tr348-fs ihcp provider update application · 2009-02-07 · indianapolis, in 46207-7263 when the...

F I R S T S T E P S / I N D I A N A H E A L T H C O V E R A G E P R O G R A M S ( I H C P )

P R O V I D E R U P D A T E A P P L I C A T I O N

General Instructions

This form is used to update provider enrollment records for a billing service location and group member. Please do not use this form to add new enrollments, add new service locations, or report changes of ownership. This form is used for the following updates:

• Changes to service location, mail to, pay to, and home office addresses for billing providers (rendering providers do not have address information)

• Update licenses or certifications for billing providers or rendering providers (Recertifications)

• Change tax identification/Social Security number, if not related to a change of ownership

• Add a new Clinical Laboratory Improvement Amendment (CLIA) Certification

• Enroll in the 590 Program, MRT, and Health Watch Note: In order to participate with First Steps Program, it is a requirement for providers to enroll as Medicaid provider. However, there are several provider specialties that are excluded from this requirement due to the fact that the specialty is NOT ineligible to participate in IHCP. Please refer to Provider Specialty Listing to identify specialties that are ineligible for participation with IHCP.

• Begin Electronic Funds Transfer (EFT)

• Reinstate a provider number (lapse in eligibility must be less than 12 months)

• Voluntarily terminate enrollment, including group members

• Can be used to enroll group members to an actively enrolled group provider

• Change rendering provider (group member) information

If enrolling a new service location or undergoing a change of ownership, please obtain a Provider Enrollment Application form available on the Internet at http://www.infirststeps.com or by request one from the Provider Enrollment line at 1-877-707-5750.

Please complete all applicable sections for the provider number and service location requested. Each section includes specific instructions. Please read the instructions carefully. Many of the updates require documentation be attached. Please include a copy of all necessary documents when submitting this form.

Mailing Instructions

Fully complete the form and enclose copies of all required licenses, forms, and certifications, and send the entire packet to the following address:

EDS – Provider Enrollment P.O. Box 7263 Indianapolis, IN 46207-7263

When the update request has been reviewed, EDS Provider Enrollment will notify you in writing about the status of your update. Please allow at least 30 business days for mailing and processing time before checking on the status of the update request.

Questions

Direct any questions about this form to Provider Enrollment at 1-877-707-5750 or visit http://www.infirststeps.com.

EDS of 15 P. O. Box 7263 July 2006 Indianapolis, IN 46207-7263 Version 1.2

http://www.infirststeps.com/

http://www.infirststeps.com/

F I R S T S T E P S A N D I N D I A N A H E A L T H C O V E R A G E P R O G R A M S

P R O V I D E R U P D A T E F O R M

1. Billing Provider Information: Submission Date:

Provider Number: Location Alpha Suffix(es):

Provider Name:

Federal Tax Identification Number/Social Security Number:

2. Service Location Name and Address Update

Generally, the service location name and address is for the site where members go to obtain services from the perspective provider. A service location maintains the supporting documentation related to the claim submitted for a service. The service location name must be the Doing Business As (DBA) name registered with the Secretary of State, except for sole proprietors or business owners who must register their Assumed Business Name with their county recorder. Anesthesiologists who provide services at multiple locations should enter their home office as their service location. The address must be a physical location. A post office box is not a valid service location address.

Provider Name: Indiana County:

DBA Name: Telephone:

Street Address:

City: State: ZIP + 4: -

Fax: E-mail:

Is claim documentation kept at this location? Yes No

If this is not an Indiana address, are services provided in Indiana? Yes No

3. Legal Name and Home Office Address Update

Please complete the contact information for the home office of the legal entity maintaining ownership of the above service location. The legal name must be the current name on tax, corporation, and other legal documents, and the name currently registered with the Secretary of State, or filed with the county recorder as the Assumed Business Name. The address must be a physical location. A post office box is not a valid home office address.

Legal Name: Telephone:

Street Address:


Fax: Email:


4. Mailing Name and Address Update

Please complete the contact information for bulletins, provider manual updates, and general correspondence. A post office box is an acceptable mailing address.

Name: Telephone:

Street Address:


Fax: E-mail:

5. Pay-to Name and Address Update

Please complete the information for the addressing of checks, remittance advices, and general claims payment information. The name listed below as the Payee Name will appear as the payee on all checks. A post office box is acceptable for this address. Complete Schedule H to authorize or delegate payments is made to any entity other than the provider.

