SINGLE CASE AGREEMENT (SCA)
|
|
- Martina Cannon
- 5 years ago
- Views:
Transcription
1 SINGLE CASE AGREEMENT (SCA) Yvonne Joyner, QP, BS Provider Relations Specialist Network Operations Chauncey Dameron, MBA Provider Relations Specialist Network Operations
2 If there is a member who needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service a Single Case Agreement (SCA) can be requested.
3 The SCA is submitted by the provider along with the Electronic Funds Transfer Form (EFT), Trading Partner Agreement (TPA), current Copies of Certificates of Insurance (COI), copies of required licenses, W-9, copy of voided check or an official letter from the bank providing the account and routing numbers and a paper TAR if the requested service must be authorized.
4 Application is available in two formats: printable and web submission. Downloadable format Provider Manuals and Forms Forms Single Case Agreement. This format should be submitted via fax to or via secure to
5 Electronic submission format: Provider Manuals and Forms Electronic Forms Single Case Agreement. When using this format, the required documents listed under Attachment B should be uploaded to the application under the section provided for additional documents.
6 These documents are available on the Eastpointe website at Provider Manuals and Forms Forms. You should be able to save them to your desktop and once complete, they can be attached to both the Downloadable and/or Electronic Form. they can be attached to the formdesk form. them to your desktop and once complete, they can be attached to the formdesk form.
7 Medical necessity must be determined for services requiring pre-authorization before the SCA can be approved. Members should not be placed or receive services until the Single Case Agreement is approved. Provider will not receive payment for services until the SCA is approved and set up in Alpha.
8 Corporate Office: 514 East Main Street Post Office Box 369 Beulaville, N.C Administration: Access to Care: Sarah N. Stroud, CEO SINGLE CASE AGREEMENT (Must select one) Funding Source: Medicaid IPRS Date of Request: (date you submit application to Eastpointe) Section:1 (This information should be the same as the information in NC Tracks) Provider Information: Provider Legal Name: Click here to enter text. DBA Name: Click here to enter text. Federal Tax ID: Click here to enter text. Agency NPI#: Click here to enter text. CEO/ Director Name: Click here to enter text.
9 Mailing Address: Click here to enter text. City: Click here to enter text. Zip + 4: (both zip and plus 4 required) Click here to enter text. Telephone Number: Click here to enter text. State: Click here to enter text. County: Click here to enter text. Click here to enter text. Primary Clinical Contact: Click here to enter text. Telephone Number: Click here to enter text. Are you working with a Care Coordinator on this case? Yes No Click here to enter text. Coordinator s name: Click or tap here to enter text. Section: 2 (must select one) Provider Type: Agency / Licensed Facility CABHA Hospital Licensed Independent Practitioner (LIP)-Solo ICF-IDD Facility only IDD, PRTF
10 Section: 3 (Must select One) Organization Legal Entity Type: C-Corp S-Corp Limited Liability Partnership(LLC) Sole Proprietorship Cooperative General Partnership For Profit Not for profit Government Section: 4 (Person to contact for billing questions) Billing Information:5 Billing Contact: Billing Address: City: State: Zip: (both zip and plus 4 required) County:
11 Section: 5 (Location where service will be provided) Service Location: Site Address: City: State: Zip + 4: (both zip and plus 4 required) County: NPI Number: Taxonomy Number: List Service requested at this site for member (Include): (Both service and billing code required for each service requested) Service Description: (Can request more than one service) Billing Code: ( a code must be provided for each service requested) License type (if applicable):
12 Section: 6 (One member per application) Client Information: Full Client Name: Client Medicaid #: Client DOB: Client Medicaid County of Origin: (if applicable) (Must be one of the twelve counties in the Eastpointe catchment area) Requested Service Begin Date: (begin date required. This date should not be prior to submission date) Requested Service End Date (if known): Section: 7 (Responses required) Accreditation Organization: Number of years Accredited: Accreditation Expiration Date: OR We are not required to be Accredited for the services we provide. Do you currently have a Contract with another LME-MCO? Yes No If yes, please list all LME-MCO s: Have you ever been sanctioned, placed on probation, and lost accreditation/certification.
13 Section: 8 Note: For all LIP s whose NPI numbers you will be using for Outpatient Services please complete this section. Please use Attachment A for additional LIP s. Licensed Clinician Information: (All requested information must be provided) Legal Name: Address: City: State: Zip + 4 (both zip and plus 4 required) Date of Birth: Social Security No.: Gender: Felony/Misdemeanor or Investigation: (If yes please explain) Yes No Professional Schools attended: Graduation: License Type: Date Issued: DEA Number: (if applicable) NPI number: Expiration Date: License Number: Taxonomy Number: Do you currently have a Contract with another LME-MCO? Yes No If yes, please list all LME-MCO s:
14 (Responses required) Please identify your Insurance Carrier(s): Professional Liability: Name: Telephone No.: Policy #: Are there any claims? Yes No Are there any current or unsettled claims? Yes No Are there any circumstances that may result in a claim? Yes No Are any of the policies cancelled? Yes No Commercial General Liability Insurance: Name: Telephone No.: Policy #: Worker s Compensation Insurance: Name: Telephone No.: Policy #:
15 (documents required when submitting the Single Case Agreement request) Required Attachments: ( Attachment B ) 1. Electronic Funds Transfer (EFT) Agreement (please complete and sign) 2. Trading Partner Agreement (TPA) (please complete and sign) 3. Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form. 4. Copies of required Licenses. 5. Request for Taxpayer Identification Number (W-9) 6. Copy of voided check or bank letter with account and routing number. Section:11 (explanation required for all Yes responses) Investigation and Sanction Attached Questions: (1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions? Yes No (if yes please describe) Click here to enter text. (1) Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances. Yes No (if yes please describe) Click here to enter text. (1) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? Yes No (if yes please describe) Click here to enter text. (1) Are you aware of any circumstances that may result in such action? Yes No (if yes please describe) Click here to enter text. (1) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? Yes No (if yes please describe) Click here to enter text. (1) Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorized individuals. (See Attachment C).
16 Investigation and Sanction Attached Questions: (explanation required for all Yes responses) (1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions? Yes No (if yes please describe) (2) Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances. Yes No (if yes please describe) (3) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? Yes No (if yes please describe) (4) Are you aware of any circumstances that may result in such action? Yes No (if yes please describe) (5) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? Yes No (if yes please describe) Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorized individuals. (See Attachment C).
17 Upon full execution of this Application/Agreement, the parties agree as follows: 1. Provider shall notify EASTPOINTE prior to the discharge of Client and shall allow designated EASTPOINTE staff to attend any discharge or treatment meetings regarding the Client served under this Agreement. 2. Provider warrants that it is in compliance with all applicable federal, state and local laws, rules and regulations, licensure and accreditation requirements governing the provision of services to Client at all times relevant to this Agreement. 3. EASTPOINTE reserves the right to refer enrollees to other providers, and no referrals or authorizations are guaranteed to take place under this Agreement. 4. Provider shall be responsible for completion and retention of all necessary and customary documentation required for the services provided under this Agreement. Provider agrees and understands that EASTPOINTE may inspect financial records concerning claims paid on behalf of Client, records of staff who delivered or supervised the delivery of paid services to Client, Client clinical records, and any other clinical or financial items related to the claims paid on behalf of Client deemed necessary to assure compliance with applicable state or federal laws, rules and regulations.
18 Provider shall provide copies of records or other information within timeframes of written request from Eastpointe. 5. Provider warrants that it has and will continuously maintain insurance coverage with a carrier authorized to do business in North Carolina, or maintain equivalent coverage under a self-insurance program that is actuarially sound, meeting the following coverage requirements: a. Professional Liability: Professional Liability Insurance shall protect the Provider and any employee performing work under this Agreement for an amount of not less than $1,000, per occurrence and proof of coverage at or exceeding $3,000, in the annual aggregate. b. Comprehensive General Liability: Bodily Injury and Property Damage Liability Insurance shall protect the Provider and any employee performing work under this Agreement from claims of Bodily Injury or Property Damage, which may arise from operations under the Contract. The amounts of such insurance shall not be less than $1,000, per Occurrence/$3,000, per Aggregate/ $1,000, Personal and Advertising Injury/$50, Fire Damage. The policy shall not include exclusion for contractual liability. c. Workers Compensation and Occupational Disease Insurance: Provider shall maintain workers compensation and occupational disease insurance as required by the statutory requirements of the State of North Carolina.
19 6. For some purposes of the Agreement (other than treatment purposes) the PROVIDER may be considered a Business Associate of the LME/MCO as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and as such will comply with all applicable HIPAA regulations for Business Associates as further expanded by the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which was adopted as part of the American Recovery and Reinvestment Act of 2009, commonly known as ARRA (Public Law 111-5). Pursuant to Controlling Authority, specifically 45 C.F.R , PROVIDER and LME/MCO may share an Enrollee s protected health information ( PHI ) for the purposes of treatment, payment, or health care operations without the Enrollee s consent. 7. All claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 Premium Payment, 834 Member Enrollment and Eligibility Maintenance, 835 Remittance Advice, 837P Professional claims, 837I Institutional claims, or the EASTPOINTE secure web based billing system.
20 8. Provider understands and agrees that claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except that Provider may submit claims subsequent to the ninety (90) day limit in instances where the Client has been retroactively enrolled with Medicaid or EASTPOINTE, or where the Client has primary insurance which has not yet paid or denied its claim. In such instances, Provider may bill EASTPOINTE within ninety (90) days of receipt of notice by the Provider of the Client s eligibility for Medicaid, or within 90 days of final action (including payment or denial) by the primary insurance or Medicare (whichever is later). 9. EASTPOINTE agrees to reimburse Provider for approved Clean Claims for covered services for the Client named herein within thirty days of the date of receipt. Within eighteen (18) days after EASTPOINTE receives a claim from Provider, EASTPOINTE shall either: (1) approve payment of the claim, (2) deny payment of the claim, or (3) request additional information that is required for making an approval or denial.
21 Signatures: By signing below, Provider certifies that all of the information and attachments provided herein are true and accurate to the best of their knowledge. Provider further understands that any false or misleading information may be cause for denial or termination of any and all agreements or contracts with EASTPOINTE. Provider understands submission of the application does not guarantee the issuance of an agreement. Provider signifies their willingness for EASTPOINTE to verify all information presented in this application and to provide additional information to EASTPOINTE, if needed, to verify the accuracy of the information contained herein. Provider agrees to provide any additional information at request of EASTPOINTE to verify information and address issues of concern prior to the approval of the application. IN WITNESS WHEREOF, each party has caused this agreement to be executed in multiple copies, each of which shall be deemed an original, as the act of said party. Each individual signing below certifies that he or she has been granted the authority to bind Provider to the terms of this Agreement and any Addendums or Attachments thereto. Enter Provider Name: _(Should be the same as the Provider Legal Name) Sign: (Original signature required) Date: (Original date required) Print Name: Title: (required)
22 EASTPOINTE (Do not write on this page) Address: 500 Nash Medical Arts Mall Rocky Mount, NC Telephone: Sarah N. Stroud Legally Authorized Representative Chief Executive Officer Date This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act. General Statute 159 Catherine Dalton Legally Authorized Representative Chief of Business Operations Date MCO Approved Begin Date: MCO Approved End Date: The request was processed on timeframe to match the service authorization request and was processed as: MCO use only: Urgent Non-Urgent
23 Attachment A (Continue from Section 8) Licensed Clinician Information:(must be entirely completed if the below NPI number will be used when submitting claims. Duplicate as needed) Legal Name: Address: City: State: Zip + 4 Date of Birth: Social Security No.: Gender: Felony/Misdemeanor or Investigation: (If yes please explain) Yes No Professional Schools attended: License Type: Date Issued: DEA Number: (if applicable) Taxonomy Number: Accreditation Organization: Number of years Accredited: Graduation: Expiration Date: NPI number: Accreditation Expiration Date: OR We are not required to be Accredited for the services we provide. Do you currently have a Contract with another LME-MCO? Yes No If yes, please list LME-MCO(s): License Number:
24 Attachment B (Continue from Section 10) Required Attachments: 1. Electronic Funds Transfer (EFT) Agreement (please complete and sign) 2. Trading Partner Agreement (please complete and sign) 3. Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form. 4. Copies of required Licenses. 5. Request for Taxpayer Identification Number (W-9) 6. Copy of voided check or bank letter with account and routing number.
25 Attachment C (Continue from Section 11) Please provide a listing of shareholders/partners with 5% or more ownership AND officers, Directors, Managers, Electronic Funds Transfer (EFT) authorized individuals. (This information should be provided for anyone with 5% ownership whether they work for the agency or not) List their: Names: Click here to enter text. Demographic information: Click here to enter text. Social Security No.: Click here to enter text. % of ownership and/or position: Click here to enter text. List their: Names: Click here to enter text. Demographic information: Click here to enter text. Social Security No.: Click here to enter text. % of ownership and/or position: Click here to enter text. List their: Names: Click here to enter text. Demographic information: Click here to enter text. Social Security No.: Click here to enter text. % of ownership and/or position: Click here to enter text. List their: Names: Click here to enter text. Demographic information: Click here to enter text. Social Security No.: Click here to enter text. % of ownership and/or position: Click here to enter text.
26 SCA PROCESS Reminders: This application is to be used when a member needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service. Application will not be processed if there is an in network provider available to provide the needed service.
27 This application is used to request both Medicaid and IPRS funded services. All questions on the application must be answered. Only one member per application. Multiple services can be requested on the same application. Both the service and service code must be provided. Funding Source: Is the requested service Medicaid or IPRS Funded?
28 SCA PROCESS Date: actual date the application is submitted to Eastpointe. Provider information on the application should be the same as the provider information in NC Tracks or the application will be determined Unable to Process (UTP). Required attachments (Section 10) must be submitted along with SCA. Zip codes require both the zip code and the plus 4.
29 COI must be current. Provider is responsible for sending updated COI to Eastpointe. Insurance requirements are listed on the application under #5 of the terms of the executed Single Case Agreement. All applications require an original signature and signature date to prevent being determined Unable to Process. Incomplete applications cannot be processed.
30 A secure and certified UTP letter is sent to provider when an application cannot be processed. It is the provider s responsibility to resubmit the SCA with the required updates indicated in the UTP letter. Resubmitted applications require an updated signature and signature date on all forms. Providers are responsible for reviewing the approved SCA for the begin and end date to determine the term of the approved SCA.
31 Medical necessity must be determined for services requiring pre-authorization before the SCA can be approved. Members should not be placed or receive services until the Single Case Agreement is approved. Provider will not receive payment for services until the SCA is approved and set up in Alpha.
32 Questions regarding the SCA, review process, Unable to Process notification, etc., will be addressed by Network Operations. Contact can be made via telephone at or by sending a secure to networkoperations@eastpointe.net
Participating Dentist Agreement with United Concordia Companies, Inc.
Participating Dentist Agreement with United Concordia Companies, Inc. Under the applicable laws of the State of Virginia, I am duly authorized to engage in the practice of dentistry. In consideration for
More informationChristina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
More informationIME Provider Account Application
IME Provider Account Application Mail completed application to: Provider Quality and Compliance PO Box 44322 Olympia WA 98504-4322 A. Application Information I am applying as a(n): Individual Examiner
More informationDEPARTMENT OF HEALTH CARE FINANCE
DEPARTMENT OF HEALTH CARE FINANCE Dear Provider: Enclosed is the District of Columbia Medicaid provider enrollment application solely used for providers, who request to be considered for the Adult Substance
More informationHome and Community Based Services Application
To use follow these instructions Home and Community Based Services Application Complete the application in its entirety using black or blue ink. Keep an unsigned and undated copy of the application on
More informationCenpatico South Carolina Frequently Asked Questions (FAQ)
Cenpatico South Carolina Frequently Asked Questions (FAQ) GENERAL Who is Cenpatico? Cenpatico, a division of Centene Corporation, is one of the nation s most experienced behavioral health companies providing
More informationOverview. IHCP Pharmacy Provider Enrollment and Profile Maintenance Packet. Before You Begin! Who Uses This Packet. General Instructions
Overview IHCP Pharmacy Provider Enrollment and Profile Maintenance Packet indianamedicaid.com >> Before You Begin! You are encouraged to use the Provider Healthcare Portal for submitting enrollment transactions
More informationTRICARE NON-NETWORK INSTITUTIONAL PROVIDER APPLICATION
TRICARE NON-NETWORK INSTITUTIONAL PROVIDER APPLICATION We expect providers to submit claims electronically. If it is necessary to submit a paper claim, the only acceptable forms are the approved red and
More informationHelpful Tips for Preventing Claim Delays. An independent licensee of the Blue Cross and Blue Shield Association. U7430a, 2/11
Helpful Tips for Preventing Claim Delays An independent licensee of the Blue Cross and Blue Shield Association. U7430a, 2/11 Overview + The Do s of Claim Filing + Blue e + Clear Claim Connection (C3) +
More informationKALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES ADMINISTRATIVE PROCEDURE 08.08
KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES ADMINISTRATIVE PROCEDURE 08.08 Subject: Claims Management Section: Financial Management Applies To: Page: KCMHSAS Staff KCMHSAS Contract Providers
More informationPARTICIPATING PROVIDER INTEREST FORM NEW MEXICO MEDICAID ATYPICAL PROVIDERS
PARTICIPATING PROVIDER INTEREST FORM NEW MEXICO MEDICAID ATYPICAL PROVIDERS The attached packet contains the forms required in order to be considered for network participation with Blue Cross Blue Shield
More informationVersion 7.5, August 2017 Page 1 of 11
Version 7.5, August 2017 Page 1 of 11 Overview IHCP Waiver Rendering Provider Enrollment and Profile Maintenance Packet indianamedicaid.com Before You Begin! You are encouraged to use the Provider Healthcare
More informationProvider Entity Disclosure of Ownership, Controlling Interest and Management Statement
Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement Optum is required to collect disclosure of ownership, controlling interest and management information from providers
More informationAccessCUBICIN Enrollment Form
Services Requested REQUIRED Choose the Services that are being Requested INSTRUCTIONS FOR COMPLETING THIS FORM Patient Information REQUIRED Include the primary contact; if other than the patient, include
More informationD. The Medicaid application and information relating to benefits shall be forwarded to the individuals listed below:
Inpatient Provider Manual SECTION D Effective: 10/1/2017 I. FINANCIAL ELIGIBILITY A. A person eligible for Board services is defined as an individual who receives, or is eligible to receive a CMHSP subsidy,
More informationVersion 7.8, December 18, 2017 Page 1 of 14
Version 7.8, December 18, 2017 Page 1 of 14 Overview IHCP Rendering Provider Enrollment and Profile Maintenance Packet indianamedicaid.com Before You Begin! You are encouraged to use the Provider Healthcare
More informationTRICARE NON-NETWORK NUTRITIONIST PROVIDER APPLICATION
TRICARE NON-NETWORK NUTRITIONIST PROVIDER APPLICATION We expect providers to submit claims electronically. If it is necessary to submit a paper claim, the only acceptable forms are the approved red and
More informationDisclosure of Ownership And Control Interest Statement
The federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a provider agreement to disclose to the U.S. Department of Health and Human
More informationClinician Tax ID Add/Update Form
Clinician Tax ID Add / Update Form (Individually Contracted Clinician use Only) PLEASE FOLLOW THE DIRECTIONS BELOW: Prior to filling out this form, review the information in your Provider Record on providerexpress.com
More informationProvider Resubmission, Dispute and Appeal Instructions
Provider Resubmission, Dispute and Appeal Instructions PLEASE READ CAREFULLY AND FOLLOW THE INSTRUCTIONS INDICATED A RESUBMISSION is defined as a claim originally denied because of incorrect coding (would
More informationNew Group Checklist. 30 days prior to the effective date, the following Group information is required:
New Group Checklist 30 days prior to the effective date, the following Group information is required: Group Policy Application completed and signed. Enrollment forms; be sure to complete any applicable
More information4 years after services are furnished.
RECORD TYPE RETENTION PERIOD AUTHORITY MEDICARE 1 42 U.S.C. 1395x (v)(1)(i) Contracts with Subcontractors Any contract between a provider and a subcontractor and between an organization related to the
More informationDear Prospective Provider, THE APPLICATION PROCESS. Step 1: Step 2: Billing Providers. Rendering Providers
P R O V I D E R E N R O L L M E N T I N S T R U C T I O N S Dear Prospective Provider, On behalf of EDS and the Office of Medicaid Policy and Planning (OMPP), thank you for your interest in becoming a
More informationQualified Medicare Beneficiary Program
Qualified Medicare Beneficiary Program Background Information The Qualified Medicare Beneficiary (QMB) program is a Federal benefit administered at the State level. The District of Columbia reimburses
More informationOverview. Before You Begin! Who Uses This Packet. General Instructions. Provider Profile Updates and Revalidations. Tips for Completing this Packet
Overview IHCP Transportation Provider Packet indianamedicaid.com Before You Begin! You are encouraged to use the Provider Healthcare Portal for submitting enrollment transactions to the Indiana Health
More informationProvider Facility Credentialing Application
Provider Facility Credentialing Application INSTRUCTIONS: All sections must be completed. Incomplete applications will result in a delay in processing. Attach copies of the following: Current license(s)/certification(s)
More informationClaim Adjustment Process. HP Provider Relations/October 2013
Claim Adjustment Process HP Provider Relations/October 2013 Agenda Session Objectives Types of Adjustments Adjustment Criteria Adjustment Process Web interchange Replacement Process Paper Adjustment Process
More informationIn order for us to process your provider participation agreement in a timely manner, please follow these guidelines:
New Mexico Medicaid Project 1720-A Randolph Road SE Albuquerque, NM 87106 505-246-9988 505-246-8485 (fax) Dear Medicaid Provider Applicant: Thank you for your interest in becoming a New Mexico Medicaid
More informationChapter 7 General Billing Rules
7 General Billing Rules Reviewed/Revised: 10/10/2017, 07/13/2017, 02/01/2017, 02/15/2016, 09/16/2015, 09/18/2014 General Information This chapter contains general information related to Health Choice Arizona
More informationHospital and Facility Types. 03 Extended Care Facility 30 End-State Renal Disease Clinic
Overview IHCP Hospital and Facility Provider Application and Maintenance Form www.indianamedicaid.com Dear Prospective Provider: Thank you for your interest in the Indiana Health Coverage Programs (IHCP).
More informationNEW YORK STATE MEDICAID PROGRAM INFORMATION FOR ALL PROVIDERS GENERAL BILLING
NEW YORK STATE MEDICAID PROGRAM INFORMATION FOR ALL PROVIDERS GENERAL BILLING Table of Contents COMMON BENEFIT IDENTIFICATION CARD...2 VOICE INTERACTIVE PHONE SYSTEM...3 PRIOR APPROVAL ROSTERS...4 ELECTRONIC
More informationPARAMEDIC PROFESSIONAL LIABILITY
8722 S. Harrison St. Sandy, UT 84070 P.O. Box 4439 Sandy, UT 84091 877-678-7342 Fax 800-498-9880 PARAMEDIC PROFESSIONAL LIABILITY 1. General Information Proposed Effective Date: Applicant is (check all
More informationPROVIDER APPLICATION PROVIDER DEMOGRAPHIC INFORMATION: Page 1. Legal Business Name: DBA Name (if applicable): Address: City: County State Zip
PROVIDER APPLICATION INSTRUCTIONS This form should be typed or legibly printed in black or blue ink. If more space is needed to write on, than attach additional sheets and reference the question being
More informationNorth Shore LIJ Health System, Inc. Facility Name. CATEGORY: Effective Date: 8/15/13
North Shore LIJ Health System, Inc. Facility Name POLICY TITLE: HIPAA Marketing and Sale of Protected Health Information Policy ADMINISTRATIVE POLICY AND PROCEDURE MANUAL POLICY #: 800.43 System Approval
More informationAGREEMENT FOR ACCESS TO PROTECTED HEALTH INFORMATION
AGREEMENT FOR ACCESS TO PROTECTED HEALTH INFORMATION THIS AGREEMENT FOR ACCESS TO PROTECTED HEALTH INFORMATION ( PHI ) ( Agreement ) is entered into between The Moses H. Cone Memorial Hospital Operating
More informationALLIANCE BEHAVIORAL HEALTH PRE-ENROLLMENT INSTRUCTIONS 23071
ALLIANCE BEHAVIORAL HEALTH PRE-ENROLLMENT INSTRUCTIONS 23071 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard Processing is 7 to 10 business days WHERE SHOULD I SEND THE FORMS? Mail forms to: Alliance Behavioral
More informationOverview. Before You Begin! Who Uses This Packet. General Instructions. IHCP Hospital and Facility Provider Enrollment and Profile Maintenance Packet
Overview IHCP Hospital and Facility Provider Enrollment and Profile Maintenance Packet indianamedicaid.com Before You Begin! You are encouraged to use the Provider Healthcare Portal for submitting enrollment
More informationKEYSTONE 65 HMO POINT OF SERVICE ( POS ) GROUP MEDICARE ADVANTAGE CONTRACT. effective as of EFF. DATE. by and between. GROUP NAME (Called the Group)
KEYSTONE 65 HMO POINT OF SERVICE ( POS ) GROUP MEDICARE ADVANTAGE CONTRACT effective as of EFF. DATE by and between GROUP NAME (Called the Group) Group Number: GROUP# and KEYSTONE HEALTH PLAN EAST (Called
More informationUSVI PROVIDER ENROLLMENT APPLICATION
USVI PROVIDER ENROLLMENT APPLICATION DOH Facility, Group Provider Enrollment, FQHC, Hospitals You should use this packet if: You are an institution, ancillary facility, group of practitioners, or sole
More informationPROVIDER Community Inpatient, Partial Hospitalization, and ECT Services 1 MANUAL I. FINANCIAL ELIGIBILITY
PROVIDER Community Inpatient, Partial Hospitalization, and ECT Services 1 I. FINANCIAL ELIGIBILITY A. A person eligible for Board services is defined as an individual who receives, or is eligible to receive
More informationSubcontractor Disclosure of Ownership, Controlling Interest and Management Statement
Subcontractor Disclosure of Ownership, Controlling Interest and Management Statement UnitedHealthcare Community Plan ( UnitedHealthcare ) is required to collect disclosure of ownership, controlling interest
More informationContact Name: Phone #:
NEW BUSINESS APPLICATION MISCELLANEOUS HEALTHCARE FACILITIES PROGRAM Wholesaler: Location: City State Contact Name: Phone #: E-Mail : NOTE Coverage is not afforded by this policy to any resident, intern,
More informationNOTICE OF CHANGE FORM
MANAGING MENTAL HEALTH, INTELLECTUAL/DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES 910.673.9111 (FAX) 910.673.6202 WWW. S A N D H I L L S C E N T E R. O R G V I C T O R I A W H I T T NOTICE OF
More informationDEPARTMENT OF VERMONT HEALTH ACCESS GENERAL PROVIDER AGREEMENT
DEPARTMENT OF VERMONT HEALTH ACCESS GENERAL PROVIDER AGREEMENT ARTICLE I. PURPOSE The purpose of this Agreement is for Department of Vermont Health Access (DVHA) and the undersigned Provider to contract
More informationWV Birth to Three Central Finance Office Payee Agreement
WV Birth to Three Central Finance Office Payee Agreement This Central Finance Office Payee Agreement is entered into by and between WV Birth to Three, and, hereinafter referred to as the Payee. GENERAL
More informationARKANSAS HEALTH NETWORK, LLC CLINICALLY INTEGRATED NETWORK ( CIN ) PARTICIPATION AGREEMENT
ARKANSAS HEALTH NETWORK, LLC CLINICALLY INTEGRATED NETWORK ( CIN ) PARTICIPATION AGREEMENT This CIN Participation Agreement ( Agreement ) is effective as of ( Effective Date ), between Arkansas Health
More informationSection A: Applicant Information (Please print and use black ink only.) Last Name First Name MI Sex M F
New Enrollment Change to Existing Anthem Medicare Supplement Plan Section A: Applicant Information (Please print and use black ink only.) Last Name First Name MI Sex M F Home Street Address (Physical Address,
More informationPRO SPORTS THERAPY, INC. (P.S.T.)
PRO SPORTS THERAPY, INC. (P.S.T.) Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork we need you to complete and bring to your upcoming physical therapy evaluation appointment.
More informationProvider Entity Disclosure of Ownership, Controlling Interest and Management Statement
Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement UnitedHealthcare Community Plan ( UnitedHealthcare ) is required to collect disclosure of ownership, controlling interest
More informationClaims Administrator Questionnaire
Claims Administrator Questionnaire About PartnerRe PartnerRe is an acknowledged leader in providing risk management solutions to accident and health markets around the world. Our team of experienced professionals
More informationComplaints/ Grievances and Concerns, Information and Referrals and Investigations
1 North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services Complaints/ Grievances and Concerns, Information and Referrals
More informationMarch FIRST STEPS EARLY INTERVENTION SERVICES SYSTEM Central Reimbursement Office Agency/Independent Contractor Agreement
FIRST STEPS EARLY INTERVENTION SERVICES SYSTEM Central Reimbursement Office Agency/Independent Contractor Agreement This Agency/Independent Provider Agreement is entered into by and between the Division
More informationIHCP Rendering Provider Agreement and Attestation Form
Version 6.4E, July 2017 Page 1 of 5 This agreement must be completed, signed, and returned to the IHCP for processing. By execution of this Agreement, the undersigned entity ( Provider ) requests enrollment
More informationMHS CMS 1500 Tips and Billing Guidelines
MHS CMS 1500 Tips and Billing Guidelines AGENDA Creating Claim on MHS Web Portal Claim Process Claim Rejection Claim Denial Claim Adjustment Dispute Resolution Taxonomy Eligibility Reviewing Claims DME
More informationClaim Submission. Molina Healthcare of Florida Inc. Marketplace Provider Manual
Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your
More informationOverview. IHCP Billing Provider Enrollment and Profile Maintenance Packet. Before You Begin! Who Uses This Packet. General Instructions
Overview IHCP Billing Provider Enrollment and Profile Maintenance Packet indianamedicaid.com >> Before You Begin! You are encouraged to use the Provider Healthcare Portal for submitting enrollment transactions
More informationALABAMA MEDICAID OUT-OF-STATE
ALABAMA MEDICAID OUT-OF-STATE Enrollment Application INSTRUCTIONS FOR COMPLETING THE APPLICATION PROCESS FOR THE ALABAMA MEDICAID OUT-OF-STATE INSTITUTIONAL This application must be completed in black
More informationCHAPTER 20 - MANAGED CARE HEALTH BENEFIT PLANS SECTION MANAGED CARE DEFINITIONS
CHAPTER 20 - MANAGED CARE HEALTH BENEFIT PLANS SECTION.0100 - MANAGED CARE DEFINITIONS 11 NCAC 20.0101 SCOPE AND DEFINITIONS (a) Scope. (1) Sections.0200,.0300, and.0400 of this Chapter apply to HMOs,
More informationProvider Enrollment Form
Provider Enrollment Form Thank you for your interest in becoming a participating provider with BlueCross BlueShield of Western New York. Please complete all information requested on this enrollment form.
More informationUNITED BEHAVIORAL HEALTH INDIVIDUAL PARTICIPATING PROVIDER AGREEMENT
UNITED BEHAVIORAL HEALTH INDIVIDUAL PARTICIPATING PROVIDER AGREEMENT THIS AGREEMENT is between United Behavioral Health ("UBH") and the undersigned provider (hereinafter referred to as the "Provider").
More informationTRANSACTION STANDARD TRADING PARTNER AGREEMENT/ADDENDUM
TRANSACTION STANDARD TRADING PARTNER AGREEMENT/ADDENDUM This Trading Partner Agreement ( TPA ) is entered into between DXC Technology Services LLC ( DXC Services ), as an agent for the Connecticut Department
More informationDisclosure of Ownership and Control Interest Form
Purpose: In compliance with 42 CFR 457.935, 42 CFR 455.104, 455.105, and 455.106, providers/disclosing entities are required to disclose including, but not limited to, information regarding (1) the identity
More informationEffective Date: 08/2013
POLICY/GUIDELINE TITLE: HIPAA Marketing and Sale of Protected Health Information Policy POLICY #: 800.43 System Approval Date: 5/18/18 Site Implementation Date: 6/17/18 Prepared by: ADMINISTRATIVE POLICY
More informationCLAIM ADJUDICATION CODES AND ACTION
1 45 Adjusted - Above contract rate Post payment and any adjustment to charges. Do not refile. 2 92 Approved Post payment and any adjustment to charges. Do not refile. 3 198 Authed units exceeded Verify
More informationCMS-1500 professional providers 2017 annual workshop
Serving Hoosier Healthwise, Healthy Indiana Plan CMS-1500 professional providers 2017 annual workshop Reminders and updates The (Anthem) Provider Manual was updated in July 2017. The provider manual is
More informationFidelis Care uses TriZetto's Claims Editing Software to automatically review and edit health care claims submitted by physicians and facilities.
BILLING AND CLAIMS Instructions for Submitting Claims The physician s office should prepare and electronically submit a CMS 1500 claim form. Hospitals should prepare and electronically submit a UB04 claim
More informationSTRIDE sm (HMO) MEDICARE ADVANTAGE Claims
9 Claims Claims General Payment Guidelines An important element in claims filing is the submission of current and accurate codes to reflect the provider s services. HIPAA-AS mandates the following code
More informationApplication for Correctional Liability Insurance
Application for Correctional Liability Insurance Instructions: 1. Please read the instructions carefully. Complete and submit all requested information and/or required attachments. This application and
More informationMINNESOTA LIQUOR LIABILITY ASSIGNED RISK PLAN APPLICATION FOR LIQUOR LIABILITY COVERAGE SHORT TERM- SPECIAL EVENT & SEASONAL
MINNESOTA LIQUOR LIABILITY ASSIGNED RISK PLAN Minnesota Joint Underwriting Association APPLICATION FOR LIQUOR LIABILITY COVERAGE SHORT TERM- SPECIAL EVENT & SEASONAL Enclosed is an Application for Coverage
More informationSMALL GROUP MASTER CONTRACT
McLAREN HEALTH PLAN, INC. G-3245 Beecher Road Flint, MI 48532 SMALL GROUP MASTER CONTRACT GROUP: EFFECTIVE DATE: McLaren Health Plan, Inc. ( Plan ), a Michigan health maintenance organization, and the
More informationProvider Facility Credentialing Application
Provider Facility Credentialing Application INSTRUCTIONS: All sections must be completed. Incomplete applications will result in a delay in processing. 2. Attach copies of the following: Current facility
More informationReimbursement Rate. Specialty 01/183- Hospital Based Medical Clinic Outpatient Services
PROMISe Application for Clinic/Outpatient Dept. Reimbursement Rate Specialty 01/183- Hospital Based Medical Clinic Outpatient Services 1. Type of Provider: Hospital Clinic/Outpatient Dept. Hospital Satellite
More informationMEDICARE NEXT GENERATION ACO PREFERRED PROVIDER AGREEMENT
MEDICARE NEXT GENERATION ACO PREFERRED PROVIDER AGREEMENT THIS AGREEMENT ( Agreement ) is entered into as of the day of, 2016 (the Effective Date ) by and between Trinity Health ACO, Inc., a Delaware nonprofit
More informationChild Resident Street Address (required - a PO Box will not be accepted) City County State Zip. Mailing address (if different) City County State Zip
PO Box 339 400 Warren Avenue Bremerton, WA 98337 APPLICATION FOR INDIVIDUAL/FAMILY PLAN COVERAGE KPS is a health care service contractor licensed and marketing in all of Washington State Please review
More informationChapter 8 Section 5. Referrals/Preauthorizations/Authorizations
Claims Processing Procedures Chapter 8 Section 5 1.0 REFERRALS 1.1 The contractor is responsible for reviewing all requests for referrals. The contractor shall not mandate an authorization, to include
More informationCredentialing Application for Practitioners
Instructions Credentialing Application for Practitioners 1. Please accurately and legibly complete all sections of this Credentialing Application, and mark non-applicable fields with N/A. If an entire
More informationHousekeeping. Link Participant ID with Audio. Mute your line UNMUTED. Raise your hand with questions
Housekeeping Link Participant ID with Audio If your Participant ID has not been entered, dial #ParticipantID#. EXAMPLE: Participant ID is 16, then enter #16#. Mute your line UNMUTED MUTED OTHER MUTE OPTIONS
More informationPolicy Change Request
Individual and Family Plans Policy Change Request Thank you for continuing your individual health plan coverage with Providence Health Plan (PHP). Please visit www.providencehealthplan.com for additional
More information220 Burnham Street South Windsor, CT Vox Fax NEW YORK MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
NEW YORK MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER CKNY1 (to be used ONLY by Dental Offices whose category of service is 0200) CKNY2 (to be used ONLY by Dental Clinics)
More informationRendering Provider Agreement
Rendering Provider Agreement IHCP Rendering Provider Enrollment and Profile Maintenance Packet indianamedicaid.com To enroll multiple rendering providers, complete a separate IHCP Rendering Provider Enrollment
More informationOUTPATIENT CLINIC/GROUP PRACTICE APPLICATION AND RELEASE FORM Please check all states which apply: FL GA KS LA MD NJ NM NV NY OH TN TX VA WA
OUTPATIENT CLINIC/GROUP PRACTICE APPLICATION AND RELEASE FORM Please check all states which apply: FL GA KS LA MD NJ NM NV NY OH TN TX VA WA PROVIDER IDENTIFICATION Outpatient Clinic/Group Name: Doing
More informationChapter 8 Section 5. Referrals/Preauthorizations/Authorizations
Claims Processing Procedures Chapter 8 Section 5 1.0 REFERRALS 1.1 The contractor is responsible for reviewing all requests for referrals. The contractor shall not mandate an authorization, to include
More informationProvider/Payee Agreement
Provider/Payee Agreement This Service Provider Agreement is entered into by and between the Department of Health and Hospitals, Office for Citizens with Developmental Disabilities (DHH/OCDD) as the Louisiana
More informationHealth Share Treatment Authorization Request for PA (HSTAR_PA) Form
Health Share Treatment Authorization Request for PA (HSTAR_PA) Form Instructions for Completing the HSTAR General Information This form is for use by providers contracted with Health Share of Oregon as
More informationDRAFT. Exhibit [X]: MCO Indian Addendum. 1. Purpose of Addendum; Supersession.
Exhibit [X]: MCO Indian Addendum 1. Purpose of Addendum; Supersession. This Addendum is intended to become part of any written agreement between the Managed Care Organization (as identified in the signature
More informationNeed help with frequent crisis, housing, transportation?
Need help with frequent crisis, housing, transportation? Kentucky Counseling Center will provide help FREE of charge to qualifying Medicaid recipients. Our Case Management program may assist in the following
More informationCredentialing Alliance PRACTITIONER DATA FORM
Credentialing Alliance PRACTITIONER DATA FORM PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. New providers receive written confirmation of their effective
More informationDISCLOSURE STATEMENT OF OWNERSHIP AND CONTROL INTEREST, RELATED BUSINESS TRANSACTIONS AND PERSONS CONVICTED OF A CRIME
DISCLOSURE STATEMENT OF OWNERSHIP AND CONTROL INTEREST, RELATED BUSINESS TRANSACTIONS AND PERSONS CONVICTED OF A CRIME For definitions, procedures and requirements refer to 42 CFR 455.100-106 (copy attached).
More information20. CLAIMS PROCESSING. A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY:
A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY: A. All Capitated Providers are delegated the responsibility of claims processing for noncapitated services
More informationThe Merck Access Program ENROLLMENT FORM
The Merck Access Program ENROLLMENT FORM P: 877-709-4455 F: 800-977-1957 The Merck Access Program, PO Box 29067, Phoenix, AZ 85038 TO GET STARTED, COMPLETE THE ENROLLMENT FORM AND FAX IT TO 800-977-1957.
More information**CONTINUATION COVERAGE RIGHTS UNDER COBRA**
**CONTINUATION COVERAGE RIGHTS UNDER COBRA** Federal law requires certain employers sponsoring group health plan coverage to offer their employees (and his or her enrolled family members) the opportunity
More informationIndiana Health Coverage Programs IHCP PROVIDER AGREEMENT
IHCP PROVIDER AGREEMENT By execution of this Agreement, the undersigned entity ( Provider ) requests enrollment as a provider in the Indiana Health Coverage Programs. As an enrolled provider in the Indiana
More informationPROVIDER MANUAL. Revised January Page 1
PROVIDER MANUAL Revised January 2018 Page 1 Table of Contents Introduction 3 General Information 4 Who Do I Call? 5 ID Card Logos 6 Credentialing/Recredentialing 7 Provider Changes 8 Referral and Authorization
More informationThe Arc of Florida will verify the availability of dental insurance coverage AND ibudget Waiver funding for all scholarship applicants.
For people with intellectual and developmental disabilities Dear Applicant, The Arc of Florida is a 501c (3) non-profit organization, serving individuals with intellectual and developmental disabilities
More informationClaim Adjustment Process. HP Provider Relations/October 2015
Claim Adjustment Process HP Provider Relations/October 2015 Agenda Types of adjustments System-initiated adjustments Web interchange adjustment process Void feature Paper adjustment process Timely filing
More informationAnthem Blue Cross and Blue Shield Medicare Supplement Application Maine
Anthem Blue Cross and Blue Shield Medicare Supplement Application Maine o New Enrollment o Change to Enrollment Send no money now! For assistance, please contact us at 800-413-3103 or contact your Anthem
More informationNEVADA MUTUAL INSURANCE COMPANY
NEVADA MUTUAL INSURANCE COMPANY PHYSICIANS AND SURGEONS SUPPLEMENTAL APPLICATION FOR PROFESSIONAL CORPORATIONS, ASSOCIATIONS PHYSICIANS AND SURGEONS SUPPLEMENTAL APPLICATION FOR PROFESSIONAL CORPORATIONS,
More informationGuidelines for the Release and Retention of Medical Records Revised February 20, 2015
COLORADO Guidelines for the Release and Retention of Medical Records Revised February 20, 2015 This is a summary of the most frequent asked questions of COPIC s Patient Safety and Risk Management Department.
More informationFrequently Asked Questions Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) Management Program
Frequently Asked Questions Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) Management Program Northwood, Inc. (Northwood) is Well Sense Health Plan s (Well Sense) Durable
More informationCorrectional Medical Facilities and Contractors
Correctional Medical Facilities and Contractors Professional Liability Coverage Application Instructions: 1. Please read the instructions carefully. Complete and submit all requested information and/or
More information