Health Care Payment Learning and Action Network Site Template

New Innovation Center Model
Letter of Intent

DO NOT use your browser's back page function or navigate away from this page while completing your LOI.   Doing so will cause you to lose information that you have entered into your LOI.   If you navigate away from this page, all information that you entered will be lost.

Section A. Organization and Contact Information

All fields are required unless marked optional.

1. Applicant

Organization Name
Doing Business As (Optional)


Organization TIN/EIN

Street Address

Street Address Line 2 (Optional)

City
ZIP Code
+4 (Optional)

Website (Optional)

2. Applicant Primary Contact


Primary Contact First Name
Primary Contact Last Name

Title/Position

Business Phone Number
Business Phone Number Extension (Optional)
Alternative Phone Number (e.g. cell phone) (Optional)

3. Applicant Secondary Contact


Secondary Contact First Name
Secondary Contact Last Name

Title/Position

Business Phone Number
Business Phone Number Extension (Optional)
Alternative Phone Number (e.g. cell phone) (Optional)

Section B. Letter of Intent

All fields are required unless marked optional.


  1. Please indicate whether the applicant organization, or any of the proposed participants in the organization, are currently participating, have formerly participated in, or have applied to any of the following initiatives listed below.

Available Initiatives

Available Initiatives

Add to Selected InitiativesRemove from Selected Initiatives

Selected Initiatives


  1. Does your organization have prior experience working with Fee-for-Service (FFS) beneficiaries?

  1. Medicare ACO Name
    (Please put N/A if this is not applicable)

  1. If a Medicare ACO, what is the ID number (e.g., V123 or A1234)?
    (Please put N/A if this is not applicable)

  • If Applicant ACO has more than one Medicare ACO ID, please specify all IDs. (Multiple IDs must be separated by commas) (Optional)

  1. Which option are you interested in applying to (choose one or more of the following)?

Available


AddRemove

Selected


  1. Does the applicant organization anticipate the entire organization will transition to the new model?

  1. Current Medicare Shared Savings Program Track (Optional)

  1. End of Current Initiative Agreement (Optional)

  1. Is the applicant organization or are any of the proposed participants currently participating in an ACO with a payer other than Medicare?

  1. How many of the counties your organization will serve are considered rural? (If not applicable, enter "0")

  1. How many Fee-for-Service Medicare beneficiaries are you currently serving?

  1. Approximately which % of providers in your organization use 2015 edition Certified Electronic Health Record Technology (CEHRT)?

  1. Considering your entire organization, what % of patient health information is exchanged electronically?

Section C. Optional Supplemental Survey

S1.
How many providers are expected to participate in the new model? (Optional)

S2.
What is the average expected panel size for each practice in the applicant organization? (Optional)

S3.
Outcome-based contracts are defined as revenue arrangements that include pay-for-performance on cost, patient experience, and quality. In the past 6 months, approximately what percentage of all patients were covered by outcome-based contract(s) among providers that will comprise your organization? (Optional)

S4.
In the past 6 months, how often did your organization or providers/suppliers know when patients were hospitalized in real-time (before they were discharged)? (Optional)

S5.
In the past 6 months, how often did your organization providers/suppliers know when patients were admitted to the ED/ER in real-time (before they were discharged)? (Optional)

Section D. Certification and Submission

All fields are required unless marked optional.


I certify that all information and statements provided in the Letter of Intent are true and correct to the best of my knowledge and belief, and that I have the authority to submit this Letter of Intent on behalf of the submitting organization named below.


Representative Name
Organization Name


DO NOT use your browser's back page function or navigate away from this page while completing your LOI.   Doing so will cause you to lose information that you have entered into your LOI.   If you navigate away from this page, all information that you entered will be lost.

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