Name: Telephone:

Street Address:


Fax: E-mail:

Billing Agent? Yes No

6. Federal Tax Information Update Taxpayer Identification Number/ Social Security Number: Effective Date:

A copy of a completed IRS Form W-9 must be submitted with this update form. Failure to attach this form will result in EDS returning this form for incomplete information.

7. Provider Licensing/Recertification Information Update Please refer to the Provider Type and Specialty Matrix to determine the appropriate code for your specialty. Primary and secondary specialties must be from the same provider type, and only codes listed on the Type and Specialty Matrix will be accepted.

Primary Specialty: Secondary Specialty:

License Number: Licensing Board:

License Effective Date: License Expiration Date:

A copy of the license from the appropriate licensing board must be submitted with this update form. Failure to attach a copy of the license may result in EDS returning this form for incomplete information.

8. Matrix Provider Information Update License or Certification Description:

Degree:

Degree Description:

NOTE: *The licensing state must match the service location state. A copy of the license from the appropriate licensing board must be submitted with this application. Failure to attach a copy of the license will result in EDS returning the entire application as incomplete.

First Steps/IHCP Provider Update Form


9. CLIA Certification Update Please complete this section with the information from your Clinical Laboratory Improvement Amendment (CLIA) Certificate. CLIA certificates are issued to specific service locations, unless you are eligible for the multiple site exception through the Department of Health and Human Services.

CLIA Number: Certification Type:

Effective Date: Expiration Date:

10. Medicare Participation Update Please complete this session for updates to the billing provider’s Medicare number. If you need to update a rendering provider’s (group member’s) Medicare number you must complete and submit Schedule G with this update form

Medicare Number: DMERC Number:

Unique Provider Identification Number (UPIN):

A copy of the assignment letter must be attached to this form. Failure to attach a copy of the letter may result in Medicare crossover claims not crossing over to the IHCP.

11. 590 Participation Update The 590 Program is a State medical assistance program providing reimbursement for medically necessary covered medical services provided off site to individuals who reside in State institutions. Check the box labeled yes if you wish to participate in this program. The following provider types cannot be 590 providers: transportation, hospice, home health, DME, and LTC facilities.

Yes No Effective Date:

12. Do you wish to participate in the Medical Review Program? Update The Medical Review Program provides determination of an applicant’s eligibility for Medicaid under the disability category. The provider completes a medical assessment of an applicant and submits the required forms to the Office of Family Resources. The MRT issues a favorable or unfavorable eligibility decisions based on medical evidence that supports whether the applicant has a significant impairment. Once the documentation has been filed, the provider may submit claims to EDS for payment of certain examination and reports. Services should not be performed unless the applicant has presented the pre-Medicaid eligibility form.

Yes No Effective Date:

13. Provider Number Reinstatement Update

Provider Number: Service Location: If you want to reinstate a provider number that has been terminated due to provider request or provider inactivity, please check yes below. Provider numbers may be reinstated when the provider number has been closed for one year or less subject to enrollment requirements. If a provider number has been closed one year or longer, a new application must be submitted to reinstate the provider number.

Do you wish to reinstate this provider number? Yes No

Please submit Schedules B and C if organizational structure or disclosure information has changed.



14. Voluntary Termination (for billing providers only). You must use Schedule G for rendering provider voluntary terminations.

Update

Provider Number: Service Location(s): If you are voluntarily terminating your participation in one of the Indiana Health Coverage Programs, please complete the date of voluntary termination and the termination reasons in the field below. Please note that only the location specified above will be terminated. If no locations are specified, then the entire provider number including all service locations will be terminated.

Retired Deceased Termed by provider: closed service locations, no longer participating in program, or for any other reason not specified

Termination Reason

Out of Business

Changed Ownership

Bankruptcy (please submit copy of bankruptcy filing or judgment)

You must complete address fields 3 (Mailing) and 4 (Pay To) of this form providing the current forwarding information.

If the termination request is for a PMP, you must contact the appropriate MCO to terminate participation due to contractual requirements for member continuity of care.

