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TRANSCRIPT
KINNEY COUNTY COMMISSIONERS’ COURT AGENDA ITEMREQUEST FORM
Court Date: 1/14/18 Submitted By: Pat Aldaco Previous Court Action:
Submission Date:1/8/18 Of?“ N“"'b°" ‘
Item Requested is: [X] For Action/Consideration [ ] Public Workshop[] Consent Agenda [] Discussion/Report [] Executive Session
This application for MCO LTSS was submitted back in 10/18. On pg. 5 there is an enrollment fee of$560.00. It is a onetime fee and it is a requirement that any agency billing Medicaid be enrolled. KCAConly has 2 clients on this program which brings in around$3000 in yearly revenue. We have 2 options. 1.pay the enrollment fee, 2. Put the clients on local cash (County).
Attachments: LYes‘or No,__l
Signatures Required: Yes/No Return Signed Originals to:
county Judge x ‘(’i»li'a’T‘§;’A°o°§'§’l{)‘gi“g’County Clerk (Brackettville, TX 78832)
County AuditorElected Of?ci 31(5): COMMENTS/SPECIAL INSTRUCTIONS.
Signature
Note: This is the only form required for agenda requests. Forms should be retumed/emailed to [email protected] hand delivered or mailed to the Of?ce of the County Judge (501 S Ann St., P.O. Box 348 Brackettville, TX 78832)Items will not be included if submitted after deadline: the first Friday of each month at 12 noon. Regular Court Meetingsare the 2nd Monday of each month.
Item Received by: Date:Time:
12/26/2018 MCO LTSS Provider Enrollment Process Extended | Texas Health and Human Services
MCO LTSS ProviderEnrollmentProcess“Extended
The deadlinefor LTSS providers sewing managed care members requiredto enroll through the HI-ISCMedicaidMCO LTSS provider enrollmentprocess is extended.The new deadline is Feb. 1, 2019.
An MCO LTSS provider is any provider who provides LTSS services under a speci?c NPI and taxonomycombinationthrough MedicaidManaged Care, but does not have an active TPI through TMEIP or an API throughthis process.
MCOLTSS providers may obtain an enrollment applicationby submitting a request toMCO_LTSS_Provider_Re—[email protected] shouldsubmit applicationsas soon as possible.Therequest nmstjncludethe provider's.business name,tax identi?cation number, NationalProvider Identi?erandtaxonomy code.
For more infonna?on contact [email protected].
hftpszllhhs.texas.govIabout—hhsIcommunications-evenlslnewslzo18/12lmco-ltss—provider-enrollment-process-extended 1/1
corporate Board of Directors ResolutionTHE FOLLOWING FORM IS FOR CORPORATIONS ONLY,
AS INDICATED ON THE DISCLOSURE OF OWNERSHIP, QUESTIONIII (D).
State Of
County Of:
On The Day Of _, 20 , at a meeting of
TheBoard Of Directors Of _ __ , A Corporation, held in the city of
, in county.
With A QuorumOf TheDirectors Present, The FollowingBusiness Was Conducted:
It was dulymoved and secondedthat the {owing resolution be adopted:Be it resolvedthat the board ofdirectorsof ove corporation do herebyauthorize
said contract.
The above -* of thosepresent and voting in accordance with the
by—lawsa
held on the
Signatureof Secretary
Subscribedand Sworn BeforeMe, , a Notary Public for the County of
, on the _ dayof ,20
Notary Stamp/SealNotary Public, County of _
State of __
Signature
MESSAGE TO NOTARY:
COMPLETE ALL OF THE BLANKS IN THISNOTARY STATEMENT.
VI mm.,,mHw..w.mm
TMHP A mm MEDICAID oounwrrok Page A-2
Rev. XXXV Revised 12/01/2016 | EffectiveO1/01/2017
AppendixA: AdditionalForms
Instructions for completing. theDisclosure of Ownership and control Interest Statement
Completionandsubmissionofthisformisaconditionofpartieipation,
certi?cationor rccertilicatiouunder anyof theprogramsestablishedby TitlesV, XVllI.XIX and XX or as a condition of approvalorrenewalof a contractor agreement betweenthe disclosingentity andthesecretary ofappropriate state agency underanyof theali,ove~titledprograms.a fullaudaccurate disclosure of ownershipand financialinterest is required.Failureto submitrequestedinformation mayresult in a refusalby the appropriateState agency to enter into anagreementor contract withany such institution in termination ofeitistingagreements.
GENERALINSTRUCTIONSPleaseanswer all questions as of thecurrent date. if the yes blockforany item is-checked.list requestedadditional informationunder theReinarltsSection referencing the item numberto be continued. ifadditionalspace is-needed.use an attachedsheet.
DETAILED INSTRUCTIONSThese instructions are-designedto clarify certain questions on theform. lnslructiuns'are_ listedin orderof question for easy reference.NO instructionshave been given for questions considered self-explanatory.
IT IS ESSENTIAL THAT ALL Al’i’l.lCAlil.E QUESTIONSBF.ANSWERISDACCURA‘l‘El.YAND ’l'liA'l' ALI. INFOIKNIATIONRECURRENT.
ITEM l- Identifying Information(a) Under identifying information’specify,in what capacity the
entity isdoingbusinessas (DEA),example,and name oftrade orcorporation.
ITEM ll — Sel?explanatory.
ITEM lll - 0wners,_Partners, Otlicers, Directors, and PrincipalsList the names ofall individualsand organizations havingdirect or
indirect ownershipinterests.or controlling interest separatelyor incombination amounting to an ownershipinterestofs percent or moreinlthedisclosingentity. 501-(c) (3) nonpro?tand state-ownedentitiesmust list the oflicersor directors thathaveagcontrolinterest intheentity and managingemployeesin Section lil(a). Since there willbe‘no entriesfor any personwith anownershipinterest (Section lii[b]),thepercentage ofownership willalwaysbe lessthan I00 percent.
Direct ownership interest -is defined as the possessionof stock.equity in capitalor any interestin the pro?tsofihe disclosingentity.A disclosingentity is de?ned as a Medicare provider or supplieror
otherentity that furnishesservicesor arrangesfor fu rnishiugservicesunderMedicaidor tlieivialerual and ChildHealth program or healthrelatedservicesunder the socialservicesprogram
indirect ownership interest is de?ned as ownership interest in an
entity that has direct or indirectownershipinterestin the disclosingentity. The amount of indirectownership in the disclosingentitythat is held by any other entity is determined by multiplying thepercentageofownershipinterest at eachlevel.Anindirect ownershipinterest must be reportedif it equities to an ownershipinterest of5 percent or more in the disclo:siItg_cnliIy.Example:ll "A“owns 25percent of thestock in a corporation thatowns 80 percent of thestockof the disclosing,entity. “A':i"interest equates to a 20 percent indirectownershipand must he reported.
Controlling interest is de?ned as the operational direction or
management of a disclosingentity which maybe maintained byanyor all of the followingdevices;the abilityor authority. expressedorreservedto amend or changethe corporate identity(i.c., joint vent ure
agreement. unincorporatedbusinessstatus) ofthe disclosingentity;theabilityorauthority tonominateor namemembersoftheBoardofDirectors or Trustees of thedisclosingentitycthe,abilityor authority.expressedor reservedto amend orchange the by-laws,constitutionor other operating or management directionof the disclosingentity:the right to controlany or all of the assets or other property of thedisclosingentity upon thesaleor dissolutionof that entity;the abilityor authority. exprcssulorreserved to control the sale of any mailof the assets in encumbersuch assets by wayof mnrtyige or other
indebtedness.to dissolve the entity or to arrange for the sale orIra nsferof the disclosingentity to new ownershipor control.
Note: All'x‘ndivr'zluu!slistedin SeitlizmIlI(a) nmsl-submitn PJI-'-2.
ITEMSlV througliVII — Changes in ProviderStatusChange in providerstatus is de?nedas any changein managementcontrol. Examplesof suchchanges would includea change in
Mcdi l or Nursing Director, a new Administrator. contracting the
operation of the facilityto a~manag‘em‘eutcorporation,2: change in
the compositionof the owning partnershipwhich under applicableState law is not considereda change in ownership;or the hiringor dismissing of any employeeswith 5 percent or more financialinterest in the facilityor in an owning corporation, or any changeofownership.
For items l\’ through Vii. if the Yes box is clieclzed.list additionalinformationrequestedunder Remarks.Clearlyidentifywhichitem isbeingcontinued.
ITEM IV — Ownership(a St1))if therehasbeen a change in ownershipwithin the last yearorifyouanticipatea-change.indicate the date in theappropriatespace..
ITEM V — Managementif the answer is Yes, list name or the management firm and
emplayer‘identi?cationnumber (EIN) or the leasingo'rgani7.atio_n.Amanagement company is defined as any organimtion that operates’and namesa businesson behalf of the owner ofthat businesswiththe owner retaining ultimatelegalresponsibilityfor operationofthefacility
ITEM VI — Smilingif the answer is Yes, identifywhich has changed (Administrator.MedicalDirector or.DirectorofNursing)andthedatethechangewasmade. Besure to includenameof thenew administrator.DircctorofNursingor MedicalDirector, as appropriate.
I'l'liM‘\’ll - AffiliationA chainafiiliuteisanyfreestandinghealth-carefacilitythat is owned.controlled, or operatedunder leaseor contract by an organizationconsistingoftwoor morefreestandinghealthcare facilitiesorganizedwithin or acrossState lineswhich is under theownershipor throughany other device.control and direction of a common party. Chainalliiiatcsinclude suchfacilitieswhether public,private, charitableorproprietary. ‘theyalso includesubsidiaryorganizations and holdingcorporations. Provider-based‘facilitiessuch as hospital—basedhomehealth agenciesare not consideredto bechainaffiliates.
[Tl-EM Vlll — Capacityif the answer is Yes, list the actual number of beds in the facilitynow
and the previous number.
ITEM IX - Disclosure of RelationshipPleasediscloseany of familialrelationshipsbetweenprincipalsand!or the provider(i.e.. liusband, Wife.Natural or AdoptiveParent.Naturalor AdoptiveChild, Naturalor Adoptive Sibling).
Page 1 Disclosureof Ownership
F00] 08 Revised08/01/20i6 I Elfectiveiolol/2016
This form is requiredfor all individuals, groups, and facilities (exclude performing providersand SI-IARSproviders).
(3)
D
x Identifyingirifornmtion‘Telephonenumber;
I
_egal‘Name:(accordingtotheIRS), '
’' DBA:
[Physical/Co‘orate-Addreé~ '
Q‘j53rV
‘£08593,93,41
3 mt’~t<‘,/M1;-rxII. Answerthefollirwingestiuns bychecking Yes or No. V
"
, ,V
V , _~ —
I
Ifanyof theqaestionsareansweredYes, list namesand‘addressesofindivi als or corporations underRemarkson theDisclosureofOwnershipI, andControlInterestSta rnentform.Identifyeachitemnumbertohecontinued.
(a) Are there any individuals or organizations having a direct or indirect ownership or control interest of live percent Yes __?—Noor more in the institution, organizations, or agency that have been convicted of a criminal o?ense related to theinvolvement of such persons, or organizations, in any of the programs established by Titles XVIII, XIX, or XX?
lb)
VIII.
Does this provider have any current employees in the position of manager, accountant, auditor, or in a similarcapacity and who were previously employed by this provider’s ?scal intermediary or carrier within the last 12
months? (Medicareprovidersonly)
— Owners,Partners,O?icers, Directors, and Principals’ Allindividualsandentities identified.in thissection are requiredto completea—,PlF-2whiehrnustrbesubmittedwiththisenrollmentapplication.
Identify individuals who are soleproprietors or owners, partners, o?icers, directors, and principals (as defined in the PrincipalInformation Form [PIP-2})of the applicant and list the percentage of ownership, if applicable. Total ownership should equal 100 percentunless otherwise noted in the instructions (seeprevious page). If ownership does not total 100 percent, the provider must submit a letterexplaining the discrepancy. As it relates to owners, include all individuals with 5 percent or more ownership in the company, whether thisownership is direct or indirect.(Add additional pages ifnecessary.)
D
N T, :1’V
Pereentagedwned:
Percentage Owned:
3., ‘Name;, PercentageOwned:
Name; , PercentageOwned:
(b)
F00108
Identify the entities with ownership of a controlling interest in the applicant (whether such ownership of the controlling interest is director indirect). Provide the entity’s name and federal taxidenti?cation number. SeeInstructions forCompletingtheDisclosureofOwnershipand ControlIntereststatement. List any additional names and addressesunder Remarkson theDisclosureofOwnershipand ControlInterest
Statement. Ifmore than one individual is reportedand any ofthesepersonsare relatedto eachother, thismust hereportedunder Remarks,
N?med '
H I l ‘VAddress: FcderaITaxI.l):V’
Page 2 Disclosure of Ownership
Revised 08/01/16 ] Effective 10/01/2016
(C) oyoueurentlyhavea ‘credirorwithasecurityinterest in Adehtlthatisowedbyyoui ‘
l V V
l‘ [Yes
;
I
._isthe creditocls)securityinterestprotectedhyatleast 5 percent of your property? , Yes ‘W’List each creditor with a security interest in a debt that is owed hy you if the creditor’s security interest is protected by at least 5 percent ofyour property. Alllistedcreditorsmust alsocompletea PrincipalInformationForm (P11-12).
I.”astIf1amelCon1panyNam'“ First Name:V l:
V V
_ yr— Percent of Securitylnterestz?
(dl “Iypeof Entity: Select a
Individual/soleproprietor C Corporation S Corporation PartnershipLimited liabilitycompany. (Enter the tax classi?cation[C=C eorpurati n, S=S corporation, P: ur!nership])_______________ __
Trustlestate ]/Other (specx?)
(6) lfthedisclosin‘
a corporation,list names,addressesoftlied'rectorsand EINs for, corporations in remalksl‘V
,
‘ Note:Each dire identi?ed_i hissection mustalsocompletea PIF AllPIE-2documentsmust besubmittedwith thisapplication. ‘
Attach addi?onalpages:g?neetLled._: V
'— . * ‘
J
Remarks:
g IV. ‘ Ownership .
(3) Has there been a change in ownership or control within the last year? Yes XNQIfYes, give date:
(5) Do youanticipate any change of ownership or control within the year? Yes meifYes, give date:
(C) Do you anticipate ?ling for bankruptcy within the year? (seeprovider agreement foradditional Y5; meinformation) ,
IfYes,give date:
(d) Are any of the new owners related to any of the former owners? Yes ?o(e) Did any former owners transfer their ownership interest to any new owners in anticipation of
or following the assessment of a civil monetary penalty? Ifyes,please lisz‘the name ofthefarmer Yes W6owners below.
Last Name:_ :I
‘I
firstName: 7 Middleilnltlalz
' CV., ManagementV
Does the provider identi?ed in Section I. above comprise or includea facility that is operatedbyYes Wa management company, or a facility that is leased in whole or in part by another organization? _.
IfYes,give date afchange in apemtions:
Page 3 Disclosure of Ownership
F00108 Revised08/01/16I Effective l0/01/2016
v1. Sta?ing_ _
y_
(3) Has there been a change in Administrator, Director of Nursing, or Medical Director within theY Nlast year? es 0
VII. A?iliation,‘
‘
, _ _
(a) ls the provider identi?ed in Section 1. above chain a?iliated? Ygs M4IfYes, provide the name, address, and FederalTax ID number ofthe chain’:corporate/homeo?ice:Name Address FederalTax ID
' VIII. v
‘Capacity
‘
(8) Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater,Ywithin the last two years? (For Hospitalsonly) es 0
IfYes, give: Year of change: Current Beds: Prior Beds:
‘VIX.’* "_Disclosureof Relationship‘II
V
, _V
_ , ._(3) Please disclose any of the following familial relationships between principals and/or the provider (Husband, Wife, Natural or Adoptive
Parent, Natural or Adoptive Child, Natural or Adoptive Sibling):
ProviderlPrir'1cipal' V
0
Has a Relatiorishiplasr 3:,ToProvider/PrincipalName 2:
Please Note: When claiming“Corporation”providersmust completeand return the followingforms:
- Corporate Board of Directors Resolution Form, original signature and notarized.- Certi?cate of Formation, Certi?cate of Filing, Certi?cate of Authority,or Certi?cate of Registration.- Franchise Tax Account Status, available at httpszlmycpa.cpa.state.tx.us/coa/1ndex.htm1.
Do you have a 501(c)(3)Internal Revenue Exemption? Yes No
Providers who answer ”yes”to the question “Do you have a S0l©(3) Internal Revenue Exemption” must submit a copy of their IRS ExemptionLetter with submissionof this applications signature page. Providers who have a 501(c)(3) Internal Revenue Exemption are not required tosubmit a copy of the Franchise Tax Account Status from the State Comptrollefs O?ice.
F00108
Page 4 Disclosure of Ownership
Revised 08/01/16 I Effective10/01/2016
* TEXASHealth and Human Services
Medicaid CHIP Services DepartmentAffordable Care Act Managed Care Organization (MCO)
Long Term Services & Suppons (LTSS) Provider Application
MCO LTSS PROVIDER APPLT(IA1'IONi‘I
i
Vllhiatkind of provider are you: D Individual El Perfonning Provider B Group IEFacility
Name of individual/perfon-ning provider/group/facility wanting to enroll: NA
A. If an individual: NA
Last Name: NA First Name: NA Middle Initial:NA
B. If a performing provider/group/facility: Kinney County
Company Name: Kinney County
Legal Provider Name: Kinney County Aging Services
Mailing address: P‘ o_ Box 911
City: Brackettville State:TX ZIP Code: 78832
Physical address:408 s Ann st_
City: Brackettville State: Tx ZIP Code:78832
Provide all applicable numbers/identifiers. NA
I
:R°Vi1Dif?R.N,UMii
Medicare Certi?cation Number: NA Medicare Certi?cation Date: NA
Federal Tax I.D. (TIN) Number: 746000381 Social Security Number: NA
National Provider Identi?er (NPI) Number: Texas Provider Identi?er (TPI) Number:
Atypical Provider Identi?er (AP1) Number: Primary Provider Taxonomy Code: 332U00oo0X
PROSelect the provider type that applies to this application.
Adult Foster Care
Agency Adult Foster Care
Emergency Response System
Employment Assistance
Habilitation
I Home Delivered Meals
Minor Home Modi?cations
Primary Home Care / Nursing Services
Primary Home Care / Nursing Services / AttendantCarte / CFC
Respite Care / Assisted Living
Supported Employment
Transition Assistance Services
Value Added
I
sA§Pl=Lr‘cn'rro‘rijf'
Last Name: Aldaco First Name: Patricia Middle Initial:
Email Address: [email protected] Phone:830-563-2015
Address:408 8 Ann St.
City: Brackettville State! TX ZIP Code:73332
Title/Position:site Director
f g'P1ioFiij,IONALLICENSUREIMEDICAPECERTIFICATION:
V
Page 1 of 5
TEXASHealth and Human Servizes Medicaid CHIP Services Department
Affordable Care Act Managed Care Organization (MCO)Long Term Services & Supports (LTSS) Provider Application
McoLTSS PROVIDERAPPLI7cATIoifr‘APlease list all professional licenses, accreditations, or certi?cations that apply for your application. Copiesofcurrent licenses, accreditations or certificationsmust be submitted with this applications.
A. Professional Licensing Board:NA
Professional Licensing State:NA
Professional Licensing Number:
Professional License Issue Date:
NA
Professional License ExpirationDate: NA
B. Professional Licensing Board:NA
Professional Licensing State:NA
Professional Licensing Number:
Professional License Issue Date:
NA
Professional License ExpirationDate: NA
C. Professional LicensingBoard:NA
Professional Licensing State:NA
Professional Licensing Number:
Professional License Issue Date:Professional License Expiration
I
Date:NA NA
1. Is your professional license, accreditation, or certi?cation revoked, suspended,or D E]otherwise restricted?
2. Have you ever had your professional license, accreditation, or certi?cation revoked, D Esuspended, or otherwise restricted?
3. Are you currently or have you ever been subject to a licensing, accreditation, orDcerti?cation board order?
4. Have you voluntarily surrendered your professional license, accreditation, or U E‘certi?cation in lieu of disciplinary action against your license?
5. Have you ever enrolled in or applied to any other States Medicaid or CI-HPprogram? [I
Have you ever been unenrolled or banned from enrolling in the federal MedicareC‘program?
7. Are you currently or have you ever been subject to the terms of a settlement agreement,corporate compliance agreement or corporate integrity agreement in relation to any state CIor federally funded program?
8. Do you currently have any outstanding debt in relation to any state or federally fundedprogram? Ifyes was answered to any ofthe questions above, ?llly explain the details
D '3including date, and the state ifapplicable.
9. Are you currently charged with or have you ever been convicted of a crime (excluding D E‘Class C misdemeanor traf?c citations)? i10. Have you been arrested for a crime but not yet charged? Cl El11. Is there an outstanding warrant for your arrest? If yes, fully explain the details,
including date, the state and county where the incident occurred, the cause number(s), El Eland speci?cally what you were convicted of:
12. Are you currently subject to court ordered child support payments? [I El13. Do you have the legal right to work in the United States? If the United States is not your
Country of Citizenship please provide a comof your green card, visa or other Eldocumentationdemonstrating your right to reside and work in the United States.
Page 2 of S
TEXA . . .Heakh andsmmanSam“; Medicaid CHIP Services Department
Affordable Care Act Managed Care Organization (MCO)Long Term Services & Supports (LTSS) Provider Application
MCO LTSS PROVIDER APPl.ICATION
14. Do you currently have a creditor with a security interest in a debtthat is owed by you? El Ela. Is the creditor's security interest protected by at least 5% of your property? Db. First Name: \
c. Last Name:d. Company Name:e. Percent of Security Interest: %
15. Are you seeking enrollment due to change of ownership? CI El16. Are any of the new owners related to any of the former owners’? E! El17. Did any former ovmers transfer their ownership interest to any new owners in
anticipation of or following the assessment of a civil monetary penalty? If yes, please listE Elthe last name, first name, middle initial of the former owners below.
18. Is anyone on this application chain store affiliated? If yes, complete the following for Ueach affiliate.
Chain store affiliation #1
Principal or subcontractor: Last Name: First Name:NA NAPercent Owned: Social Security Number:
% NA NA
Physical address:NA
City: NA State: NA ZIP Code:NA
Chain store affiliation #2Principal or subcontractor: Last Name: First Name:NA NAPercent Owned: Social Security Number:
% NA NA
Physical address:NA
City: NA State: NA ZIP Code: NA
Chain store affiliation #3Principal or subcontractor: Last Name: First Name:NA
Percent Owned: Social Security Number:% NA NA
Physical address: NA
City: NA State: NA ZlP Code: NA
V
1\{.V. ‘
19. Does any owner or controlling interest party have one or more professional licenses,accreditationsor certi?cations? If yes, complete the following for each. Cupies of D Ecurrent licenses, accreditatians or certificationsmust be submitted with thisapplications.
Page 3 of 5
TEXASHealth and Human Services Medicaid CHIP Services Department
Affordable Care Act Managed Care Organization (MCO)Long Term Services & Supports (LTSS) Provider Application
Mco rrss PROVIDERAppucariou.Ownership and Controlling Interest Professionallicense, accreditation, or certi?cation #1
License Accreditation/Certi?cation Issuer:NA
License Accreditation/Certi?cation Number:NA
License Accreditation/Certi?cationissue Date:NA
License Accreditation/Certi?cation Expiration Date:NA
Ownership and Controlling Interest Professional license, accreditation, or certi?cation #2
License Accreditation/Certi?cation Issuer:NA
License Accreditation/Certi?cation Number:NA
License Accreditation/Certi?cation Issue Date:NA
License Accreditation/Certi?cation Expiration Date:NA
Ownership and Controlling Interest Professional license, accreditation, or certification #3
License Accreditation/Certi?cationIssuer:NA
License Accreditation/CertificationNumber:NA
License Accreditation/Certi?cationIssue Date:NA
License Accreditation/Certi?cation Expiration Date:NA
m .. ,.,In
A
20. Does the applicant, owner, or controlling interest party have a relationship (family orbusiness) with a separate provider? '
21. Is the owner or controlling interest party currently or have you ever been subject to theterms of a settlement agreement, corporate compliance agreement or corporate integrityagreement in relation to any State or Federally funded program?
22. If yes was answered to any of the questions above, fully explain the details including thedate, state, name of the board or agency (if applicable), any adverse action against your
applicable).license (if applicable) and details of outstanding debt or settlement agreements (if
specifically what you were convicted of:
23. Has the owner or controlling interest party been arrested for a crime but not yet chargedor is there an outstanding warrant for arrest? If yes, fully explain the details, includingdate, the state and county where the conviction occurred, the cause number(s), and
payments?
States?
a. Provider/Principle1:
24. Is the owner or controlling interest party currently subject to court ordered child support
25. Does the owner or controlling interest party have the legal right to work in the United
26. Please disclose any of the following familial relationships between principals and/or the provider: Husband,Wife, Natural or Adoptive Parent, Natural or Adoptive Child, Natural or Adoptive Sibling.
Has a Relationship as: To Provider/Principle 2:
located at27. Provider must complete and submit theDisclosure of Ownership and Control Interest Statement
http://www.tmhn.com/Provider Forms/Provider%20EnrollmenVF00108 Disclosure of Ownershitxndf.28. Provider must complete and submit Principal Information Form (PIF2) located athttp://www.tmhp.com/ProviderForms/Provider%2OEnrollment/PlF2%20Principal%20Information%20Form.pdf.
29. Provider must submit the Internal Revenue Service (IRS) W-9 Form‘
~ “?APi=Lr(:ATioNFEE’5
Page 4 of 5
' Health and Human ServicesTEXAS Medicaid CHIP Services Department
Affordable Care Act Managed Care Organization (MCO)Long Term Services & Suppo?s (LTSS) Provider Application
MCO LTSS PROVIl)ERAPPLPCATIQN‘‘
In accordance with ACA and 42 CFR 455.460, certain providers are subject to an applicationfee for allenrollmentapplications. The calendar year 2016 application fee amount is $560.00 per application (entityenrollment). If the applicant is required to pay the application fee, you must submit payment in the form of a papercheck, money order, or cashier's check, when submittingthis application. Payment should be made out to theTexas Health and Human Services Commission (HHSC). Please include "ACA MCD MCO LTSS Provider Re-enmllment Fee" in the memo line of the check.
An application fee is not required and will not be accepted if the applicant is enrolled in and has paid the Medicareenrollment application fee or another state’s Medicaid programsenrollment application fee. If the applicantclaims they are not required to pay the Texas application fee, you must submit proof of payment to Medicare oranother state’s Medicaid program when submitting this application. Otherwise, please include the application feewith your application paperwork.
‘ .srcnAruREs'Signature of applicant: Date:
Applicant Printed Name:
Signature of applicant: Date
Applicant Printed Name:
Written CommunicationEnrollmentApplications:Attn: MCDMCOLTSS Provider EnrollmentMailCode H312HHSCMedicaid & CHIP Services Department, Operations Management909 W. 45th Street Bldg. 2Austin,Texas 78751
EmailCommunicationMCO LTSS Provider Re—Enro||[email protected]
Page 5 of S
Provider Information Form (PIF-1)
EachProvidermust completethis Provider Information Form (PIF-1), beforeenrollment. A provideris any person or legal
entity that meets the de?nition below.
Each Providermust also completea PrincipalInformation Form (PIF-2), for each person who is a Principalof the Provider (see
the PIF-2 form for a completedefinition of everyperson who is considered to be a Principalofthe Provider).
All questions on this form must be answeredbyor on behalf of the Provider, byALL providertypes (all spaces must be
completedeither with the correct answer or a “NA”on the questions that do not applyto the Provider).
Allhigh-categoricalrisk levelprovidersmust submit ?ngerprints for enrollment or revaliclationin Texas Medicaid.
The Provider or provider’sdulyauthorizedrepresentativemust personallyreview this completedform and certify to the validity
and completenessof the information providedby signing the HHSC Medicaid ProviderAgreement or other State Health-Care
Program Agreement.
“Provider” - Any person or legalentity, includinga managedcare organization and their subcontractors, furnishing Medicaid
services under a State Health—CareProgram provideragreement or contract in forcewith a State Health-CareProgram, and
who has a providernumber issued by the Commission or their designee to:
1. providemedical assistance under contract or provideragreement with HHSC, DSHS or its designee;or
2. providethird party billingservices under a contract or provideragreement with HHSC, DSHS or its designee.
A “Third-PartyBiller”is a type of “Provider”under the abovede?nition and is a person, business, or entity that submits claims
on behalfof an enrolled health care provider,but is not the health care provideror an employeeof the health care provider.For
these purposes, an employeeis a person for which the health care providercompletesan IRS Form W-2 showingannual income
paid to the employee.
:‘ of Enro?ing:‘_(Gro11p/Cnmpam/namearL_ust,lFirst,MiddleIni?al) :_I
3' MaideiiName:
l.ilno€_yCmn,.,é[j1n&§5<arv/5 M15}:1‘‘Listanyother ?or ] ofyour me’ used: ; , National Pmviderldenti?_er_(NPI):(10-dx'git)
' a
is’,name,or,
-V
"73055‘?5é’5I
'2PrimaryTaxpnpSn2y'Code:_
zpravidermayindicateup to 15Yaxtmomycndes;attachiziiiiliiaiirtlpugesifneeded)
P P ” folled‘TiI1mnomvCode:(theszeadesan:infarmiztianalunddescvilzeserviczsthtprovidzrpe?izrmsbutfarwhichihzprnvidgrdoesnotcurrentbfbillDxasx
For additional names or addresses, attach pagesas necessary.“ [Physic dtlress(whereheglfliycareisrendered): Provjdm‘MUS1‘maythephysicalgram;whzretj mai 1355is encmgzlpnthlsphysicnl ?eld, the applicrztinnmay bedenied. 5 ‘ .-,
‘ ‘ ‘ ' . ‘ Shite' ‘
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state, 2112‘‘~
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Suite ‘_ '~ City‘ . State .ZIP-
6‘1
_ f acmttnuagaddressisldiiferentthanyourphysicaladdress, indicateyourrelationshipptothe accounting address:
Third Party Biller Management Company Employer Self Other (explainbelow)
‘ l?iouch_ose0?1en}>leaseexplain;I '
NI’-l
V1 .....TMHP ASTATE MEDICAID CONTRACTOR Page 1
F00115 Revised 12/18/2017 | Effective01/01/2018
Provider Information Form (PIF-1)
I-rlxiaixatiMM/DID/Y_Y‘IY
F""‘*K
‘ issxgénstg:‘MM/DD/YYYY‘ _
g I Tums MEDICAIDA4HEALTHFARLl‘AxrNEI*dHl'r
TMHP ASTATE MEDICAID cuxmwzmn Page 2 Provider Information Farm (PIF-1)
F00ll5 Revised 12/18/2017 I EffectiveO1/01/2018
Professional Licensing or Certi?cation Board: Licensing State:
M14M14LicenseAocrediiationCergiiicaiionIssuer: "LicenseAccreditationCerti?éotionI’~!nmber:r
M11M14Issue om;MM/no/Yrvv Expiration I‘)_ate:MMlD_lJ/YYYY
.[ _
‘1'
LicensingStare:.
nut:‘ LicenseAeEred1Iatron‘Certi?c:itionNlrrnlzerz
NVal. ' ‘Insole/Date: Eirpira?nnpa:-MM/Do/Y'v_Y.Y_
N reCLIACerti?cation Number:(a_2!m:ha copyofthe_CLlAcertlyicnriun,ifupplicablz)
V '- ‘
_- I
,x
.Hospitals providing laboratoryservices, andindependentlaboratories(includingihose‘locatedin physician’:of?ces), must answerall CLIA certi?cation questio _ _
_ rulesandIegtilakionsanavailnbleonthé,GMSvv_ebsi_teaewyw-.=ms.gav;
W:\'LTl
cLxA'ceni?ca:im_uAddress: (list theaddressmm:on the cm cmgsame,ifupplicublé) '
Number ‘f Streeg‘
Suite City Suite , ZIP
CLIA Certi?cationExpirationIigte(ifqppli'cnhle):,
AU?2 PreviousPhysicalmdnssz
1~ru'mpe:.j ‘,su;eq~ , . Suite V City _ , State ZIP
NV-JrPr¢vionsAu:ou;n §Add_ress:‘_ if
i
j Number’ ,
' ‘ Street‘ Suite Cityx
State ‘ZIP
i\Ll&Do you plan to use a Third Party BillertosIIl)iI1it)"o'u1"l1ealt‘h"-'careclaims?
I
.
Yes t!No IfYes.providethefallowinginformutionabout the billingagent.
Address:—
A
Ng?rFederalTax'IDNumber: N V‘ContactPersonName:
I ‘
Telephone Number:‘
>4: we‘I mM::,mHmmW.m
TMHP ASTATE MEDKCAID mnnmcmn Page 3
F0O115 Revised 12/18/2017 [ Effective0l/0l/20l8
Provider Information Form (PIF-1)
List all Pmviders and medicalentities that you have a contractual relationship with and, if known, the NPI/AP! and TPI of each provider or entity. (attachndditizmalsheetstfnecessm-y)
1. Name; 'Socia.lSecI|rityNnnsber: ,DaleofBirth:MM/DDIYYYY‘
0 N f+ N /40
K 'P\l|YSic.Iladd.ress: ‘
K :0 0'
.0
,N'umhz1' suite;V
City s1ate_,_ z_n>
1121:’‘ V‘, -Npx/AP_I:‘‘
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NA N4'2. socaalsecurxgynmbegg,
--— _, DaleofBirth:MM/DD/YYYY
N )4}V
N/4‘s‘..a¢e'
City .s;a{e‘y'“z1p'y'K
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' 1=e'am?1—1faxjD: ?rm:‘
~ HNPI/API:
M0 NA M?7Name:' ‘
v . —?spcia,1securiq-'Numbe:='
Dau«o£nI:_:h:MM/x5bjyYyy,'
NH N4 N4'i’iiYsi_ca1Address=,‘ ;
’V ,,
V VNumber street _ sun‘; __ _City‘ State _ .2117 , -
N-I91: ,
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5 Nl5I]APIi:‘_'
I M#— M?:. Sncial SccI:1rityNumbe‘x-. DlaieofBirth: ‘l\/lr§_(l,DDIi'_‘_x"YY‘
N N ICL I?r. 1>hysica1Add:es§:-
_y « ‘y . -
A.'
_ -Number‘ street. Suite 1 , Ity _j I
I
‘scam , znr
N?,i;eaem1_7axID:‘ '_ TPI: '*N1>t/A1>1:«' ,_
NW NA N?5_ .' 0 . ' f I . ‘_Soci_alSecu;'ity,NuIn,ber: DateofBirlh:MM/DDIYYYYO;
/W95 WSuit; 0 I Cit}; [state ZIP
FederalTax ID: TPI: NPI/API::
NA MI4-‘
V1TMHP
FOOll5
Tm: Mzmmu p. HEAL'rI-uzuuzNxmzssumA STATE MEDICAID CoNnu\Cl'0n Page 4 Provider Information Form (PIF-1)
Revised 12/18/2017 I Effective01/01/2018
V ,""$nnk:tinn"is necolqsnment,l‘l[u1¢l,‘lnap‘ositionof penel?eeor‘ damages,‘
~ exclusion,debafsnent?nspenslon.revocation, or any other synonymous a_cf_1onLact gnneellations,
‘V' Haveynn ever been snnctiénejl(esde?ned'allove)in any state or federal prdgnansi
additional sheetsifnecessary)
Yes ?lblo‘ I
IfYes, fulbrexplain the details, includingdate, the state wherethe incidentucmrred, the agency taking theaction, and theprogram a?eeted.(attach
eseionnllicensein certificationm 11 qfdisciplinary action?
_ v ?caytilznk/statuscheckwithyear licensingonmjicatinnbeard.). (yo.;m.a,tm',.a
IfYes was answeredto any ofthesequestions,fullyexplainthe details, includingdate, thestate wherethe incidentoccurred.name afthe board or agency, and any adverseactian against your license.(attach additional sheetsifnecessary)
‘_ Yes - ___No
Yes
—-Yes —. :
[fYes was answered to any ofthe questions,fully explain the details includingdate, and the state ifappheable.
V1TMHP ASTATEMEDICAID commcron Page 5 Provider Information Form (PIF-1)
F00115 Revised 12/18/2017 I El‘fectiveO1/01/2018
“Convieted”nieinsthan,-_ , _ _ ,
V
"_(n) A judgmentqfqony
_tion has been enteredagainst an individual orentityby a Federal, Stéiteorlocalcdurl,
' or??ikdlessofwherher' ‘
VW ' 7
—
V‘'
'
V ' "lhereis V:post-trial dtio' entofoonvietidnor
‘r an appeal pending,or_ _
V
errecordVrelntingtothecriminalcunduct'héasbeen’ pungedforotherwise.'rVowed
(b) Aliedéral, eourthas niadea_?ridir|go_fVguiltahgainsthanindividuallorentity;‘
_V
loéal has accep‘_ plea fguilty or noloeontendereby«inindividual or entity, or
V
dgin‘en_to(canvia1mi'has_hethheld.
Areyou currently charged withClass C misdemeanortrafficCi
V
5)? , _ —
‘
, . . - V"V
V
Toanswerthis uestion, usethefederalMedicd/Medicarede?nitionof“Canvicted"in 42 VCFR;§ 1001.2asdescribedabove,and '
whichinclude ‘
‘ed iijudied?ans?ndullothértypesofpretrial diversionprogram‘Ydumaybesubjectto a criminalhistigry_
‘check '
W ''
'
-
V i
ve you everbeen of a crime (excluding __'
hr‘ .1-layeyoubeen-arri:
V
foratriniebut notyetgch‘- Isgtherean onIstanding.w?rr.intfor your arrest? .
IfYes,fulbxexplain the details, includingdate, thestate and county wherethe conviction occurred, thecause numher(s),and speci?callywhntyau were convictedof (attach additional sheetsifnecessary)
' a iirst otfender,V'defer'redadjudication or otherpmgriI or ‘
*
Yes
‘VYes7 ‘No‘
Yes‘
3Areyoucurrentlyeulijeetcan ‘‘
IfYes,provide details.
Areyoucurrentlybehind30 daysor niore'oiieourtorderedchild support pziyments?V’
V VV
IfYes.provide detailsofhowthesepast»due payment ubligatiunswillbemet. {attach additional sheetsxfneeessuvy)
Yes‘
ates?_1 youa_citinenof theUnite
IfNo, provide the country ofwhichyou are a citizen.
Yes /[A.’§<')‘
If youarenot acitizen of the United‘Stntes,Vdo’yuuhavea legal right to worklntheUnit d States?
IfYes; dttaeh'a copyofyour green‘card,visa, rdocumentatiandemonstra?ngyuurtrxgresideundworkin theUnitedSmteVs.;‘
I acknowledgethatl am required to submit proofof ?ngerprinting.
E1 T.mm.,i..mm
TMHP Asrzmz MEDICAID conmmon Page 6
?ngerprint criminal Background check (FCBC) for High-categorical Risk Providers
Yesir"
Provider Information Form (PIF-1)
F00115 Revised 12/18/2017 I E?ectiveol/01/2018
Principal Information Form (PIF-2)Requiredforany person or entity that meets the de?nitionofa “Principal"ar “Subcontractor”
as de?nedbelow.
A separate copy of this PrincipalInformation Form (PIF-2) must be completedin full for each Principal or Subcontractor of theProvider, beforeenrollment.
A Principal of the Provider is de?ned as follows:
- All owners with a direct or indirect ownershipor control interest of 5 percent or more.
- All corporate o?icers and directors, all limited and non-limited partners, and all shareholdersof a providerentity(includinga professional corporation, professional association, or limited liabilitycompany).
o All managing employeesor agents who exercise operational or managerialcontrol, or who directlyor indirectlymanage the conduct of day-to-dayoperations.
- All individuals, companies,?rms, corporations, employees,independentcontractors, entities or associations who havebeen expresslygrantedthe authorityto act for or on behalf of the provider.
- All individuals who are able to act on behalf of the providerbecause their authorityis apparent.
A Subcontractor ofthe Provider is de?ned as follows:
- An individual, agency,or organization to which a disclosingentity has contracted or delegatedsome of itsmanagement functions or responsibilitiesofprovidingmedical care to its patients; or
- An individual, agency, or organization with which a ?scal agent has entered into a contract, agreement, purchaseorder, or lease (or leasesof real property) to obtain space, supplies
All spaces must be completedeither with the correct answer or a “NA”on the questions that do not applyto the PrincipalorSubcontractor.
All owners that havea 5 percent or more direct or indirect ownershipinterest in a providerthat is assigneda high—categorica1risk levelmust submit ?ngerprints for enrollment or revaliclationin Texas Medicaid.
TheProvider or provider’sdulyauthorized representative must personallyreview each copy of this completedform and certifyto the validityand completenessof the information providedby signing the Provider Agreement.
Check person or entity: Person Z?ntityIfEntity, pleasecompletethefollowinginformation.
I Legalnameasshownon the W9 IRS form:
Kinney['£>U()1§/1‘_Tax ID number as shownontheW9Sforrn:
_
CompanyName:
Addresses on the W911! form:Numbe'r"St're:et",‘:‘ . . 1- _'
«;- Suite‘ Citydk'
StateI
ZIP,at 53 ms gm/,.gggaze rrx 7gai2"ea.
Howis the ent.ity,or'g'anized,to,conductbusiness activities? Examplesinclude:SoleProprietor (Unincorporated),‘Pro?zssionalAssociation,General‘
—
Partnership,LimitedPartnership,LimitedLiabilityPormersl?p,_LimitedLiabilityCompany.Corporation,Nonpro?t,Governmental’‘ -
’
Do you conduct businessIniideryasiass
IfYes,provide the assumedname below. -'
Cgawermcnf*P
H
umed me? “24 ND
5,,W_yc,,,,,Wg5,,,3_g,,,,,,
: IPlF—2TMHP A STATE MEDICAID CONTRACTOR Page 1
F00112 Revised 12/18/2017 I Effective01/01/2018
Ifyou selectedPerson above,pleasecompletethefollowinginformation.i.astNam'eé" '1 '
~
, FirstNameIMidd.leInitial:
Ame' rI:.istany etheralias, name,or formofynurname everneed:
NWThefollowing informationmust be completedby all Principals, Subcontractors, and Creditors. For additional names or addresses, attachpages as necessary.
Check principal or subcontractor D Principal I:] Subcontractor
Physicaladdress". ‘
, :"
Number'l
-
I
Suite ‘City ._ : State ZIP
,1_\c‘§:ounl(inglbilJ.ingadd.rcss:—
,r _ s
— V
eV ,
V
Nurnlier‘, I Street -
V
‘
-*
V
_‘ SuiteH
__._City ‘ State ZIP
NY4Xfyouraccounting addressis diiferent than your physical address, indicateyour relationship to thelaccimntingaddress:
|:\ Billingagent I] Management company |:| Employer D Self C] Other (explainbelaw) M,4,IfyauchaseOther, pleaseexplai
NellSloclalseeurityNnmber: _
‘
I Federal number:—
Nlér NllSpedaityafpru?te:(i.e.,pediatrics,generalpractice,etc) . ' Medicareintermediary:(ijfapplicahle)
N W A
NVlrM,d;?,€§mVia_,,V,,,,,,,,,,,:(,-f,,1,“,,,,-,,,‘,,,e)'
V
. . :'
Meaizaxéfeaecéiyedgmnn/DD/Yvw?fapplicable)‘
MY» MYXDriver’slicensenumber:_
l
_
l
_ State: _ Drivefs license expirationdate:MM/DD/XYYY
NH NW NWDameofbirth:MMIDDlYY,YY£f, N&/ Gender:'» _ Male |:I Female
:1P|F—2TMI-ll’ ASTATE MEDICAID CONTRACTOR Page 2
F00ll2 Revised 12/18/2017 I Effective 01/01/2018
Do you have oneormoreprofessional licenses, accredltntions, or certi?cations?V
—
Yes ¢No IfYes,provide thefollowinginformation.1.’
1
V Professional Licensing orCerti?cationBoard: LicensingState:
N?r. NW
‘
licenseAccrerlitatinn‘Certi?cationIssuer: . LicenseAccreditation Certi?cationNumber:
N?v~ 7}lamDuke(MM/DD/YYYY): llxpirntionum (MM/DD/YYYY):
2. ProfessionalLicensingor Cetti?cetioniionrd: licensing State:'
JimV
LicenseiAccredilationCerti?ycationrlssuer:NWLicense AccreditationCertificationNumber:
N?r Nl?re
MW
Issue Date(MM/DD/Yn'Y}:__ ExpirationDate(MM,/DD/YYYY):
'
V
3. ProfessionalLicensingorCerti?cation Board:V
Licensing State:
MlLicense Accreditation Certi?cation Niunber:License Accreditation‘Certi?cationIssuer:
ALI}'
Iss'ue1'J'ate"(MM/DD/YYYY): Expiration‘Date(MMIDD/YYYUY):*
4. ProfessionalLicensing-M-‘Certi?cationBoard:1
, lllicensingState:morn' ‘LicenseAccreditationCerti?cationIssuer: LicenseAccreditationCerti?cation Nurnher:'
NW NIZl—Expiration Date(MM/DDIYYYY):'
‘
V [safeDate (MMIDD/YYY Y):
N11PreviousPlllysiculaddress:
_, - — -
_
Nuinl>er_ ‘
‘ ‘Street “i ’ Suite City’ _
— . State ’ ZIP
‘Previousltccountiynddressi —
_ _V
'
Number; -*-Streetrr' '
Suite ' ..City State ZIP
M, Your title inthe?mviderorgonizatiorn-forwhich enrollment is being sought:
3&6‘Dir av“Your dutiestotheproviderorganization:{attachadditionalshzetstfinecessary)
"/Slew’:See [¢«Hzic/LitaSl/wee?!’V1TMHP ASTATE MEDICAID CONTRACTOR Page 3
F00112
PlF—2
Revised 12/18/2017 | Effective01/01/2018
' Your role in the providerorganization: ExamplesureAccauntant, Agency,Attorney,’Banker,Bookkeeper,Business.Cure Giver.Consultant; Contractual,CorporateO?cer,Director..Docm5ElectedO?icinl,Employee,Empluyer,GovernmentO?icial, Individual(Contracted), Individual (FiscalAgent),Limited
— Parfner, ManagingEmplo;{ee,‘MedicalDirettnr, Non-LimitedPartner, Nurée, O?izial.Owner(Direct),,Ownei(Indirect)Parent, Recruiter; Repfesentiztive.,
' Shareholder;Subcanhqcta?orlvnlmawn:(attach additionalsheetsifnecessary) ‘ S
'
—
'‘
'
D orE?ectiyedateofyour role intheprovideroxganization:—MWDD/YYYY
LO/I6/ISVV
Do youhave a relationship with a sepa.ra_teprovider? Yes |/No If “Yes,"Vejrplninrelationship withthe separate provider helosv;
. TI_'Is,provider names,andphysicallocationalunder whichyou havebilledor inwhichyonrwete a principal/Includecurrent and previous .TPI: : {attachadditionalsheetS'y‘7nece.tSary) '
'
V .~ ,'
,' ,
NPrList all Providers and medical entities that you havea contractual relationship with and, if known, the NPI/APIand TPI of eachprovider or entity. (attachadditional sheetsifnecessury)
‘Name:
‘ 1'
_I I
,'
_ VSocialSecurity_Number:, Dateofhirth:MM/DI)_/YYYY,I
Thysicaladdress: ‘
V
'
' . .V V
, Number ‘
‘Street Suite ''
., City State ZIP
1:ede:;Va1Taix-iV’:* : » Tpi: '
NPIIAPI:
2. Name:,1._~‘ ,_
_. V’ l ‘L l
_ SVocizlSecurityNuVmber: Dateofbirth:MM/‘DD/YYYY
M NVlr N73?Physicaladdressga-V
V V
. I ‘‘
_ _V
_.Number V Street,— '
V
'
VSuite __
‘
City -, State ZIP
eFederalTaxID: , 5 'V, TPI: _. , NPIIAPi:
3. Name: .'
. ' __
SocialSecnrityNtilnber:7 . naceorbinnmim/on/vvfw—*.
S
‘ 1?1iv63.°“l“d“'=ss=1
~~ ; T i.1.
1
. S
7* ‘I
V , Nuinber Street _'
_ X ‘ Suite , City State’ ZIP
_—iiedVerglTaxID: TPI: .4 , _ NPI/1151:’4. Name: *
‘
_‘
_ _ ~ Social SecurityNumbcr:'
‘’Date.ofbirtl1:MM/DD/Y_Y,YY
NY} NPr N1}‘ Physicnladdress: _ : '
' '
' V‘ I
V
Number Street , _ Suite ~
, City State ZIP
_FederalTaxID: TPI:‘
. N91/A?:mun ASTATE MEDICAID CONTRACTOR Pa9e4 P":-2
F00112 Revised 12/18/2017 I Effective 01/01/2018
“Sanction” is de?ned as,reconpmenl;{pey|nenthold, Imposition of penalties nrldyalnhges,contractcancellations,, exclusion, delxarmem, suspension, revocation,or anyrotherysynonyrnonsaction. '
‘
1'
'
l-laveyou everbeen sanctioned (as de?ned abloveflnanystate federaliprogramil V
Yes No
IfYes.fully explain thedetails, includingdate, the state wherethe incidentoccurred, the agency taking theaction, and theprogram a?ected.(attachadditional sheetsifnecessary)
rlsynnrprofessinnallicenseorlcerllilicatinncurrentlyr‘e'v'zoked,lsnspendedorntherwiserestricted? Yes J2/Noptherwiserestricted?V
V
. . _ Iyes No
Areyoucurrently,or have you ever been, subjectto a licensing orcerti?cationbeardlo "’ ‘ ''
'
K ' '
‘ Yes moYes: s
l
yllayeyou ey liedyour professional licenseor certi?cationlrevoked,lsnspendedi
Hatyeyo‘
voluntarilysurrenderedyour professional licensenrpertl?catlon in it(Yau
‘'y besubjectto alicenseor certi?catianveri?cation/statuscheckwithyourlic
IfYes was answered to any afthesequestions, fully explain thedetails, includingdate, the state wherethe incidentoccurred.name ofthe board or agency, and any adverseaction against your license.(attach additional sheetsifnecessary) ‘
‘,Areynu cllrrentlyor haveyonever been subject to the tennisof a settlen-tent,agreemen,__cnrpuratecompliance‘
, 3 '
V» *3.-‘
' igreementor corpiirate ' agreement in relation to any State or Federally funded program?’'‘
- YES M0 "
l
debtin relationtoany Stateor Federallyfundedprogram?l
‘
Yes °.Do you fcunentljihnveQ
IfYes was answered to any afthesequestions, fully explain the details, includingdate, the state wherethe incidentuccurred,and name ofthe board or
agency. (attach additionalsheetsifnecessary)
_Toanswerthisauestien,inset _ edicarerde?nitiunof“Convicted”in42:CFR.V
l _descr'be_lal1o\{e,;and.whichincladesdeferredadjudication'_ndal thertypesofpretrialdiversionpragrams.‘Youmay bembyecttq' criminalhistory, ,
Yes net’-V310-I
IfYes.fully explain the details, includingdate, thestate and county wherethe conviction occurred.thecause number(s).and speci?callywhatyou were convictedof{attach additianal sheets necessary) V
VITM!-LP A STATE MEDICAID CONTRACTOR Page 5 PIF-2
F0O112 Revised 12/18/2017 I Effective01/01/2018
Are you cur}-entlyesulyjecttocourt ordered childsupyort payments?_
' _,. ‘ '
'
l
: Yes W9IfYes.pleaseprovide details.
Trmoreon court orderedchildsinpportpayments?_
*
; _ » Yes Z‘:V you currently behind'30’da‘y'_
IfYes, provide detailsofhowthesepast-duepayment obligationswillbemet. (attach additional sheetstfnecessury)
0
SK
' Are you a citizen oftheUniiedétatesé‘
1 -V 1
‘ _Yes
IfNo, provide the country ofwhichyou are a citizen.
If you :13:non:ciizliciiofthe United States, do you havea legal right to workin the United States? , . ,
V
[fYcs.attach ('1copybfyour greenraird,visa, or otherdocumentationdemonstratingyour right tu resideand workin the, Yes — NoUnitedStates. , . V
'
V
‘ ‘
:1P|F—2TMHP A STATE MEDICAID CONTRACFOR Page 6
F00112 Revised 12/18/2017 | Effective 01/01/2018
MEDICAID PROVIDER AGREEMENT
I. APPLICANT/PROVIDERINFORMATION
(2) Business ‘Name(if different than legalname)
(1) Legal nameorapplicantor- [provider (hereinafter,jointly
* referred to‘ as the f“Provider”)
gKmn€'\[évecnjifl Kmrr:(L‘['ouniLL.L
L(3) Natl’ nal y"Provier Identi?er (4) ,TaxpayerID o.(NPI) r v Atypical Provider I '
FIdenti?er(API)' W 7 .;‘«
I zp 90:3’(5) “ 7.Medicaid _'fappIicable)_ (6) . MedicareproviderIDnumber: (if "
«
‘” ' applicable)‘ '
A
*
S5éoj:n?‘0@ /K144’Provider, named in Section 1.1 of this Medicaid Provider Agreement (the “Agreement”) as a
condition of enrollment or continuedenrollmentas a provider under the Texas Medical AssistanceProgram (Medicaid), agrees to comply with all of the following terms and conditions of thisAgreement.
II. LEGALAUTHORITY
This Agreement between Provider and the Health and Human Services Commission (HHSC)is authorizedby, and in compliance with, the provisions of the Code of Federal Regulations(CFR), 42 CFR § 431.107 and the Texas Administrative Code (TAC), l TAC §§ 352.5 and352.7.
III. TERM
The effective date of this Agreement is the date stated in the providerenrollmentnoti?cation letter
sent by HHSC or its designee to Provider. The Agreement will end on the date stated in such
provider enrollmentnoti?cation letter, unless terminatedsooner in accordancewith any of the terms
set forth in Article X of this Agreement (relating to Termination). Provider must revalidate for
enrollment in Medicaid and obtain a new Medicaid Provider Agreement when required. Provider
understands and agrees that no HHSC signature is required to make this Agreement valid and
enforceable.
IV. REQUIREMENTS-ALLPROVIDERS
4. 1 COMPLIANCEWITH LAWS,REGULATIONS,RULES,POLICIESAND PROCEDURESRELATING
y
i
4.2
4.3
T0 MEDICAID.(a) Provider, its employees, and its agents must comply with the requirements of the
Texas MedicaidProvider Procedures Manual (Provider Manual) as applicable,as well as
all state and federal laws and rules,regulations,governing or regulating Medicaid, as they
may be amended from time to time. ProviderManual may be accessedvia the internet at
www.tmhp.com. Provider must comply with Title 1,Part 15,Chapter 352 of the Texas
AdministrativeCode (TAC).(b) Provider is responsible for ensuring that the Provider, its employees and its agents
comply with the requirements of Title 1,Part 15, Chapter 371 of the Texas AdministrativeCode, related to fraud and abuse program integrity. Provider and its principalswill beheld responsible for violationsof this Agreement through any acts or omissionsof the
Provider, its employees,and its agents.(c) For purposes of this Agreement, a principal (Principal)of the Provider,
includes all owners with a direct or indirect ownership or control interest of ?ve percent
or more; all corporate o?icers and directors; all limited and non-lirnitedpartners; allshareholdersof a legal entity, including a professionalcorporation, professionalassociation, or limited liability company; and managing employee(s)or agents who
exercise operationalor managerial control or who directly or indirectly manage the
conduct of day-to-day operations.((1)Provider must comply with any change in federal or state laws, regulations, rules or
policy that modi?es any term of this Agreement on the date such a change in statutes,
regulations, rules or policy becomes effective.
MEDICARECERTIFICATIONOR ENROLLMENT.Provider must be actively enrolled in Medicare or certi?ed by Medicare (if applicable), or
both, unless otherwise speci?ed by HHSC or its designee or speci?cally exempted inaccordancewith 1 TAC § 352.13.
LICENSE,CERTIFICATION,on ACCREDITATION.Provider must be licensed, certi?ed, or accredited to the extent required by state and federal
laws, regulations, statutes, rules, and policy to enroll or re-enroll in Medicaid.Providermust
be in good standing related to its licensure, certi?cation, and accreditation throughout the
term of this Agreement.
4.4 OUT-OF-STATEPRovmERs.Out-of-State Providers must meet the requirements for out-of-state provider eligibility inaccordancewith 1 TAC § 352.17.
4.5 EXCLUSION,SUSPENSION, DEBARMENT, REVOCATION OR OTHER ACTION.
Provider and its principals must not be excluded, suspended,debarred, revoked or any other
synonymous action from participationin any program under Title XVIII (Medicare),TitleXIX
(Medicaid), or under the provisions of Executive Order 12549, relating to debarment and
suspension. Provider andits principalsmust not be excluded, suspended,debarred, revoked or
any other synonymous action from participation in any other state or federal health-care
program. Provider must notify HHSC or its designee within ten business days of the time it
receives notice that any action is being taken against Provideror any person de?ned under the
4.6
4.7
provisions of Section 1128(A) or (B) of the Social Security Act (42 USC §l320a-7), whichcould
result in exclusionfrom the Medicaidprogram. Provider must fully comply at all times with the
requirements of 48 CFR, Ch. 3, relating to Health and Human Services.
SCREENINGEXCLUDEDPARTIES.
Provider must Searchthe U.S, Department of Health and Human Services (IHIS) Office of the
Inspector General (OIG) (HHS-OIG), or any successor agency’s, List of ExcludedIndividuals/Entities (LEIE) and website, and the HHSC-Office of Inspector General (OIG), or
any successor agency’S Exclusions Database website to determine if any of Provider's
prospective or current employees, suppliers, and contractors have been excluded from
participation in Medicare, Medicaid, the State Children’s Health Insurance Program or any
other federal and state health care program since the last search, and to immediately report to
HHS-OIG and HHSC-OIG any exclusion information the Provider discovers. Exclusionary
searches for prospective employees, suppliers, or contractors shall be performed prior to
employment or contracting. Except as provided under 42 CFR l00l.l90l(c), no Medicaidpayments will be made for any items or servicesdirectedor prescribedby a physician or otherauthorizedperson whois excluded from Medicare, Medicaidor any other federal or state health
care program when the individual or entity furnishing the items or services either knew or
shouldhave known of the exclusion.This prohibitionapplies even when the Medicaid payment
itself is made to anothercontractor, practitioner,provider, or supplier who is not excluded.See
42 CFR 100l.190l(b). Additionally, Provider shall be subject to: (1) civil monetary penalties
if it employs or enters into contracts with excluded individuals or entities; and (2) any otherremedies or sanctionsavailable under federal or state law.
DISCLOSUREBY PROVIDERSREGARDING SUBCONTRACTORSAND SUPPLIERS.(a) In accordancewith 42 CFR.455.lO5, Provider must submit, within 35 days of the date of
a request by the Secretary of the United States Department of Health and Hmnan Servicesor HHSC, full and complete information about the ownership of any subcontractorwithwhom the Providerhas had business transactionstotaling more than $25,000.00 during the
12monthperiod ending on the date of the request; and any signi?cant business transactionsbetween the Provider and any wholly owned supplier, or between the Provider andsubcontractorduring the ?ve-year period ending on the date of the request.
(b) In accordancewith 42 CFR Part 455, Federal Financial Participation is not available for
providers who fail to comply with a request made by the Secretary or HHSC.
4.8 DISCLOSUREBY PROVIDERSREGARDINGINFORMATIONON PERSONSCONVICTEDOF
CRIMES.(a) In accordancewith 42 CFR §455. 106, Provider Shall disclose information on persons
convictedof crimes as follows:(1) INFORMATIONTHAT MUST BE DISCLOSED. Before the Provider is enrolled, has its
enrollmentrevalidated, or at any time upon request by HHSC, Providermust discloseto HHSC the identity of any person who:i. Has ownership or control interest in the Provider, or is an agent or managing
employee of the provider; and
ii.Hasbeen convicted of a criminaloffense related to that person’s involvement in any
program under Medicare, Medicaid or the title XX servicesprogram since the
inception of those programs.(b) Provider must disclose all convictions of Provider or Provider’sprincipalswithin ten
business days of the date of conviction. For purposes of this disclosure, Provider must
use the de?nition of “Convicted” contained in 42 CFR 1001.2,which includes all
convictions, deferred adjudications, and all types of pretrial diversionprograms. Providermust?illyexplainthe details, including the offense, the date, the state and county where the
convictionoccurred, and the cause number(s). Information must be sent in writing to the
following address:
Texas Health and Human Services Commission—Of?ceof Inspector GeneralP.O. Box 85211 — Mail Code 1350Austin, Texas 78708
4.9 INFORMATIONPROVIDEDTO HHSC.
4.10
4.11
(a) Provider certi?esthat it reviewed all of the information submitted in connectionwith its
application to participate in the Medicaid program, including the Provider infonnationfonns (PIF-1) and principal infonnation form (P117-2),and Provider certi?es that thisinfonnation is current, complete, and correct.
(b) As a condition of continuedenrollment, Provider must keep information submittedas part
of its application for participation in the Medicaidprogram current at all times by informing
HHSC or its designee in writing of any changes to the information contained in its
application, including, but not limited to, changes in ownership or control, federal tax
identi?cation number, Provider licensure, certi?cation, or accreditation, phone number, or
Providerbusiness addresses.Changes due to a change of ownership or controlinterest must
be reported to HHSC or its designee within 30 days of the change. All other changes must
be reported to HHSC or its designee within 90 days of the change.(c) HHSCor its designee may review Provider’s applicationany time after the applicationhas
been accepted and for the term of this Agreement. Upon review, HHSC or its designee may
determine that the information contained therein does not meet the Medicaid program
enrollment requirements. Information supplied by the Provider is material to the
determinationas to whether or not the Provider is eligible to participate in the Medicaid
Program. Any material misrepresentationshall constitute good cause for the terminationof the Provider, and Provider may no longer be eligible to participate in the Program.
Provider may have the opportunity to correct any errors or omissions as determined by
HHSC or its designee within a timeframe designatedby HHSC or its designee.
SURETYBOND.As applicable,the Providermust maintain a current surety bond for each enrollmentlocation, in accordancewith 1 TAC § 352.15.
RECORDKEEPING.In accordance with 42 CFR § 431.107,Providermust create and maintainall recordsnecessary
to disclose the extent and medical necessity of services the Provider furnishesto clients or
membersin the Medicaid program and any information relating to payments claimed by the
Provider for furnishing Medicaid services. On request, Provider also agrees to provide these
records immediately and unconditionally to HHSC, HHSC’s designee, the Texas AttorneyGeneral’ s MedicaidFraudControl Unit, theDepartmentofFamilyandProtectiveServices(DFPS),
theDepartmentof StateHealthServices(DSHS), and the United States Department of Health andHuman Services. Providers must provide this information to HHSC contractors andsubcontractors as directedby HHSC. The records must be retained in the form in which they
are regularly kept by the Provider for a minimum of seven years from the date of service (ten
years for hospital based rural health clinics); the individual about whom the records relate
becomes 21 years of age; or, until all audit questions, administrativehearings, investigations,court cases, or appeals are resolved; whicheverperiod is longest.
4.12 FRAUD,WASTE,AND ABUSE.Provider must cooperate and assist HHSC and any state or federal agency charged with the
duty of identifying, investigating, sanctioning, or prosecuting suspected fraud, waste, and
abuse. Provider must also allow these agencies and their designees unconditional and
unrestricted access to its records and premises as required by Title 1 TAC § 371.1667.HHSC
payment for goods and servicesunder this Agreement is conditionedupon the existence and
accessibility to HHSC of all records required to be maintainedunder the Medicaidprogram,including all records necessary to fully disclose the extent and medical necessity of servicesprovided, and the correctness of the claim amount paid. If Provider fails to create, maintain,or produce such records in full accordance with this Agreement, HHSC may seek fullrecoupment, and Provider will be ineligible for payment for the services either under this
Agreement or under any legal theory of equity.
4.13 AUDITS.
4.14
The Texas Attorney General’s Medicaid Fraud Control Unit, HHSC’s Office of Inspector
General (OIG), and internal and external auditors for the state and federal government may
conduct interviews of Provider employees, agents, subcontractors, and their employees,witnesses, and clientsor members without the Provider’s representative or Provider’s legal
counselpresent. Provider’s employees, agents, subcontractors and their employees,witnesses,
and clientsor members must not be coercedby Provider or Provider’s representativeto accept
representation from or by the Provider, and Provider agrees that no retaliationwill occur to a
person who denies the Provider’s offer of representation. Nothing in this Agreement limits a
person’sright to counselof his or her choice. Providersmust complywithrequests for interviews
in the form and the manner requested. Provider must ensure by contract or other means that
its agents, employees and subcontractors cooperate fully in any investigation conductedby
the Texas Attorney General’s Medicaid Fraud Control Unit or the OIG or its designee.
Subcontractors include those persons and entities that provide medical or dental goods or
services for which the Provider bills the Medicaid program, and those who provide billing,
administrative, or management services in connection with Medicaidcovered services.
Cosr REPORT,AUDITAND INSPECTION.Provider must comply with all state and federal laws andrulesrelating to the preparation and
?ling of cost reports, audit requirements, and inspection and monitoring of facilities, quality,utilization, and records.
4.15
4.16
4.17
4.18
SITEVISITS.
Centers for Medicare and Medicaid Services (CMS), its agents, its designated contractors,
or HHSC or its designees may conductunscheduled and unannounced site visits. A failureto permit a site visit by CMS, its agents, its designees or HHSC or its designees shall begrounds for termination of this Agreement.
NONDISCRIMINATION.Provider must not exclude or deny aid, care, service, or other bene?ts available underMedicaid or in any other way discriminateagainst a person because of that person’s race,color, national origin, gender, age, disability, political or religious affiliation or belief.Provider must provide services to Medicaid members or clients in the same manner, by the
same methods, and at the same level and quality as provided to the general public. Providermust grant Medicaid recipients all discounts and promotionaloffers provided to the generalpublic. Free services to the general public must not be billed to the Medicaid program forMedicaid members or clients and discounted servicesto the generalpublicmust not be billedto Medicaid for a Medicaid memberor clientsas a full price, but rather the Provider must bill
only the discountedamount that wouldbe billed to the generalpublic
AIDS and HIV.Provider must comply with the provisions of Texas Health and Safety Code Chapter 85, and
HHSC’s rules relating to workplace and con?dentiality guidelines regarding HIV and AIDS.
CLAIMSANDENCOUNTERDATA.(a) Provider must submit claims for payment in accordance with billing guidelines and
procedures promulgated by HHSC, or other appropriatepayer, including electronicclaims.Provider must ensure that information submitted regarding claims or encounter data is
true, accurate, and complete, and that the Provider’s records and documents are bothaccessible and validate the services and the need for services billed and represented as
provided. HHSCmayreferanyfalsi?cation or concealmentof a materialfact for prosecutionunder state and federal laws.
(b) Provider must submitencounter data required by HHSC or any managed care organizationto document services provided, even if the Provider is paid under a capitated fee
arrangement by a Health Maintenance Organizationor Insurance Payment Assistance.(c) All claims or encounters submitted by Provider must include the Provider’s National
Provider Identi?er (NPI) or, as applicable, Atypical Provider Identi?er (API), and be forservices actually renderedby Provider, with the following exception.PhysicianProvidersmust submit claims for services rendered by another in accordance with HHSC rules
regarding Providers practicing underphysician supervision.Claims must be submittedinthe manner and in the form set forth in the Provider Manual, as applicable, and withinthe time limits establishedby HHSC for submission of claims. Claims for payment or
encounter data submitted by the Provider to a Managed Care Organization (MCO),Health MaintenanceOrganization (HMO) or IndependentPracticeAssociation (IPA) are
governed by the Provider’s contract with the MCO, HMO or IPA. HHSC is not liable or
responsible for payment for any Medicaid covered services provided under the MCO,
HMO or [PA Provider contract, or any agreement other than this Medicaid ProviderAgreement.
(d) Provider is prohibited by federal and state law ?om charging a member or clientor any
?nancially responsible relative or representative of the clientor member for Medicaidcoveredservices, except where a co-payment is authorizedunder the MedicaidState Plan
(42 CFR §447.20).(e) As a condition of eligibility for Medicaid bene?ts, a client or member assigns to HHSC
all rights to recover from any third party or any other source of payment (42 CFR §433.145
and Human Resources Code §32.033). Provider must accept the amounts paid under
Medicaidas payment in full for all covered services (42 CFR § 447.15), except as providedby HHSC’s third-partyrecovery rules (Texas Administrative Code Title 1 Part 15 Chapter
354 Subchapter J).(1') Providermust verify that claimsandencounters submittedforpayment are true and correct
and are receivedby HHSC or its designee, and must implement an effective method to
track submittedclaimsagainst payments made by HHSC or its designees.(g) Providermust verify thatpayments received are for actualservicesrenderedandmedically
necessary. Provider must refund any overpayments, duplicate payments and erroneous
payments that are paid to Provider by Medicaid or a third party as soon as any such
payment is discoveredor reasonably shouldhave been known.
V. ADVANCEDIRECTIVES-NURSINGFACILIrIEs, HOMEHEALTHCARE
PROVIDERS, PERSONAL CARESERVICESPROVIDERS,AND HOSPICES
5.1 Provider must comply with the provisions of 42 CFR § 431.107?))(4), regarding advanced
5.2directives requirements.Providermust maintain writtenpolicies andproceduresconcerningadvancedirectivesin
compliancewith state and federal laws.5.3 The clientormember must be informed of their right to refuse, withhold, or have medical
5.4
treatment withdrawnunder the following state and federal laws:(a) The individual’s right to self-determinationin making health-caredecisions;
(b) The individual’s rights under the Natural Death Act (Health and Safety Code, Chapter166) to execute an advance written Directive to Physicians, or to make a non-writtendirective regarding their right to withhold or withdraw life-sustaining procedures in the
event of a terminalcondition;(c) The individual’srights underHealth and Safety Code, Chapter 166,relating to written
Out-of-HospitalDo-Not-ResuscitateOrders; and,(d) The individua1’srights to execute a DurablePower of Attorney for Health Care under the
ProbationCode, ChapterXII, regarding their right to appointan agent to make medicaltreatment decisionson their behalf in the event of incapacity.
Providermust document whetheror not the individualhas executedan advance directive and
ensure that the documentis in the individual’s medicalrecord.5.5 Providercannot conditiongiving servicesor otherwisediscriminateagainst an individual
5.6based on whether or not the client or member has or has not executedan advance directive.
The Providermust provide written information to all adult clientsor members on the
Provider’spolicies concerning the client or Member’s rights.5.7 The Providermust provide educationfor staff and the community regarding advance
directives.
VI. STATEFUNDCERTIFICATIONREQUIREMENTFORPUBLIC ENTITYPROVIDERS
6.1 Public Providers are those that are owned or operated by a state, county, city, or other localgovernment agency or instrumentality. Public entity Providers of the following services mustcertify to HHSC the amount of state matching ?inds expended for eligible services accordingto established HHSC procedures:(a) School health and related services(SHARS);(b) Case management for blind and visually impaired children (BVIC);(c) Case management for early childhoodintervention (ECI);(d) Servicecoordinationfor intellectual and developmental disabilities (IDD);(e) Service coordinationfor mental health (MH);(1) Mental health rehabilitation (MHR);(g) Tuberculosis clinics; and(I1)State hospitals.
VII. STAFF AND SUBCONTRACTORS-HOME AND COMMUNITY SERVICE
SUPPORT SERVICESAGENCY
7.1 If Provider is a Home and Community Support Services agency O-ICSSA),Provider must hirePersonalAssistance Services and Support Services providers chosen by the client or memberor the client or member’s legally authorizedrepresentative, if requested, and provided theindividualwho will provide the services:(a) meets minimum requirements for the service;(b) is willing to be employed as an attendantby the Provider; and(c) is willing and determinedcompetent by the Provider to deliver one or more of the
services according to the clients or members individual service plan.
VIII. CLIENTOR MEMBERRIGHTS
8.1 Provider must maintain the client or member’s state and federal right of privacy andcon?dentiality to the medical and personal information containedin Provider’s records.
8.2 Providers cannot not restrict the client or member’s right to choosea Provider unless that right
8.3
has been restrictedby HHSC or by waiver of this requirementfrom CMS. Providermustensure
thatthe clientor member’s acceptance of any service is Voluntary.Provider cannot restrict the client or member’s right to chooseany qualifiedProvider of familyplanning services.
IX. THIRDPARTYBILLINGVENDOR PROVISIONS
9.1 In accordance with 1 TAC § 352.5 (b)(9), Provider must ensure that, if a third-party billingvendor (Biller) is used for claim submission, the third—partybilling vendor is registered withHHSC pursuant to l TAC § 354.1187, relating to Responsibilities of Third Party BillingVendors. Provider must submitnotice of the initiation and termination of a contract with
any person or entity for the purpose of billing Provider’s claims, unless the person issubmitting claims as an employeeof the Provider and the Provider is completing an IRSForm W-2 on thatperson. This notice must be submitted within ?ve working days of theinitiation and terminationof the contract and submitted in accordance with Medicaidrequirements pertaining to Third Party Billing Vendors.Any delay in the required submittaltime or failure to submit may result in delayed payments to the Provider and recoupment fromthe Provider for any overpayments resulting from the Providers failure to provide timelynotice.
9.2 Provider must have a written contract with any personor entity for the purpose of billingProvider’s claims, unless the person is submitting claims as an employeeof the Provider andthe Provider is completing an IRS Form W-2 on that person. The contract must be signed anddated by a Principal of the Provider and the Biller. It must also be retained in the Provider’s andBiller’s ?les according with the Medicaid records retention policy. The contract between theProvider and Biller may contain any provisions they deem necessary, but, at a minimum,must contain the following provisions:(a) Biller must not alter or add procedures, services,codes, or diagnoses to the billing
information received from the Provider, when billing the Medicaid program.(b) Biller may be criminally convicted and subject to recoupment of overpayments and
imposed penalties for submittal of false, fraudulent, or abusive billings.(c) Provider must submit to Biller true and correct claim information that contains only those
services, supplies, or equipmentProvider has actually provided to recipients.(d) Provider may be criminally convicted and subject to recoupment of overpayments and
imposed penalties for submittal of false, fraudulent, or abusive billings, directly orindirectly, to the Biller or to Medicaidor its contractor.
(e) Provider and Biller must not establish a reimbursement methodology to Biller thatcontains any type of incentive, directly or indirectly, for inappropriately in?ating, in anyway, claims billed to the Medicaidprogram.
(f) Biller must enroll and be approvedby the Medicaid program as a Third Party BillingVendor prior to submitting claims to the Medicaid program on behalf of the Provider.
(g) Biller and Providermust notify the Medicaidprogram within ?ve business days of theinitiation and termination, by either party, of the contract between the Biller and theProvider.
X. TERMINATION
10.1 Correspondence/notice of enrollment from HHSC or its designee states a termination date; thisAgreement terminates on that date with or without other advancenotice of the termination date.
10.2 Provider may terminate this Agreement by providing at least 30 days writtennotice to HHSC ofintentto terminate.
10.3 HHSC may terminate this Agreement without cause at any time, when, in its sole discretion,HHSC determines that termination is in the best interests of the state of Texas. Reasons fortermination may include, but are not limited to circumstances listed below, and which mayinclude the actions or circumstances involving the Provider or any person or entity with anaf?liate relationship to the Provider:(a) failure to meet the requirements of participation for the category of service provided;
(b) failure to repay an overpayment;(c) failure to provide true and accurate information on claims;(d) failure to comply with site visits;(e) the exclusionfrom participation in Medicare, Medicaid, or any other publically funded
health-care program;(i) the loss or suspension of professional license or certi?cation;(g) any failure to comply with the provisions of this Agreement or any applicable law, rule,
regulation, or policy of the Medicaid program;(h) any circumstances indicating that the health or safety of clientsor members is or may be at
risk, including abuse, neglect or exploitation;(i) the circumstances for termination listed in 42 C.F.R. § 455.416,as amended; an
(j) thecircumstances for termination listed in 1 T.A.C. §§§37l.l703, 371.1705,and 371.1707,as amended;
(k) upon further review of the Provider’s application, at any time during the term of thisAgreement, HHSC or its designee, determines Provider is ineligible to participate in theMedicaidprogram; and the errors or omission cannot be corrected;
(1) if the Provider has not submitted a claim to the Medicaid program for at least 24 months;(m) the Provider or a controlling person of the provider is listed on:
(1) the HHSC employee misconductregistry as unemployable;(2) the nurse aide registry as revoked or suspended;(3) the UnitedStatesSystemforAwardManagementmaintainedby the GeneralServices
Administration;(4) the Listof ExcludedIndividualsand EntitiesDatabasemaintainedby the UnitedStates
Depanmentof HealthandHuman Services,O?ice of InspectorGeneral;(5) the Exclusions Database maintained by the Texas Health and Human Services
Commission-Office of Inspector General;(6) the DebarredVendor List maintained by the Texas Comptroller of Public Accounts
and the period of debarmenthas not expired;(7) HHSC’s debarrnent list;(8) any other applicable database.
(11)Provider is required to register with the Texas Secretary of State and the provider’s statuswith the Secretary of State is “not in existence,”
(0) Provider or a controlling person of the Provider has been con?rmed by the Department ofFamily and Protective Services as having committedabuse, neglect or exploitation;
(p) any other circumstancesresultingin Provider’s ineligibility to participate in the Medicaidprogram.
10.4 HHSC will provide written noti?cation of the termination of the Agreement and any rights toappeal HHSC’s determinationwill be includedwith the notice of termination.
XI. ELECTRONICSIGNATURES11.1 Provider’s signature on a document submittedto HHSC certifies, to the best of the Provider’s
knowledge, the information in the document is true, accurate, and complete. Documentssubmittedto HHSCwith electronic signatures may be accepted by mail or fax when the senderhas met the national and state standards for electronic signatures set by HHSC and the TexasUniform Electronic TransactionsAct (UETA).
10
11.2 Both Provider and the Provider’s representative whose signature is on an electronic signaturemethod bear the responsibility for the authenticity of the information to whichthe ProviderandProvider’srepresentativeare certifying.
XII. COMPLIANCEPROGRAMREQUIREMENT
Provider must have a compliance program, or be employed by or be a performing Provider for aTexas Medicaid Provider that has a compliance program, containing the core elements asestablishedby the Secretary of Health and Human Services referenced in § l866(j)(8) of the SocialSecurity Act (42 U.S.C. § l395cc(j)(8)), as applicable.
I attest I have a compliance plan. Yes?oElA
XIII. INTERNALREVIEWREQUIREMENT
Providermust ensure that neither Provider, nor any of its employees, owners, managing partners, orcontractors (as applicable), have been excluded from participation in a program under Title XVIII,XIX, or XXI of the Social Security Act.
If the applicant is enrolling as a performing Provider for a Texas MedicaidProvider, the applicantneed only attest to the applicants own status.
I attest that an internal review was conducted to confirm that neither the applicant or the re-validating provider nor any its employees, managing partners, or contractors (as applicable), havebeen excluded from participation in a program under Title XVIII, XIX, or XXI of the SocialSecurity Act.
y(esElNo
14.1 “Con?dential Information” means any communication or record (whether oral, written,electronically stored or transmitted, or in any other fonn) provided to or made available tothe Provider electronically or through any other means that consists of or includes any or allof the following:
(a) Protected Health Information in any form including without limitation,ElectronicProtected Health Information or Unsecured ProtectedHealth Information (as de?ned in45 CFR 160.103and 45 CFR 164.402);
(b) Sensitive PersonalInformation (as de?ned in Texas Business and Commerce Codesection521.002);
(c) Federal Tax Information (as de?ned in IRS Publication 1075);(d) Personally Identi?able Information (as de?ned in OMB Memorandum M-07-16);(e) Social Security Administration data; and(I) All information designated as con?dential under the constitution and laws of the state of
Texas and of the United States, including the Texas Health & Safety Code and the TexasPublic Information Act, Texas Government Code, Chapter 552.
XIV. PRIVACY,SECURITY, AND BREACHNOTIFICATION
ll
14.2 Any Con?dential Information received by the Provider under this Agreement may only be
14.3
14.4
15.1
15.2
disclosedin accordance with applicable law. By signing this agreement, the Provider certi?esthat the Provider is, and must remain for the term of this agreement, in compliance with allapplicable state and federal laws, rules, regulations and guidance (and amendmentsthereto)with respect to privacy, security, and breach noti?cation, including without limitation thefollowing:(a) The relevant portions of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), 42 U.S.C. Chapter 7, Subchapter XI, Part C;(b) 42 CFR Part 2 and 45 CFR Parts 160 and 164;(c) The relevant portions of The Social Security Act, 42 U.S.C. Chapter 7;ThePrivacy Act of
1974,as amended by the Computer Matching and Privacy Protection Act of 1988, 5U.S.C. § 552a;
(d) Internal Revenue Code, Title 26 of the United States Code, including IRS Publication1075;
(e) OMB MemorandumM-07-l 6;(0 Texas Businessand Commerce Code Chapter 521;(g) Texas Health and Safety Code, Chapters 181and 611;(h) Texas Government Code, Chapter 552, as applicable; and(i) Any other applicable law controlling the release of information createdor obtained in the
course of providing the services described in this Agreement.Provider will comply with all amendments, regulations, and guidance relating to those laws,to the extent applicable.Provider must ensure that any subcontractor of Provider who has access to HHSC
Con?dential Information signs a HIPAA-compliant Business Associate Agreement withProvider and Provider must submit a copy of that Business AssociateAgreement to HHSCupon request.
XV. NIISCELLANEOUS
REPORTINGFRAUD,WASTE,AND ABUSE.Provider must inform and train all of Provider’s employees, agents, and independentcontractors regarding their obligation to report fraud, waste, and abuse. Individuals withknowledge about suspected fraud, waste, and abuse in any HHSC program must report theinformation to the Texas Health and Human Services Commission’s-Office of InspectorGeneral. To report fraud, waste, and abuse Providers may go to www.oig.hhsc.texas.govandselect "Report Fraud” or call the Inspector General’s hotline (1-800-436-6184)to report fraud,waste and abuse.
DEFICIT REDUCTIONACTor 2005, SECTION6032.If Provider receives annualpayments of at least or totaling $5,000,000.00from HHSC or its designee, Provider shall stablish written policies for all its employees(including management), and its contractor or agents that provide detailedinformation about:(a) the False Claims Act established under sections 3729 through 3733 of Title 31 United
States Code; and
12
(b) and state laws pertaining to civil and criminal penalties for false claims and statements,
and whistleblowers protections under such laws with respect to the role of such laws in
preventing and detecting ?aud, waste, and abuse in federal health care programs, as
de?ned in Section 1l28(b)(t).
Provider shall include as part of such policies, detailed provisions regarding the Provider’s
policies or guidelines and procedures for detecting fraud, waste and abuse; and
Provider shall include in any employee handbook for the Provider, a speci?c discussion of
the laws discussedin sections 15.2 (a) and l5.2.(b) of this Agreement, the rights of employees
to be protected as whistleblowers and the Provider’s policies and procedures for detecting
and preventing fraud, waste and abuse.
15.3 ASSIGNMENTProvider may not assign, transfer, or convey this Agreement, in whole or in part, without theprior written consent of HHSC, which may withheld or granted at the sole discretion ofHHSC. Except where otherwise agreed in writing by HHSC, assignment will not releaseProvider from its obligations under the Agreement.
15.4 SOVEREIGNIMMUNITY.Nothing in this Agreement or any conduct by a representative of HHSC or its designeesrelating to this Agreement shall be construedas a waiver of the state’s sovereign immunity to
suit.
15.5 BANKRUPTCY.Provider must notify HHSC or itsdesigneeif the Provider ?les or is the subject of a bankruptcypetition. TheProvider must provide HHSC or itsdesigneewith notice of the bankruptcy no
later than ten days after the case is ?led. The Providermust serve HHSC or itsdesigneewithall pleadings Provider?les in the case.
15.6TITLEs.The titles of the provisions to this Agreement are for reference only are not to be consideredin interpreting this Agreement.
15.7 ELECTRONICSIGNATURES.Provider’s signature on a document submittedto HHSC certi?es, to the best of the Provider’sknowledge, the information in the document is true, accurate, and complete. DocumentssubmittedtoHHSCwithelectronic signaturesmay be acceptedby mailor fax when the senderhasmet the national and state standards for electronic signatures set by HHSC and the TexasUniform Electronic TransactionsAct (UETA).
Both Provider and the Provider’s representative whose signature is on an electronicsignaturemethod bear the responsibility for the authenticity of the information to whichthe ProviderandProvider’srepresentativeare certifying.
13
15. 8 GOVERNINGLAW AND FORUMThis Agreement shall be governed and construed in accordance with the laws of the state ofTexas without reference to its con?icts of law provisions. Provider consents to personaljurisdiction in the state of Texas.
15.9 INDEMNIFICATIONProvider will indemnify, defend, and hold harmless HHSC, its of?cers, agents, designees andemployees, from any loss, damage, claim, liability or expense arising out of Provider’sperformance as a Texas Medicaidlong-terrnservices and supports Provider, except that Providerwill not be liable for the negligence or willful misconduct of HHSC.
15.10 INDEPENDENTCONTRACTORProvider is, and will be an independent contractor without authorization,express or implied, to
bin HHSC or the state of Texas to any agreement, settlement, liability or understandingwhatsoever.
15.11 SUPERSEDINGEFFECT r
On its effective date, this Agreement supersedes and replaces any existing agreements or
contracts previously executed by Provider to provide long-termservices and supports through aTexas Health and Human Services (HHS) agency. This Agreement does not impair Provider’sobligation to repay HHSC any money owed to HHSC pursuant to prior agreements or contracts
with HHSC or other Texas HHS agency, or the ability of HHSC to recoup such amounts frompayment made pursuant to this Agreement.
15.12 INCORPORATIONOF DOCUMENTProvider agrees that the provider enrollment noti?cation letter is incorporated by referenceinto this Agreement
XVI. ACKNOWLEDGEMENTSAND CERTIFICATIONS
By signing below, Provider acknowledges and certifies to all of the following:16.1 Provider acknowledges and certi?es that Provider understandsthe requirements of this
Agreement and must comply all of its terms and conditions.
16.2 Provider acknowledges and certi?es that Provider understandsthat falsifying entries,concealment of a material fact, or pertinent omissions may constitute fraud and may beprosecuted under applicable federal and state law. Fraud is a felony, which can result in ?nesor imprisonment.
16.3 Provider acknowledges and certifies that HHSC may declare an overpayment and seekrecoupment for any and all paid services,as well as seek other administrativeremediesincluding payment hold, exclusion, debairnent, termination of this Agreement, and monetary
penalties, as a result of any falsi?cation, omission, or misrepresentation in connection withthe Provider’s application for enrollment or with claims ?led by the Provider.
16.4 Provider acknowledges and certi?es that Provider must abide by all
14
Medicaid state and federal laws, rules, regulations, policy program instructions, and TitleXIX of the Social Security Act. The state and federal Medicaid laws, rules regulations,policy and program instructions are available through the Medicaid contractor. Providerunderstandsand acknowledges that payment of a claim by Medicaid is conditionedupon
the claim and the underlying transaction complying with such state and federal laws, rules,regulations, policy and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the Provider’s compliance with all applicableconditionsof participationin Medicaid.
16.5 LOBBYINGCERTIFICATIONS.Provider certi?es to the best of one’s knowledge and belief, that:(a) No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for in?uencing or attempting to in?uence an of?cer or
employeeof an agency, a Member of Congress, an of?cer or employee of Congress, or
an employee of a Member of Congress in connection with the awarding of any federalcontract, the making of any federal grant,the making of any federal loan, the entering
into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modi?cation of any federal contract, grant, loan, or cooperativeagreement.
(b) If any funds other than federal appropriatedfunds have beenpaid or will be paid to any
person for in?uencing or attempting to in?uence an of?cer or employee of any agency,
a Member of Congress, an of?cer or employee of Congress, or an employee of a
Member of Congress in connection with this federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form-
LLL, "Disclosure of Lobbying Activities," in accordancewith its instructions.
(c) The undersigned shall require that the language of this certi?cation be includedin the
award documents for all subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans, and cooperative agreements) and that all subrecipientsshall certify and disclose accordingly.
((1) This certi?cation is a material representation of fact upon which reliance was placedwhen this transactionwas made or entered into. Submission of this certi?cation is a
prerequisite for making or entering into this transaction imposed by section 1352, title
31, U.S. Code. Any person who fails to ?le the required certi?cation shallbe subject
to a civil penalty of not less than $10,000 and not more than $100,000 for each suchfailure.
16.6 CHILD SUPPORT.HHSC shall withholdpayments from any Provider who is found to be ineligible to receive
payment in accordance with Texas Family Code § 231 .006,relatedto ineligibilityto receivestate grants or loans or receivepayment on state contracts due to delinquencyin the payment
of child support .Under Section 231.006, Family Code, the vendor or applicantcerti?es that the individual
15
or business entity named in this contract, bid, or application is not ineligible to receivethe speci?ed grant, loan, or payment and acknowledges that this contract may beterminatedand payment may be withheld if this certi?cation is inaccurate.
16.7 AFFERMATIONS.Provider af?rms, without exception, as follows:(a) Pursuant to Texas Government Code §2270 002, Provider af?rms that it: (a) does not
boycott Israel; and (b) and will not boycott Israel during the term of this Agreement.
(b) Provider af?rms that it is not engaged in business with Iran, Sudan, or any foreign
terrorist organization.
Print Name ofApp1icant/Provider:
Applicant/Provider’sSignature:Date Signed:
For applicants that are entities, facilities, groups, or organizations, an authorizedrepresentativemust complete this application with authority to sign on the applicant’sbehalf. The authorizedrepresentativemust ?ll out the information above and print their name and title where indicatedbelow.Representative’sName: __
Representative’sPosition/Title: __
16
‘id:-ntitltatlnnnumber (Em). to report on an Inlermalionreturn the amount paid to
WW9‘Revmmmm ‘
Requestfor Taxpayer_ §'°‘L‘§l,,,,,,;,,,m,,,,,,,,,,m,,y Identi?cation Number and Certi?cation ,.,,,d,.,....ms,InternalRevenueService
.1 Norm:(as shownon yourIncometax rolum). Name is required on tltisllnozdo not leave this line blank.KINNEYcountry
2 Business narnnldismgnmtcd entity name.Itdillrnenttrom about‘:
i
‘
~» - . -» .4Exoml' 51 “NY NY"?
3 check nnproprlato hot: for tenor.-ittear clasenrcahan.check only one ol the Icllowmg seven boxes,“Mm El:“‘i:"'I:_:'(f1‘:"'?'fdi‘l,’idua"‘s
:SE6D lrtdivlduallsolnproptintoror U Ccorporatlnrt D Scorpemtiun El Partnership E} Trustlestate msrgugtigng an uagg 3);slnglo-member LLC
E y 5,, yr 3§ Limitedliabilitycornpany. Enter lhoilottctassrticatian(c=c corporation, s=s corporation. Faprmncrzrhlp)> ":"”’r""::':"rM‘c:"':mung‘6 Note. Fora single-member LLOthat Is disregarded. do not check u.c:check tho nnpmpnaw box in the line above tor 5* "“’ ‘°" ' "E the tax classi?cation at the slnglememtrer owner. coda ('1 ant/l ~:3 I2)Otherlceolnslructiurtsii GOVERNMENTENTITY Hm-~-"=---"*“~"*=‘°'“"'“"
5 AddfUss_(rtumb¢t'. street. and opt. arsultu no.)501 5 ANNSTREET
3 City. store.and ZIPcode
BRACKETTVILLE.TEXAS 78832 '1 list account nun-rborlsihiya (optional)
Requester‘: nameand address (nntlcnali
See speci?c Instrucuonsdn
page'2.
T Taxpayer Identi?cation Number (TIN)Enter your TINin the appropriate-box. TheTIN provided must match the namcgiven on line 1 to avoid 545°‘ “""“'"V ‘“""°°"backupwilhholding.For Indlviduals.,thisis generally your social security number(SSN). However.for a ‘Iresidentaliemsoleproprietor. or disregarded entity. see the ‘Part I instructions orrpage 3. For other - -entitles.It is your employer identi?cationnumber (EIN).Ityou do not haven number, see How to get aUNon page3.
orINote.It the accountis in more than one name.see the Instructions Ior line 1 and thecltarton page 4 IarQutdallneson whose number to enter.
7 I4 I_‘ 6DOLD0"3 8 N1 'Wce?i?cationtlndarpenaltiesof perjury.Icertify trial:
-1. Tlternumbershown on this form is my correct taxpayer identi?cationnumber (or lam waiting lora number to be issuedto me): 81"‘2. I am not subject to backup withholdingbecause: (a) I amexempt from backup withholding.or (ta)I have not been notiliedby the InternalRevenueService (IRS) that I am subject to backup withholdingas a result ol :2 failureto report all interest or dividends. or (c) the IRS has notltted me that I amno longer sublectto backup wlthholdingrand3- | ama lJ.S.citizonor other U person (de?ned below); and4, The FATCA codnls) entered on this Iorrn (ll any) indicetlngthztt I amexempt trom FATCA reporting is correct.Certi?cation lnstructions.~Youmust crosscutltem 2 above iiycu have been notilied by the IRSthat you are currently subletilin backup Wi"I"°’d'“9because you have failedto report all interestand dividends on your tax reIurn.—Forreal estate transactions, item 2 does not apply. For mortgage
I
interestpaid. acquisition or abandonmentoi secured property. cancellation of debt. contribulionstoan individualretirementarrangement (IRA).andgenerally. payments other than interestand dividends.you are not required to sign the certl?cati .but you must provide your correct TIN.‘See theinstructionson page 3. '
379" Slgnaturt: orHere U5. person b '
General InstructionsSectionrelerencen arc In the Internal nevcnuuCode unless otherwise noted.
- Farrnt 58(ho omortgagolnterestj; I098-ElstirdrentIoanintorosl).1098-T(tuition)- Farm Imasc (canceled dam)Future unvnlopmenls. Inlormationabout developments affecting Form W-Srtsucti .Pam, 1059.,‘ (wQu;sm¢nr,,,,,,bmm‘,mnmy 0: secumg prgpeyly)-35 lmzlslmlonenacted otterwe roteese it)is at wvnt/.irs.gov/I929.-
Use Form W41only it you an: :t—U.S.poison (including a resident alien),toprovide your correct TIN.
II you do not return Form W-9 to rlrazrequesrer with.1 TIN,you might onsubpzclto backup tvirrtncldingSee What Is backup withholding? on page 2.
By signing the tilted-out-term.you:1. Cartily that the TINyou are giving is correct(or you ow walling tom numpet
to be second}.
2. Ccrtilythat youarenot subject to backup withholding.or8. Claimexemption horn backup withholding it you are rt U.S.uxemvlnz-yee.,Il
npptcoble. you me also ccrtllying that I15 -1us. person. your utlocnhloshrvooiany partnership income rromn u.s. trade or business is not sub)!-‘Cl la the
Purpose of FarmNIntdivtdualor entity (Form W-9 requester) who Is required to litean mlorrnationreturn with the IRSmust obtain your correcttaxpayer iuentillcatlonnumber (TIN)’which may be yoursocial security number (SSN), Individualtaxpayer Identi?cation"umber (ll'II\lI.adoption taxpayer Identi?cationrturnburIATIN).or employeryou. or other-antqunt roportnblo on an lnlarrnationroturn. Examples ol Intonationreturnsinclude.but are not lirnitndto. tho lollowingz- Form 1099-INT(interest earned or para)_-Form, I099-‘DIV(dividends.Including those lrom stocks or mutual Iunds)' Form I099-M150(vorfou: types at income.prizes. awards.orgrcss procoréds) withholdingtax on Icrclgn partners‘ share at ellecrively connected income. mu!‘Farm‘D994! (stock or mutualfund sales and cc-nain outer transaction: by 4. cnrtlry that FATCA cadets) entered on this term orany) Indicating that youam“Wkmi
oxompt from u1o‘FATc/t reporting. lstzurrect.see Wrcrr is F/IYCAreporting?on.Fun“ 1039.5 (,,,,,gm,s "am ma, cum, ,m,mmi°,,5,_ page 2 tor lurthur inlorrnanan.- Form 1095-K (merchant cord and third party nutworlt tmnsoctmns)
out.No. 1023‘lX Form W-9 (Rev. 12-2014)
11/26/2018 Mail - Kinneycou ntyNutrliian@hotmai| .com
National Provider Identi?er
Wed 11/7/2018 9:18 AM
Inbox
To:kinneycountynutrition@hotmailcom <[email protected]'r\>;
Enumeration Date: November 7, 2018
A request for a National Provider Identifier for the following provider was recently submitted to
L1ttps:[[nppes.cms.hhs.gg_\Land you were listed as the contact person. This is to inform you that the request wassuccessfullyprocessed and the following NPI hasbeen assigned:1720556863.
KINNEYCOUNTYAGINGSERVICESEINI=====038‘l
Practice Location:408 S Ann St
' Provider Taxonomies:
Taxonomy: 332U0OO0OXDetails: Home DeliveredMealsThis is the Primary Taxonomy.
Ifyou have any questions about this notification you may Contact the NPI Enumerator at:
NPI Enumerator
PO Box6059
1-800-465-3203 (NPI Toll-Free)
1-800-692-2326 (NPI TTY)
customerservice@npienumeratorcom ;
You may view or change this provider's NPPESinformation by logging onto the NPPESwebsite at
?ps:[[nppes.cms.hhs.gg.
Please note: if you are not the provider, you are required to inform the provider of the information in this e-mail andfurnish a copy of this notification to the provider.
l
l
htips:/Ioutlook.|ive.ccimIowa/?|!em|D=AQMkADAwATZiZmYAZC1jM2MZLTl5N2|tMDACLTAWCQBGAAADZUOpV3E4u0qQdea0kiormwcAsAj0lY5gQ0eD...1/1l
. Can I schedule a ?ngerprinting appointment online for a person who does not have a driver’s license orsocial security number? (cont.)- Passport book or card
- Permanent Resident card (I-551)- Enhanced Tribal Card (ETC)- Foreign passport- Temporary paper licensesissued by the state of Texas
For more information regarding valid identi?cation,visithttps:IIwww.txdps.state.tx.usladministrationIcrime_recordsIdocslproveidforflngerprinting.pdf
9. What if my fingerprints have already been submitted to Medicare or another state’s Medicaid program?
If you submitted your ?ngerprints to Medicare or another state’sMedicaid program as a requirement of enrollment orrevalidation,we may be able to rely on the background check performed by Medicareor that state to meet thisrequirement. You must submit a letter containing the details on company letterhead to HHSC. The letter must includethe following information:
- Document whether ?ngerprints were submitted- Document that ?ngerprints were submitted to a- List of providers and/owners whose ?ngerprints- Date that the ?ngerprinting was completed
ailing the changes on company letterhead to HHSC. Theach new owner must also submit a Principal Information Form
information for existing owners, you shouldletter must be signed by an authorized represen A
(PIF-2) to HHSC.
11. What are the guidelines for submitting proof of fingerprinting to HHSC?
The fingerprinting vendor willprovide you with a thermal receipt verifying that ?ngerprinting occurred.You must send acopy of this receipt to HHSC MCO LTSS Provider Enrollment for each provider and/or individualwho meets theownership requirements. You must include your applicationnumber with the submissionof your thermal receipt. Ifyouare a provider or owner at multiple locations,you must submit copies of the thermal receipt for each location.
If these guidelinesare not met, your application will experiencea delayin processingby HHSC.
Note: Rememberto keepthe original thermalreceiptforyour records.
12. How do I submitproof of fingerprinting or changes to owners to Texas Medicaid?
You must submit the following documentation to HHSC:
0 Copies of the thermal receipts verifying that ?ngerprinting occurred for all required individuals- Letters verifying the submission of ?ngerprints to Medicare- Letters verifying the submission of ?ngerprints to another state’sMedicaidprogram° Letters regarding ownership changes
Pleasesend the required documentation to: HHSC Medicaid& CHIP ServicesDepartment,OperationsManagementMCD MCO LTSS ProviderEnrollmentMailCode H312909 W. 45th Street Bldg.2Austin,Texas 78751
Texas Medicaid Provider Fingerprinting Requirement Frequently Asked Questions(FAQ) Page 2 of 3
13. What if my proof of fingerprinting is not submitted timely. or is not complete?
Newly enrolling or revalidatingproviders must submit proof of ?ngerprinting (thermal receipts) with their completedapplication.Ifthe required proof is not submitted, the provider willreceive a de?ciency letter requesting the proof of?ngerprinting. The provider willhave 30 days to submit the requested information. The applicationwill be closed if thede?ciency is not addressedby the 30 day deadline.Applicationsmay be re-opened subject to certain limitations.
14. How are rejected ?ngerprints handled, and how will I know if someone on my staff or my ownfingerprints were rejected?
Sometimes DPS or the FBI rejects ?ngerprints. If this happens, the person willbe contacted by phone or emailby thefingerprinting vendor, based on the preferred method of contact entered when the background checkwas requested, toschedulea reprint. The person should not be charged a second time for ?ngerprinting. The person may go online orscheduleby phone with the ?ngerprint vendor for a reprint.
The reprint must be completed within one year of the initial appointment. If the second set of ?ngerprints is alsorejectedand was completed within one year of the initial appointment, HHSC-IG can request a name-based search ?om the FBI.This searchmust be requested within 90 daysof the second set of ?ngerprints. IfHI-[SC-IG is not noti?ed of the secondrejection within the 90-daytimeframe, the person will require a new set of ?ngerprints, and will be required to pay a new?ngerprinting fee.
Note: Ifyour ?ngerprints have beenrejectedor youhave questionsregardingthe fingerprintrejectionprocess,pleasecontactthe InspectorGenera/'sof?ceat [email protected].
Texas Medicaid Provider Fingerprinting RequirementFrequently Asked Questions(FAQ) Page 3 of 3
13. What if my proof of fingerprinting is not submitted timely, or is not complete?
Newly enrolling or revalidating providers must submit proof of ?ngerprinting (thermal receipts) with their completedapplication. If the required proof is not submitted,the provider willreceivea de?ciency letter requesting the proof of?ngerprinting. The provider will have 30 days to submit the requested information. The applicationwillbe closedif thede?ciency is not addressedby the 30 day deadline.Applicationsmay be re-opened subject to certain limitations.
14. How are rejected fingerprints handled, and howwill I know if someone on my staff or my ownfingerprints were rejected?
Sometimes DPS or the FBI rejects ?ngerprints. If this happens, the person willbe contacted by phone or emailby the?ngerprinting vendor,based on the preferred method of contact entered when the background checkwas requested, toschedulea reprint. The person should not be charged a second time for fingerprinting. The person may go online orscheduleby phone with the ?ngerprint vendor for a reprint.
The reprint must be completed within one year of the initial appointment. If the second set of fmgerprints is also rejectedand was completed within one year of the initial appointment, HHSC-IG can request a name-based search from the FBI.This search must be requested within 90 daysof the second set of ?ngerprints. IfHHSC-IG is not noti?ed of the secondrejection within the 90-day timeframe, the person will require a new set of ?ngerprints, and willbe required to pay a new?ngerprinting fee.
Note: Ifyour?ngerprintshave beenrejectedor youhave questionsregardingthe fingerprintrejectionprocess,pleasecontactthe Inspector Generalsofficeat [email protected].
Texas Medicaid Provider FingerprintingRequirement Frequently Asked Questions(FAQ) Page 3 of 3
WW9 Request for Taxpayer “I;, . .V
. . ue . o rt},§,”..,,,,,,°°‘°',,‘°°',.,,’,‘2,1§;,,,,Identrficatton Number and certification ,,,,,,,,,,.,,,,-,5_l?tI?\3'H€W?l-IOSBNDOG.1 Nametttashownonyour Incometax return).Name is required onliftsline:do not leavethis lineblank.Kttmevcouuw
A; 2 Business narnttldimrgurtied entity name.it eillerent lrom «bowGg
3 Checknnoropriatn boxrortauamttmt classi?cation:checit only am: oi the followingseven boxes: 4 Exnrnplipns{codesequivonlyInEDtwvmatmhrg?oghtmorD Ccorporalion D-s Corporation El Partnemhip E] Trustlesioto §.°,?.?,‘£.§Z’,:{,"§§‘§‘§9'£§;'}?"d""h""
_§% U Limitedliabilityeentpeny. Enter lhohut ctnssilioatiorttc.-ccorporation. s=scorporation. Paparlncmhlpl > :‘°f"’:_”"":':‘:::::"”T——“'= Not.)-‘ ie- mberLLCthaidis arc. theckwl tut ‘ha’ I novel """‘P‘°" ‘
‘°"°"‘9Qrz uui'L.3r1§.ii"r.'?i.tio'.??.«tmr.9t.4.‘..°§.u.s.'2'$..m.°.°"°"° ° ”'° °‘‘’'‘ °‘‘’’‘’’‘’‘’''‘'‘’ “"‘"‘° "”” °'oodetrtnnylEg IE]omeeeinsn-muons)» GOVERNMENTENTITY mr.....«mm»mw-m«s-
.“-5‘ Address (rturnonr. struetmnd apt. or suite no.) Retzuestefsnameandaddress (optional:u .
n, 501 5 ANNSTREET
‘é a city. state. ma zu=code"7 BRACKETTVILLE,TEXAS78332 '
7 ustamountnurnbortslhera(optionn?
Taxpayer Identi?cation Number (I_'IN[V
EnteryourTINIn the appropriate box. TheTIN provided must match the name given on line 1 to avoid 59'3"‘ 5°'°"""Y "“""""-backupwithholding.For indIviduais..thistsgeneraiiy yoursocialsecurity number-(SSN).'Huwever. foraresident alien.sole proprietor. or disregarded entity. see the Part I instructionson page zt.Forother ~ -entities,it‘Isyour employer identi?cationnumber (EiN)..IIyou do not have a number. see How to get aTINonpage 5. or
Nata. ll the account is in more than one name.see the Instructions for line 1 and the chart on page 4 torguidelines on whose number to enter. -
Employer tdentttioaiionnunltsarl
Certi?cation -
Underpenattiea of perjury. Icertlly ttiat:1. Thenumber shown on this (arm is my correct taxpayer identi?cationnumber‘.(or lam waiiingtor anumber to be issuedto me); and2. lam notsublectto backup withholdingbecause: (11)I am exempt lrorn backup withholding. crib) I have not been noti?ed by the Internal FtevenueService (IRS)that I am sublect to backup withhrridingtzsa result of It laiiure to report all interest or dividends.or (c) the IRS has noti?ed methat I am
1no longer sublectto backup withholding;and‘
3. I lift a U.S.citizenor other U.S. person (de?ned below): and4. TireFATGAcode(5) entered on this term (tiany) indicatingthat Iamexempt from FATCA reporting ts correct.Certificationinstructions. You rrtust cross out item 2 above it you hnvebeen notiiied by the MS that you are currently subject to backup withholding
Abecause you have tailed to report all interest and dividends on your tax return. For real estate transactions.item 2 does not apply. Fornturlgago
linterestpaid. acquisition or abandonmentoi secured property. cancellation of debt. contributions to an individualretirement arrangement (IRA).and igenerally. payments other than Interest and dividends.you are not required to sign the Gerti?cati .buty0U must provide your cam! TIN’599 "Winstructionson page 3.__
6 r / 7 «/5mortgage interest); I093-E (student loan Interest). 1098-T
oar}.>
General InstructionsSectiontolerances are to the Internal Rave-moCoda unless otherwise noted. .pom, 1599.‘: tumgi,-tga amt) ‘
Futuredevrotnprnutu. lnlorrnntionaboutdeveioomenlsnllocling Farm W-I9tsuctt .rum.1og9.)\(ggqu;9|1|on'pr gbandanrmxtl orsecured property)as legislation enacted alter we release mixat www.lI3.yav[IW9.usemmW9 ‘W Hyou we 3 "5. Wm WWW a mug” mm’ mPurpose of Farm provide your current TIN.
h, . .
_ . ' ' irlon st: 124:!Anrrtatwciuelorcnirty (Form W-9 requester) who is required to tilean tninrrnatmn ”V°" "° "°‘ ""’!"'FM" W 9 "1 W f?quaster wrmoYIN.)'W ""9return with the titsmust obtain youreomct taxpayer roanttrtcartm numur (TIN) to backup withholding. sea.wnaris baclrup withholding? on page 2~whichrnaytsoyoursocialsocurityt'Iumher(SSNl. Individualtaxpayer identi?cation By signing the ?iient-outlorm. you:nrrt1thei'lmNI.ado IltmI: at Identtrcattonnutnbu ‘rt .oremoteer - - - -iaeutittcattonltutllbgv(ElM,.qt,na)r’opanortlanInrarmattartr(:IutrNl',Ihnamounytpaid to
,9 ],',,°,§,':'j,,‘,"“'"‘° “N 7°" "° 9"""“ " °°"-°°' ‘" W" W" wwmg W ‘' "um"u or tnorrnount rtbtu intarmatio I .E toe Hlonttlicn _
'
, .rvt?lne‘lzwtlltlle.but IlirttIe7i"i§?lnoIolIowir(t‘9':a“"1 amp 0 H a2. Certtly that you arenot subtractto backup withholding.-or. -
' id’ ‘l :tu.s.o amntrm .||' M "M M i~.wW -=' M .....:..,..- Formlass-DIV(orvttlenr1s.Including those Irornstocks or rnuiubt lunds)
My pmM',,,.,p‘mm mm,,u_5__.,_.,,;,,., b,,.t,.¢,,, t, not gg§‘pg| la thatt FurrrtI099-Misc (various type: at Income, prizes. awards.orgrcss prbcecds) withholdingtatr on foreignpartners‘ share at elleetivety‘c<mnenter.ir'ncnmo.and i- Font: toss-B (stock or mutualfur-idsates rind certain other transactions try 4. conlty that FATCA code(5)-entered on lhiatorm iiiany) IndicatingthatyouareI
lwltersi exempt train the FATGAreporting. Inl:t7mtl:LseeWhat]: FIITCAreporting?on ;’- Form I099-S (proceeds lrornreal estate tmnnnclionsl "9" 2 '°' """‘” '”'°'m""°“‘I FonrrI099-K(merchant curd aw third party network transactions)
i
Form -9 (Rev.
KINNEY COUNTYAGING CENTERSITE DIRECTOR
DEFINITION:
CONDUCT MANAGEMENT& ADMINISTRATIVE FUNCTIONS FOR THEENTIRE PROJECTSTAY TN COMPLTANCE WTTH AREA AGENCY OF AGTNG. DEPARTMENT OFAGTNG & DTSAELTTTES. S KTNNEY COUNTY POLTTCTES & PROCEDURES,STATE OF TEXAS HEALTH DEPARTMENT & STATE OF TEXAS FIRE CODES
SUPERVISION RECEIVED AND EXERCISED:
RECEIVES LIMITED SUPERVISION FROM THE COUNTY ATTORNEYEXERCISES DIRECT SUPERVISION OF STAFF
DUTIES:
THE DUTIES OF THE SITE DIRECTORY WILL INCLUDE THE FOLLOWING:(DUTIES MAY BE ADDED IF NEED ARISES TO EFFECTIVELY OPERATETHE KINNEY COUNTY AGING CENTER)
D KEEP ALL ASPECTS OF THE KCAC IN COMPLIANCE WITH AAA/DADS%ALL MONTHLY MENUS. MEALS. RECTPES. PAPERWORK. TRATNTNG
MANUELS FOR STAFF & VOLUNTEERS, SOME JOB DUTIES & FUNCTIONSMUST MEET AAA/DADS REOUTREMENTS'Z\ VEED ALT. MONT?-IT.V ?TTAPTF'.RT.V VEAPLV REPORTS X: RTT.T.TI\TGCURRENT & ON TIME FOR KINNEY COUNTY, AAA, DADS & TDA4} PREPARE YEARLY BUDGETS FOR KINNEY COUNTY, DADS/AAA&TDA GRANT
5\SUPERVTSE STAFF & VOLUNTEERS — KEEP THETR RECORDS
CURRENT & CORRECT— HAVE MONTHLY EDUCATTON MEETTNGS6\HOME DELTVERED & CONGREGATE CLTENTS — KEEP THETR RECORDSCURRENT & CORRECT — HAVE YEARLY EDUCATTON & SURVEYS
7\DOCUMENT & HANDLE ALL COMPLATNTS. CONCERNS. OR ARUSE —
WITH CLIENTS, STAFF, POLICIES & PROCEDURES, OR THE KCAC8) ATTEND ANY MEETING — AS REQUIREDWEE ARLE TO FTLL TN FOR ANY OF THE STAFF THAT TS ARSENCE
1m I(F‘.F‘.P r‘rmmr.v\1rr nTMn1:'.p!: mi‘ DU‘T‘TF!.Q X, 'T‘PATT\TTT\'l(2 MATERIAL FORSITE DIRECTOR, HEAD COOK, ASSISTANT COOK, DRIVER &VOLUNTEERS
Healthand HumanServices
MCO LTSS APPLICATION PACKET CHECKLIST*Please answer all questions in the application and submit all forms from the packet. if thequestion does not apply a response is still needed* All applications must be typed. Incompleteapplication packets will not be processed and will be rejected.
‘All questions require a response. Please enter NA if not_ applicable.
MCO LTSS Provider Enrollment ‘Verify that your NPI, and taxonomy match according to the NationalApplication NPlRegistry- htt s:l/n ire ist .cms.hhs. ovl
*Please read question 13, and 25 thoroughly
_ _ *All questions require a response. Ifthe question does not apply,Disclosure Of Ownership and please check the “no" response.cgntr¢)| |nfere5t Statement :A||individuals listed in section III(a) require a PIF-2.
provider Information Form (P”:_ ‘A PIF-:1is required for all providers. Please be sure to completethe entire document.1) ‘No response should be left blank.
principal Information Form (PH:-_* PIF-2form needed foreach personand entity listed on theDisclosure of Ownership form Section Ill (a).2) ‘Entity or Person should be checked. Do not check both*
Medicaid Provider Agreement ‘Please retum pages 1, 11, and 16 ONLY.
W-9
*Please review page 5 of the MCO LTSS Applica ‘ to determine '
check/Proof of payment the enrollment fee is necessary for your facility. 1 adlcbCertification/Licenses ‘A copy of ALL licenses and certi?cations are required.
When claiming "Corporation” on the Disclosure of Ownershipand Control Interest Statement providers must complete andreturn the following forms:
0 Corporate Board of Directors Resolution Form, (must benotarized)
Corporate Board of Resolution 0 Certificate of Formation, Certificate of Filing,Certificate of Authority, or Certificate ofRegistration
0 Franchise Tax Account Status, available athttpsi//mycpa. cpa. state. tx.us/coa/lndex.hti1il
‘it your taxonomy is 251 EODOOOX,253200000X, or 251G00000X?ngerprints are required.Fingerprints" The website for Texas Medicaid’s ?ngerprinting vendor ishtt - s:IIuenroll.idento - o.comIservicecodeI11H7TG. You can
schedule appointments online or by phone at 1-811-289-6114. Foronline scheduling, we recommend using Google Chrome to accessthe vendors website. To book an appointment by phone, you need asix-digit service code. Texas Medicaid’s service code is 11H7TG.