home Infusion Provider?*
  • G2. Is your pharmacy accredited with JC (Joint Commission), ACHC and/or another accredited body?*
  • G3. Is your pharmacy Accredited, certified and/or licensed for sterile compounding?*
  • G4. Is your pharmacy contracting to participate in the Medicare Part D Home Infusion Network?*

  • Can your pharmacy provide the below services?

  • G5. Deliver HI drugs in a form that can be easily administered in a clinically appropriate fashion*
  • G6. Provide infusible Medicare Part D drugs for both short-term acute care and long-term chronic care therapies*
  • G7. Ensure the professional services and ancillary supplies necessary for the provision of HI Therapy are in place before dispensing HI Covered Prescription Services, consistent with the quality assurance requirement for Medicare Part D Sponsors described in 42 CFR 423.153(c)*
  • G8. Provide Covered Prescription Services, such as HI drugs within twenty-four (24) hours of discharge from an acute setting, unless the next required dose, as prescribed, is required to be administered later than twenty-four (24) hours after discharge*
  • G9. Does pharmacy location listed above have a Clean Room?*
  • G10. Does pharmacy location listed above have a Hood?*
  • G11. Does your pharmacy have a Sterile environment to compound infusion therapy drugs?*
  • G12. Is pharmacy identified with a Home Infusion Taxonomy Code on the NPPES website?*

  • Section H: Mail Order

  • H1. Does pharmacy offer mail/delivery services?*
  • H2. Understand if pharmacy mails or delivers via UPS, USPS, Fed-Ex, etc., pharmacy must request a Mail Order Pharmacy Agreement?*
  • H3. Is your pharmacy URAC Accredited?*
  • H3. If Yes, provide the URAC Accreditation date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • H4. Is your pharmacy VIPPS Accredited?*
  • H4. If Yes, provide the VIPPS Accreditation date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • H5. Does your pharmacy understand mailing under the retail pharmacy contract is prohibited?*
  • H6. Is your pharmacy licensed in each state that it will mail Covered Prescription Services, including compliance with any non-resident pharmacy requirements?*
  • H8. Pharmacy agrees to provide copy(s) of applicable non-resident licensure or registration upon request*
  • H9. Pharmacy acknowledges, understands and agrees that it is prohibited from mailing covered prescription services under a retail agreement without explicit written authorization from EHO360*

  • Section I: Specialty

  • I1. Does pharmacy dispense specialty products?*
  • I3. Is your pharmacy URAC Accredited?*
  • I3. If Yes, provide the URAC Accreditation date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I4. Is your pharmacy VIPPS Accredited?*
  • I4. If Yes, provide the VIPPS Accreditation date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I5. Is your pharmacy licensed in each state that it is mailing Covered Prescription Services, including compliance with any non-resident pharmacy requirements?*
  • I7. Pharmacy agrees to provide copy(s) of applicable non-resident licensure or registration upon request*

  • *Additional Credentialing may be required to dispense specific specialty products.

  • Section J: 340(B) Certification

  • J1. Company hereby certifies that as of the Effective Date of this Application hereof that Company:*
  • J3. If 340B Covered Entity, do you segregate your inventory?*

  • Section K: Marketing and Prescriber Detailing Operations

  • K1. Does your pharmacy offer direct or indirect compensation to physicians or other prescribers for referrals to prescribe particular Compounded Drugs or to direct prescriptions to particular pharmacies?*
  • K2. Does your pharmacy market to physicians or other prescribers to promote your pharmacy’s Compounded Drug services, or any specific compound preparation or prescription?*
  • K2. If yes, describe the employment/contractual relationship between the pharmacy and the detailers (check all that apply):
  • K3. Describe personnel by answering the questions below (if applicable)*
    Rows
  • K4. Does your pharmacy have a website?*
  • K5. Does your pharmacy market delivery of medications?*
  • K6. Does your pharmacy market or promote your drug services at trade shows, to payers, physicians or other prescribers?*
  • K7. Does your pharmacy have any partnerships with prescribing physicians?*