15. EFT (Schedule I) Update Provider Number: Service Location(s): You must attach a completed Schedule – EFT Form to the update request form before a change will be made to your EFT information.

16. Provider Organizational Structure (Schedule B) and Disclosure Information (Schedule C)

Update

Provider Number: Service Location(s): You must attach a new, completed Schedule B and C for any changes to your organizational structure and disclosure information. Do not use this form for ownership changes (CHOW); it is to be used for changes to the organizational structure or disclosure information submitted on your original enrollment application. Providers are required to report changes to disclosure information within 45 days of effective date of change.

17. Change of Ownership (CHOW) Notification Provider Number: Service Location(s):

Long-term Care Provider Non Long-Term Care Provider

Expected Date of Ownership Transfer:

Actual Date of Ownership Transfer: This form may be used to report the date of an expected transfer of ownership. All billing provider types, the old owner may complete the Provider Update form. The new owner must complete a new Provider Enrollment Application form indicating in box 1, that the enrollment is for a CHOW and complete all information in Schedule D – Change of Ownership.



18. Group Information. (You must complete Schedule G.1-G.2 Rendering Linkage Assignment to update rendering information or add new rendering providers.)

Update

Updates include changes to any of the following information: specialties, eligibility effective start and end dates, Medicare numbers, License numbers, Recertification updates.

New Rendering Enrollment is for a practitioner who has never been enrolled in the IHCP. Requires a separate provider agreement for each new enrollment.

Currently enrolled means that the IHCP number for the rendering provider is active (with no lapse in eligibility).

19. Certification Statement for Signature On File. Update For the billing provider to be exempt from Edit 228 – No signature on file, a signed Certification Statement must be on file with the IHCP. Please complete the Certification Statement for Signature on File Addendum to authorize submission of claims without a signature. This statement must be signed by the provider (can be any authorized official listed on Schedule B or C), or delegated official listed on Schedule H.

20. Provider Update - Authorized Signature. (Please submit Schedule H if you are not the owner.) Must be signed or update will be returned as incomplete. The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth herein. The undersigned acknowledges that the commission of any Medicaid or CHIP related offense as set out in 42 USC 1320a-7b may be punishable by a fine of up to $25,000 or imprisonment of up to five years or both.

The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. Rendering providers must sign Schedule G to authorize updates.

Provider Name (please print):

Tax ID/Social Security Number:

Authorized Official’s Name (please print): Title:

Signature: Date:



21. Comments or additional instructions:



Schedule B – Organizational Structure

1. How is this provider entity legally organized and structured? Check the entity type that best describes the structure of the enrolling provider entity. Please check only one box.

For Profit Corp Partnership Sole Proprietorship (Individual)

Not-for-Profit Corp Government Owned Limited Liability Partnership (LLP)

Limited Liability Co (LLC) Other (Please Specify)

2. Is the provider entity registered with the Secretary of State? Yes No

If yes, please submit a copy of the state registration papers (405 IAC 1-19.1b). If no, please submit a copy of the Assumed Business Name form on file with the county recorder’s office.

3. Date Business Started:

4. Is this entity incorporated? Yes No If yes, enter the Incorporation Date:

5. Is this entity chain affiliated? If yes, the information about the company or organization must be included in the disclosure information.

Yes No

6. Is the provider entity operated by a management company, or leased in whole or in part by another organization?

If yes, the information about the company or organization must be included in the disclosure information.

Yes No



Schedule C.1 – Disclosure Information

Disclosure of Ownership and Control – List below the Name, Title, Federal Employer Identification Number (FEIN), Social Security Number, and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in the prospective provider entity.

This includes any person or entity that has a direct or indirect ownership interest equal to five percent or more of the value of the provider entity; or owns an interest of five percent or more in any mortgage, deed of trust, note or other obligation secured by the provider entity if that interest equals five percent of the value of the property of assets of the provider entity. Copy this page to list additional names.

Legal Name

FEIN

Title

Social Security # - -

Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Disclosure of Ownership and Control – List below the Name, Title, FEIN, Social Security Number, and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in any subcontractor in which the provider entity has direct or indirect ownership of five percent or more. Copy this page to list additional names.

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address



Schedule C.2 – Disclosure Information (Continued)

Managing Individuals – List below the Name, Title, FEIN, Social Security Number, and Business Address of ALL agents, officers, directors, and managing employees who have expressed or implied authority to obligate or act on behalf of the provider entity. Any individual who has operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of the provider entity should be included. This may include such individuals as a general manager, business manager, administrator, or director. Copy this page to list additional names.

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address

Legal Name

FEIN

Title


Business Address



Schedule C.3 -Disclosure Information (Continued)

1. Indicate below if any of the individuals listed in Schedule C.1 or C.2 above, are related through blood or marriage, either as spouse, parent, child, or sibling. List their names and degree of relationship. Copy this page if additional space is required.

Name Name Degree of Relationship

2. Indicate below if any of the PERSONS or ENTITIES listed in Schedule C.1 or C.2 above, or any secured creditor(s) of the provider entity, have ever been sanctioned either through criminal conviction, or exclusion from participation in any program under Medicare, Medicaid, or the Title XX services since the inception of the programs.

Name Type of Sanction Date of Sanction

3. Indicate below if any of the PERSONS or ENTITIES listed in Schedule C.1 or C.2 above, or any secured creditor(s) of the provider entity, have ever been placed on prepayment review.

Name Provider Number

4. Indicate below if any of the PERSONS or ENTITIES listed in Schedule C.1 or C.2 above, has an ownership or controlling interest in any other current or prospective provider.

Name Provider Number

5. Indicate below any former agent, officer, director, partner, or managing employee from the lists in this schedule, who has transferred ownership to a family member related through blood or marriage, either as spouse, parent, child, or sibling, in anticipation of or following a conviction, or imposition of an exclusion.

Name Name Degree of Relationship



Schedule G – Rendering Providers Linkage Assignment

Group Provider Number (or Name if new):

Service Location: Note: Individual Practitioners (sole proprietorships) do not have group members, only group practices have group members. If the rendering provider is not actively enrolled, a signed provider agreement must be submitted for each new rendering provider you are enrolling. Rendering providers (group members) must authorize enrollment information submitted by a group. Please have group members sign this form to authorize the linkage request. You must submit a separate application with assignment for each additional service location.

The signature below authorizes the billing of claims through any method, paper or electronic, submitted on my behalf by the group provider.

Rendering Provider Name (Group Member)

Rendering Provider Number

Rendering Provider Specialty Code Alpha Service Locations

Group Linkage Start Date UPIN Social Security

Number License # Rendering Provider Medicare Number

- -

Rendering Provider Signature Medicaid First Steps Program

Medical Review Team 590 Program Participation

Yes (Required, See Page 1)

Yes Yes Yes

Action New Update Terminate Linkage Effective:

Term Program MRT Terminate Effective:

Rendering Provider Name (Group Member)

Rendering Provider Number

Rendering Provider Specialty Code Alpha Service Locations

Group Linkage Start Date UPIN Social Security

Number License # Rendering Provider Medicare Number

- -

Rendering Provider Signature Medicaid First Steps Program

Medical Review Team 590 Program Participation

Yes (Required, See Page 1)

Yes Yes Yes

Action New Update Terminate Linkage Effective:

Term Program MRT Terminate Effective:



Schedule H – Delegated Administrator Authorized Signature Form

Please complete this schedule if you are an authorized official and want to delegate an administrator for authorized signature purposes. As the authorized official of your business, you may delegate an administrator to make the changes you select below to your IHCP enrollment file information.

What is an authorized official? The authorized official must be a general partner, agent, officer, director, or managing employee who has expressed or implied authority to obligate or act on behalf of the provider entity. Any individual who has operational or managerial control over, or who directly or indirectly conducts the day-to-day operations for the provider entity. The authorized official includes such individuals as a general manager, business manager, administrator, or director. The authorized official has the responsibility to sign and execute the provider

What is a delegated administrator? The delegated administrator is a person or entity (such as billing agency) to whom the enrolling provider’s authorized officer has granted the legal authority to do any or all of the following:

• Enroll the organization in the Indiana Health Coverage Programs (IHCP)

• Make changes or updates to the organization's status in the IHCP

• Accept payment for services

• Submit claims for payment on behalf of the enrolled entity

• Commit the organization to the laws and regulations of the IHCP

Delegated Administrators are excluded from having the authority to provide signature for the provider agreements. The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete the signature for the provider agreement.

Furthermore, as the authorized officer of the enrolling provider, I assign signature authority to the delegated administrator thfollowing selection(s):

Change Mail To (non check related info) Address

Change Pay To (checks and RAs) Address

Change Home Office Address

Change Service Location (cert code letters) Address

Submit Name Change

Submit License or Certification Updates

Change Tax ID, Submit W-9

Group Member maintenance

Submit Claims for Payment

Submit Enrollment Applications

Add, Change, or Stop EFT

Submit Specialty changes

The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth herein. The undersigned acknowledges that the commission of any Medicaid or CHIP related offense as set out in 42 USC 1320a-7b may be punishable by a fine of up to $25,000 or imprisonment of up to five years or both.

Enrolling Provider or Business Entity Name

Authorized Official’s Name (please print)

Authorized Official’s Signature Date

Delegated Administrator Name (please print)

Delegated Administrator Signature Date

Please submit one form per Delegated Administrator.



Schedule I – Electronic Funds Transfer (EFT) Form

Complete all fields below and attach one of the following documents to this form for verification purposes: A voided check, deposit slip, or copy of a bank statement listing your bank account number and account holder’s name. If needed, your American Banking Association (ABA) transit routing number can be obtained from your bank.

Note. Important EFT account requirement information is given on the following page.

Does the bank account listed below belong to a billing agency? Yes No

Provider Name:

Provider Number: Service Location Alpha Suffix(es):

ABA Transit Routing Number: Bank Account Number:

IHCP Provider Tax ID: Account Holder Tax ID Number:

Name on Bank Account:

Bank Name:

Bank Address:

Bank Telephone Number: ( ) - Type of Account: Savings Checking

Type of Authorization: Start Cancel Change Is the change due to a change of ownership? Yes No

On behalf of the provider entity named above, I agree to keep, and disclose upon request to authorized agencies, records that fully disclose the extent of claim payments received from and services rendered to members of the Indiana Health Coverage Programs (IHCP). I accept, as payment in full, the amount paid by the IHCP for claims submitted with the exception of authorized cost sharing by members. I understand payment of IHCP claims is from state and federal funds and that any false claims, statements, documents or concealment of a material fact may be prosecuted under state or federal law. I ensure that this EFT request complies with the regulation set forth in 42 CFR 447.10, which prohibits State payments for any IHCP service to be made to anyone other than a Provider, a non-cash member, or to one of the listed exceptions. I understand that an IHCP payment may be sent via EFT to an account held by the following only: (1) to the Provider; (2) a non-cash member; (3) a government agency on reassignment by the Provider (IRS); (4) a third party by court order on reassignment by the Provider (child support); (5) a business agent (billing service, account firm) if three specific criteria are met (see page 2*); (6) the employer of the Practitioner (if a contract so requires); (7) a health care facility, or a health care delivery system (if a contract so requires) if the organization itself submits the claim directly to the IHCP.

I authorize the electronic transfer of IHCP payments for all program elections to be made to the above provider number. I understand that I am responsible for the validity of the above information. I agree to notify EDS within ten days of any change in any of the information included on this form.

This section must be completed by an authorized officer or owner of the billing provider.

Printed Name and Title of Official Telephone Number

Official’s Signature Date



Continued Schedule I – Electronic Funds Transfer (EFT) Form

BILLING AGENTS. The following section must be completed if a billing agent is receiving payment on behalf of the provider. The exception for a business agent is limited to agents who furnish statements and receive payments in the name of the provider, and the service provided by the agent is: (1) related to the cost of processing the bill; (2) not related to a percentage or other basis to the amount billed or collected; and (3) not dependent upon the collection of payment. Further, a payment for a provider may not be made to or through an individual or organization (collection agency or service bureau), or by power of attorney thereof, that advances money for accounts receivable that a provider has assigned, sold, or transferred to the organization for a fee or deduction of accounts receivable.

Complete the section below if EFT funds will be paid to a Billing Agent’s bank account and not the account of the

Billing Agent Name

Telephone Number

Billing Agent’s Tax ID

Billing Agent Address

Authorized Billing Agent Contact Name

Title

Authorized Billing Agent Signature

Date



tr348-fs ihcp provider update application · 2009-02-07 · indianapolis, in 46207-7263 when the...

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