  • Section L: General Questions

  • L1. Is your pharmacy currently affiliated with another chain code through NCPDP?*
  • L2. Is your pharmacy currently participating in a franchise?*
  • L3. Does your pharmacy mail prescriptions?*
  • L4. Is your pharmacy currently open for business?*
  • L4. If No, expected opening date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • L5. Is the pharmacy able to transmit claims electronically in the required format?*
  • L7. Is the pharmacy able to participate with the on-line Drug Utilization Review?*
  • L8. Is the pharmacy able to participate in external audits and grievance procedures?*
  • L9. Is the pharmacy currently in good standing with the State Board of Pharmacy and/or other Federal or State licensing authorities?*
  • L10. Has your pharmacy or Pharmacist-in-Charge (PIC) ever been denied a license or permit or had its license or permit suspended, revoked, or been fined or had other disciplinary action by the State Board of Pharmacy or other federal or state licensing or regulatory authorities?*
  • L11. Under current ownership, has this pharmacy, or any of its principals, ever filed for bankruptcy or reorganization?*
  • L11. Was the bankruptcy or reorganization more than 4 years ago?*
  • L12. Will the pharmacy maintain patient profiles, prescription, and signature logs as required by applicable State, Federal and U.S. territorial laws, and advise members that their signature acknowledges their receipt of prescriptions and allow release of any and all claim information?*
  • L13. Has the pharmacy or any of its present owners, officers, or employees ever been convicted of any state or federal law violations?*
  • L14. Are you or the pharmacy under any restriction of practice imposed by any State Board of Pharmacy?*
  • L15. Does the pharmacy comply with all State/Federal/U.S. territorial regulations, including CMS rules and regulations?*
  • L16. Do you have a written policy to actively review business operations and finance to minimize potential fraud waste and abuse?*
  • L17. Is the pharmacy located in a rural area?*
  • L18. Is the pharmacy open a minimum 5 days per week / 8 hours per day?*
  • L19. Does your pharmacy have any offshore activity that involves the use of PHI? (i.e. Call Center, claims reconciliation, etc.)*
  • L20. Does your pharmacy comply with the regulations to protect PHI?*
  • L23. Has pharmacy previously been suspended, terminated or excluded from Administrator’s network in the past five (5) years for failing to adhere to the terms of this Agreement or any prior or subsequent agreements with Administrator or Administrator’s successor?*
  • L24. Has pharmacy previously been suspended, terminated or excluded from any Pharmacy Benefit Management (PBM) network in the past five (5) years for cause?*
  • L25. Does your pharmacy regularly monitor and provide oversight of the operations at each of its Pharmacies and their pharmacists and maintain a credentialing program for itself and each of its Pharmacies?*
  • L26. Pharmacy has and will continue to provide the necessary training to its staff to comply with all State and Federal programs?*
  • L27. Is the pharmacy able to comply with OBRA 90 rules and guidelines?*
  • L29. Does your pharmacy understand waiving member copays is against the pharmacy contract and/or pharmacy manual?*
  • L30. Does your pharmacy timely acquire and remediate medication situations related to a manufacture recall?*
  • L31. Does your pharmacy have a policy to destroy and/or return expired medications on the shelf?*
  • L32. To the best of Company’s knowledge, has or will Company, any Pharmacy location (including pharmacies currently in the network and new pharmacies included in the network after execution of this Agreement), pharmacist, subcontractor, or other personnel furnishing (or which will furnish) Covered Prescription Services to Members, been or be (i) listed as debarred, excluded, or otherwise ineligible for participation in federal health care programs or (ii)convicted of a criminal felony (for North Carolina, Tennessee and Vermont pharmacies, please include misdemeanor convictions)?*
  • L33. Are there any liability claims / is there a malpractice history associated with the pharmacy?*
  • L34. Does your pharmacy have a Code of Business Conduct/Ethics that your sales and detailers need to adhere to?*

  • Section M: MEDICARE

  • Conflict of Interest

    The below initials confirm that the undersigned has policies and procedures in place to ensure that ALL staff responsible for the administration or delivery of Part D services has signed a conflict of interest statement, certification, or attestation at the time of hire, and annually thereafter throughout the employment tenure.

  • OIG and GSA Certification

    The below initials confirm that the undersigned has policies and procedures in place to review the Office of the Inspector General (OIG) and General Services Administration (GSA) exclusions material at the time of hire, and monthly thereafter throughout the employment tenure to ensure that ALL staff is not currently excluded from any Federal health care programs. Should a staff member be identified on the list(s), the staff member will be immediately removed from any and all work relating to a Federal health care program.

  • Authorized Signatory Information


  •

  • Sign and Submit

  • The undersigned hereby authorizes EHO360 and its designated agents to review any and all records that it reasonably believes necessary for credentialing purposes.

    Signature of Authorized Pharmacy Representative.

    I certify, represent and warrant that any and all information provided to each of the items related to this credentialing form and in connection with the credentialing process, is true, accurate and complete and it has not failed to state any facts or provide any documents that may be material to EHO360 in connection with its credentialing process. Failure to provide true, accurate, and complete information in this credentialing application may result in sanctions, up to and including denial to participate and/or termination from all EHO360 networks.

  • M4. Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: