Hospital and Facility Types. 03 Extended Care Facility 30 End-State Renal Disease Clinic

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1 Overview IHCP Hospital and Facility Provider Application and Maintenance Form Dear Prospective Provider: Thank you for your interest in the Indiana Health Coverage Programs (IHCP). This IHCP provider application is customized to meet your individual provider type and specialty enrollment needs. It is important to complete each field in the application to prevent the form from being returned for correction. Ensure that the appropriate person(s) have signed your forms. If you are currently enrolled and you need to make multiple changes to your current provider profile, this form can be used for that purpose. If you have a specific change request, refer to the provider maintenance forms. For example, use the IHCP Address Maintenance Form to change an address or the Electronic Funds Transfer (EFT) form to make a change to your direct deposit account with the IHCP. Provider Type and Specialty: The following provider types are applicable to this application: Hospital and Facility Types 01 Hospital 05 Home Health Agency 02 Ambulatory Surgical Center 06 Hospice 03 Extended Care Facility 30 EndState Renal Disease Clinic 04 Rehabilitation Facility Refer to the Provider Type and Specialty Matrix available on the IHCP Web site at to determine the document requirements for your provider type and specialty. Based on your provider type, the matrix informs you about whether you qualify to be a billing provider. Enter your type and specialty information in Fields 4042 of Schedule A Provider Information. You may submit as many as 15 taxonomies per National Provider Identifier (NPI). If you need more space than what is provided, you may attach a separate sheet listing additional taxonomies and their associated NPI. Business Structure: To properly enroll in the IHCP, compare the structure of your business to the different location types described below, taking into consideration how payment for services is reported to the federal Internal Revenue Service (IRS). All hospital and facility providers receive a billing provider category. A billing provider is an entity that submits claims for services to the IHCP by any submission means, including paper, electronic, or the Web interchange for reimbursement. The billing provider may be a sole proprietor (sole business owner), organization, or corporation. Schedules, Provider Agreement, and Addenda: Complete the following sections. The IHCP Provider Application Packet is divided into the following sections: Schedule A Provider Information This section collects information related to the prospective provider including name, address information, provider type, and provider specialty. Complete all fields. In addition, Providers may also indicate participation in additional programs. The following programs are listed in Schedule A: HealthWatch is a preventative health care program offered to Medicaideligible members younger than 21 years of age. Physicians or nurse practitioners who are enrolled as Medicaid providers are qualified to perform HealthWatch screenings. Reimbursement for HealthWatch services is higher than equivalent services billed using standard CPT codes. HealthWatch screenings must be completed in accordance with < Page 1 of 30> IHCP Hospital and Facility Provider Application and Maintenance Form, Overview

2 recommendations set forth in the HealthWatch Provider Manual Periodicity Schedule. Check the box labeled yes to receive the HealthWatch Provider Manual. The 590 Program is a State medical assistance program providing reimbursement for medically necessary covered medical services provided off site to individuals who reside in State institutions. The following provider types cannot be 590 providers: transportation, hospice, home health, DME, and long term care facilities. There are no outofstate 590 providers. The Medical Review Program provides determination of an applicant s eligibility for Medicaid under the disability category. The provider completes a medical assessment of an applicant and submits the required forms to the Office of Family Resources. The MRT issues a favorable or unfavorable eligibility decisions based on medical evidence that supports whether the applicant has a significant impairment. Once the documentation has been filed, the provider may submit claims to EDS for payment of certain examination and reports. Services should not be performed unless the applicant has presented the pre Medicaid eligibility form. To participate solely in the Medical Review Program, the provider should check the Medical Review Program ONLY. Providers that choose not to participate in the IHCP Programs and have been requested to submit medical records, should check MRT Medical Records. Schedule B Organization Structure This section collects information about the business structure of the prospective provider including information about the ownership and officers of the business. Schedules C.1C.4 Consent to Release Social Security Numbers. The top of Schedule C.1 contains a section that describes the purpose for release of social security numbers and to whom a Social Security number may be released. Schedules C.1, C.2, and C.3 contain signature fields to acknowledge consent for each individual named in the Schedules. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social security number will result in rejection of this application. Disclosure Information Schedule C.1. This section collects information required by federal regulation that details information about those entities or individuals with five percent direct or indirect ownership in the prospective provider s business and the degree of relationship for each individual. Ownership and Control, Subcontractor Relationships Schedule C.2. List the Name, Title, FEIN, and Business Address of any person or entity that has an ownership or controlling interest in any subcontractor in which the provider entity has direct or indirect ownership of five percent or more. Managing Individuals Schedule C.3. List all managing individuals as defined on Schedule C.3. Relationships and Background Information Schedule C.4. Documents family relationships involved in the provider entity and provider background information. The disclosure of social security numbers is used only for the purpose of determining whether persons and entities named in the application are federally excluded parties. Refusal to provide a social security number will result in rejection of this application. Schedule D Institutional Provider Information This section collects information distinct to each facility type. Providers must complete applicable fields. Profile Maintenance Signature Page This page is completed and signed when an additional service location is enrolled, or the form is used to make several changes to the billing provider profile. Provider Agreement The IHCP Provider Agreement must be completed and signed. The Provider Agreement is the first document in this packet following the IHCP Pharmacy Provider Application. Federal W9 Form The W9 form must be completed and signed. Addenda Additional forms are available from the IHCP Web site at The Electronic Funds Transfer Addendum is included in this packet. Submission of this form allows providers to obtain payment by direct deposit. Submit the Claim Certification Statement for Signature on File Addendum to allow adjudication of paper claims without a hand written signature on each form. UB billing providers are required to complete the Claim Certification Statement for Signature on File Addendum. Submit the Change of Ownership Addendum if you are the purchaser of an activelyenrolled provider. Additionally, a copy of the purchase or sales agreement must be included. < Page 2 of 30> IHCP Hospital and Facility Provider Application and Maintenance Form, Overview

3 Mailing Instructions: Please retain a copy of the completed application packet for your records. Enclose the signed Provider Agreement and copies of all required documentation as listed on the provider application checklist, and mail the entire packet to the following address: EDS Provider Enrollment P.O. Box 7263 Application Processing: When the Provider Enrollment Unit receives, reviews, and processes the provider application, the provider will receive notification. If the application is incomplete or the required supporting documentation is not present, the entire application packet is returned. An instructional letter stating the reason(s) the enrollment request was not completed is included with the packet. If the IHCP denies the application, the provider receives notification explaining the denial reason. Please allow at least 30 business days for mailing and processing before checking the status of the submitted provider application. Refer to the IHCP Web site at for additional information or contact the Provider Enrollment Helpline at for assistance in completing IHCP provider application. Application Checklist: The following checklist is designed to assist providers and the IHCP in completing and verifying that information is included in this packet. Provider Use Only Did you remember to Complete all IHCP Provider Application Schedules (A, B, C, and D) Documented the ZIP + 4 for the physical location of the hospital or facility (Required) Complete and sign the IHCP Provider Agreement (Original signature required) Complete and sign the current Federal W9 form for tax identification purposes Include copies of license(s) or permits for your provider specialty or specialties Include a copy of your Medicare Assignment Letter, if applicable Complete the Change of Ownership Addendum, if applicable Include all other elected addenda For IHCP Use Only < Page 3 of 30> IHCP Hospital and Facility Provider Application and Maintenance Form, Overview

4 Schedule A IHCP Hospital and Facility Provider Application and Maintenance Form 1. Request Type: Provider Information New Enrollment Additional Service Location Update 2. National Provider Identifier: 3. ZIP + 4: (Nine digits required) 4. Taxonomies: 5. IHCP Provider Number and Alpha Suffix: (If currently 6. Document Submission Date: 7. Requested Enrollment Effective Date: enrolled) 8. Change of Ownership? No (If, complete the Change of Ownership Addendum) Billing Provider Office Location Name and Address The billing provider office location name and address is for the site where members obtain services and is either owned or rented by the billing provider. This location maintains supporting documentation related to the claim. The billing provider office location name must be the Doing Business As (DBA) name registered with the Secretary of State, except for informal associations (Sole Proprietorship and General Partnerships). Providers, who provide services at a place of service site, such as a hospital or nursing facility, should enter their home/business office as their billing provider office location address and not the place of service address. The address must be a physical location. A post office box is not a valid billing provider office location address. 9. DBA Name: 10. Indiana County: 11. Telephone: 12. Street Address: 13. City: 14. State: 15. ZIP + 4: (Nine digits required) 16. Is claim documentation kept at this location? No 17. Are services provided in Indiana? Legal Name and Home Office Address The home office is considered to be the legal entity maintaining ownership of the above billing provider office location. The legal name must be the current name on tax, corporation, and other legal documents, and currently registered with the Secretary of State, or filed with the State as the Assumed Business Name. The legal name and business name, as well as the address, must match what is on the W Legal Name: No 19. Street Address: 20. City: 21. State: 22. ZIP + 4: (Nine digits required) 23. Telephone: 24. Tax ID Number: < Page 4 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule A

5 Mailing Name and Address The mailing address is the location where the IHCP sends provider bulletins, newsletters, manuals, and general correspondence. A post office box is acceptable for a mailing address. 25. Name: 26. Telephone: 27. Street Address: 28. City: 29. State: 30. ZIP + 4: (Nine digits required) Pay To Name and Address The pay to address is the location where the IHCP sends checks, remittance advices, and general claims payment information. If this is a billing agent s address, please provide the name, address, and phone number of the billing agent. The name listed below as the Payee Name will appear as the payee on all checks. A post office box is acceptable for this address. Billing agents must furnish proof of authorization to be the billing agent for provider. 31. Payee Name: 32. Billing Agent Name: 33. Telephone: 34. Street Address: 35. City: 36. State: 37. ZIP + 4: (Nine digits required) Contact Name The contact person is the person who answers questions about the information provided in this form. 38. Contact Name: 39. Telephone: 40. Contact Would you like a link to t he Web interchange application sent to your address? No 42. Are you willing to receive IHCP bulletins and newsletters via or the Web? No Provider Specialty Information Refer to the Provider Type and Specialty Matrix on the IHCP Web site to determine the appropriate provider type, specialty codes, and enrollment requirements for this application. Only one provider type code is permitted per application. Submit a separate application for each additional provider type. 43. Provider Type (two digit code): 44. Primary Specialty (three digit code): 45. Additional Specialties: 46. Taxonomies (Enter only those taxonomies that apply to this service location): Licensing Information 47. License Number: 48. Effective Date: 49. Expiration Date: 50. Licensing State: Note: A copy of the license from the appropriate licensing board must accompany this application. EDS will return the entire application as incomplete if a copy of the license is not attached. < Page 5 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule A

6 Indiana State Department of Health Licensing Information Institutional providers that are surveyed and licensed by the Indiana State Department of Health (ISDH) are enrolled after EDS receives a completed CMS1539, Certification and Transmittal Form (C&T) from the ISDH. The ISDH must survey each institutional provider to determine if the provider meets federal and state qualifications to participate in the IHCP. 51. Certified or Licensed by the ISDH? No 52. Completed the ISDH survey process? Providers who answer No in Field 51 must contact the ISDH to complete the survey process prior to IHCP enrollment. CLIA Certification Document your Clinical Laboratory Improvement Amendment (CLIA) Certificate information in this section. CLIA numbers are assigned to one specific service location unless CMS exemption status is met. 53. CLIA Number: 54. Certification Type: 55. Effective Date: 56. Expiration Date: No Note: A copy of the certificate must be attached to the application. Failure to attach a copy of the certificate will result in denied claims for laboratory services. Medicare Participation Please provide the appropriate Medicare identification numbers. Outofstate providers must submit proof of participation in Medicare and their state s Medicaid program. See the Type and Specialty Matrix for specific document requirements. 57. Medicare Number: 58. Issuing State: 59. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Number: 60. Address for Location Where the Medicare Number is Assigned: Notes: A copy of the Medicare number assignment letter (or a Medicare Remittance Notice with correct Medicare number) is recommended to ensure accuracy of Medicare number assignment. 61a. Are you currently, or have you ever been enrolled as an IHCP provider? No Previous IHCP Enrollment Information 61b. IHCP Provider Number(s): Other IHCP Program Participation Providers may elect to participate in additional programs. The application overview provides detailed information about each of the programs listed in this section. 62a. Participate in the HealthWatch Program: 62b. Participate in the 590 Program: No 62c. Participate in the Medical Review Program: No 63. Percentage of your patient population with the following payment sources: (63a, b, c, and d must add up to 100%) 62d. Participation: Patient Population Information No Medical Review ONLY MRT Medical Records 63a. Medicaid: 63b. SelfPay: 63c. Medicare: 63d. TPL: < Page 6 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule A

7 IHCP Hospital and Facility Provider Application and Maintenance Form Schedule B 1. Provider Entity Legally Organized and Structured As (Check only one): Organizational Structure For Profit Corporation Partnership Sole Proprietorship Not For Profit Corporation Government Owned Limited Liability Partnership Limited Liability Company Other, please specify * If yes, submit a copy of the state registration papers (405 IAC 119.1b). If no, and your No business name is different from your name, please submit a copy of the Assumed Business Name form on file with the State. 2. Registered with Secretary of State*: 3. Date Business Started: 4a. Entity Incorporated: No 4b. If answered in 4a, Incorporation Date: 5. Chain Affiliated ** No ** If yes, the information about the company or organization must be included in the disclosure information. 6. Operated by Management Company or Leased (Whole or Part) by Another ***If yes, the information about the company or Organization*** : No organization must be included in the disclosure information. < Page 7 of 30> IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule B

8 Schedule C IHCP Hospital and Facility Provider Application and Maintenance Form C.1 Disclosure Information Ownership and Control, Provider Entity Instructions: Please complete all four sections of Schedule C Ownership and Control, Provider Entity; Ownership and Control, Subcontractor Relationships; Managing Individuals; and Relationships and Background Information. Nonprofit providers must list the business entity that owns their tax identification number. Disclosure of Social Security Numbers: Disclosure of social security numbers is used for the purpose of determining whether persons and entities named in an application are federally excluded parties and to verify licensure. The IHCP Provider Application and Profile Maintenance Form's C Schedules are used to collect information required by State and federal regulations. The regulations detail information about those entities or individuals with five percent direct or indirect ownership in the prospective provider s business and the degree of relationship for each individual. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social security number will result in rejection of this application. *Consent To Release Social Security Numbers: All persons whose names are written in boxes marked 1a of Schedules C1, C2, and C3 are asked to place their signature in box 1b. A signature in box 1b shall indicate that the signatory agrees to the following statement regarding the disclosure of his or her social security number: My signature in box 1b in Schedule C1, C2, or C3 indicates that I give my express consent to the Office of Medicaid Policy and Planning and its contractors to disclose my social security number for the sole purpose of verifying my eligibility to participate in the Medicaid program with the Office of the Inspector General, the Centers for Medicare and Medicaid Services, licensing bodies, and other appropriate state and federal agencies. I further consent that the Office of Medicaid Policy and Planning and its contractors may disclose my social security number to such appropriate organizations or agencies after this application has been approved so that the Office may review my ability to continue to participate in the Medicaid program. Disclosure of Ownership and Control, Provider Entity List the Name, Title, Federal Employer Identification Number (FEIN), and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in your provider entity. This includes any person or entity that has a direct or indirect ownership interest equal to five percent or more of the value of the provider entity; or owns an interest of five percent or more in any mortgage, deed of trust, note or other obligation secured by the provider entity if that interest equals five percent of the value of the property of assets of the provider entity. Copy this page to list additional names. If a corporation is publicly held and no person owns five percent or more of the corporation, or if the corporation is notforprofit entity, then proceed to schedule C3 and list the Board of Directors with the information requested. < Page 8 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule C

9 C.1 Disclosure Information Ownership and Control, Provider Entity (Continued) < Page 9 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule C

10 C.2 Disclosure Information Ownership and Control, Subcontractor Relationships Disclosure of Ownership and Control, Subcontractor Relationships List below the Name, Title, FEIN, and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in any subcontractor in which the provider entity has direct or indirect ownership of five percent or more. Copy this page to list additional names. < Page 10 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule C

11 C.3 Disclosure Information Managing Individuals Managing Individuals List below the Name, Title, FEIN, and Business Address of ALL agents, officers, directors, and managing employees who have expressed or implied authority to obligate or act on behalf of the provider entity. Any individual who has operational or managerial control over, or who directly or indirectly conducts the daytoday operation of the provider entity should be included. This may include such individuals as a general manager, business manager, administrator, or director. Copy this page to list additional names. Notforprofit providers must also list their managing individuals. < Page 11 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule C

12 C.4 Disclosure Information Relationships and Background Information 1. Indicate if any of the individuals listed in Schedule C.1, C.2, or C.3 are related through blood or marriage, as spouse, parent, child, or sibling. List the names and degree of relationship. Copy this page if additional space is required. Nonprofit providers must complete schedule C.4. Use N/A as appropriate. 1a. Name of Person 1: Name of Person 2: Relationship: 1b. Name of Person 1: Name of Person 2: Relationship: 1c. Name of Person 1: Name of Person 2: Relationship: 2. Indicate if any persons or entities listed in Schedule C.1, C.2, C.3, or any secured creditor(s) of the provider entity, have ever been sanctioned either through criminal conviction, or exclusion from participation in any program under Medicare, Medicaid, or Title XX services since the inception of the programs. 2a. Name: LPI or NPI: Date of Sanction: Type of Sanction: Date Sanction Ended: 2b. Name: LPI or NPI: Date of Sanction: Type of Sanction: Date Sanction Ended: 2c. Name: LPI or NPI: Date of Sanction: Type of Sanction: Date Sanction Ended: 3. Indicate if any persons or entities listed in Schedule C.1, C.2, C.3, or any secured creditor(s) of the provider entity, have ever been placed on prepayment review. 3a. Name: LPI or NPI: 3b. Name: LPI or NPI: 3c. Name: LPI or NPI: 3d. Name: LPI or NPI: 4. Indicate if any persons or entities listed in Schedule C.1, C.2, or C.3 have an ownership or controlling interest in any other current or prospective provider. 4a. Name: LPI or NPI: 4b. Name: LPI or NPI: 4c. Name: LPI or NPI: 5. Indicate any former agent, officer, director, partner, or managing employee from the lists in this schedule, who has transferred ownership to a family member related through blood or marriage, either as spouse, parent, child, or sibling, in anticipation of or following a conviction or imposition of an exclusion. 5a. Name of Person 1: Name of Person 2: Relationship: 5b. Name of Person 1: Name of Person 2: Relationship: < Page 12 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule C

13 Schedule D IHCP Hospital and Facility Provider Application and Maintenance Form Institutional Provider Information Complete the appropriate portions of this schedule based on your provider type and specialty. Hospital 1. Provider satisfies the requirements of 42 USC Section 1395ww(d)(5)(D)(iii) to qualify as a sole community hospital: No 2. Provider qualifies as a teaching hospital (used for rate setting): 3. Number of Beds: No Psychiatric Hospital A copy of the Private Mental Health Institution license from the Division of Mental Health and Addiction must be included with the application. If the facility s bed count is 16 bed or less, you must complete Addendum to be designated a 16 bed or less psychiatric facility. Long Term Care Facility 4. Enrolling in Medicaid solely for reimbursement of services provided to Qualified Medicare Beneficiaries (QMBs)? No Psychiatric Residential Treatment Facility To be eligible for enrollment as a PRTF, the facility must be licensed under 470 IAC 313 as a private, secure, childcaring institution, and must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Council On Accreditation (COA), or the Council on Accreditation of Rehabilitation Facilities (CARF). All enrolled facilities must comply with the requirements in 42 CFR 482, Subpart G governing the use of restraint and seclusion, and submit an attestation letter to the enrollment broker. Copy of the Attestation Letter submitted with application. Copy of the license for secure facility submitted with application. Copy of the credentialing verification from approved accrediting entity. 5. Affiliation: Psychiatric Hospital Mental Health Facility Acute Care Hospital No Freestanding Facility < Page 13 of 30 > IHCP Hospital and Facility Provider Application and Maintenance Form, Schedule D

14 Signature Page IHCP Hospital and Facility Provider Application and Maintenance Form Signature Authorization for Profile Maintenance ENROLLMENT AND PROFILE MAINTENANCE: An official with the provider must complete and sign Items 16 to authorize the request to make changes to a currently enrolled service location profile. The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth herein. The undersigned acknowledges that the commission of any Medicaid or CHIP related offense, as set out in 42 USC 1320a7b may be punishable by a fine of up to $25,000 or imprisonment of up to five years or both. The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. The form will be returned if the appropriate signatures are not submitted. 1. Hospital or Facility Name (please print): 2. Tax ID: 3. Authorized Official s Name (please print): 4. Title: 5. Authorized Official s Signature: 6. Date: To the Signatory: Please complete the IHCP Delegated Administrator Addendum if you are not an authorized official with your group. Provider profile maintenance can be processed only if the appropriate signature is present. < Page 14 of 30> IHCP Hospital and Facility Provider Application and Maintenance Form, Signature Page

15 Overview IHCP Provider Agreement New Enrollee or New Provider Type: IHCP Provider Agreement Overview If the application you completed is a firsttime enrollment in the Indiana Health Coverage Programs (IHCP), you are required to complete and sign a Provider Agreement to fulfill your enrollment requirements. Providers whose eligibility has lapsed for one year or greater are required to reenroll to restore their eligibility. A full enrollment packet must be submitted for processing. An owner or official with your business must sign the IHCP Provider Agreement. An original signature is required. A new IHCP number is assigned to each Provider Type enrolled in the IHCP. Additional Service Location: If the application you completed was used to enroll an additional service location to your existing business, you are not required to sign an IHCP Provider Agreement. Provider Agreement Summary: The Agreement details the requirements for participation in the IHCP. Included are provider responsibilities regarding updating provider information, protecting patient health information, requirements for claims processing, overpayments, and record retention. In addition, the Agreement details obligations regarding the appeals process, civil rights regulation compliance, utilization, control, and disclosure rules. The entire Agreement must be read, signed, and returned with the application. A signed copy must be retained by the provider. < Page 15 of 30 > IHCP Provider Agreement, Overview

16 Provider Agreement IHCP Provider Agreement This agreement must be completed, signed, and returned to EDS for processing. 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 Health Coverage Programs, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members. As a condition of enrollment, this agreement cannot be altered and the Provider agrees to all of the following: 1. To comply, on a continuing basis, with all enrollment requirements established under rules adopted by the state of Indiana Family and Social Services Administration ( IFSSA ). 2. To comply with all federal and state statutes and regulations pertaining to the Indiana Health Coverage Programs, as they may be amended from time to time. 3. To meet, on a continuing basis, the state and federal licensure, certification or other regulatory requirements for Provider s specialty including all provisions of the state of Indiana Medical Assistance law, state of Indiana Children s Health Insurance Program law, or any rule or regulation promulgated pursuant thereto. 4. To notify IFSSA or its agent within ten (10) days of any change in the status of Provider s license, certification, or permit to provide its services to the public in the state of Indiana. 5. To provide covered services and/or supplies for which federal financial participation is available for Indiana Health Coverage Program members pursuant to all applicable federal and state statutes and regulations. 6. To safeguard information about Indiana Health Coverage Program members including at a minimum: a. members name, address, and social and economic circumstances; b. medical services provided to members; c. members medical data, including diagnosis and past history of disease or disability; d. any information received for verifying members income eligibility and amount of medical assistance payments; e. any information received in connection with the identification of legally liable third party resources. 7. To release information about Indiana Health Coverage Program members only to the IFSSA or its agent and only when in connection with: a. providing services for members; and b. conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the provision of Indiana Health Coverage Program covered services. 8. To maintain a written contract with all subcontractors, which fulfills the requirements that are appropriate to the service or activity delegated under the subcontract. No subcontract, however, terminates the legal responsibility of the contractor to the agency to assure that all activities under the contract are carried out. 9. Provider also agrees to notify the IHCP in writing of the name, address, and phone number of any entity acting on Provider s behalf for electronic submission of Provider s claims. Provider understands that the State requires 30days prior written notice of any changes concerning Provider s use of entities acting on Provider s behalf for electronic submission of Provider s claims and that such notice shall be provided to the IHCP. 10. To submit claims for services rendered by the Provider or employees of the Provider and not to submit claims for services rendered by contractors unless the provider is a healthcare facility (such as hospital, ICFMR, or nursing home), or a government agency with a contract that meets the requirements described in item 8 of this Agreement. Healthcare facilities and government agencies may, under circumstances permitted in federal law, subcontract with other entities or individuals to provide Indiana Health Coverage Program covered services rendered pursuant to this Agreement. 11. To comply, if a hospital, nursing facility, provider of home health care and personal care services, hospice, or HMO; with advance directive requirements as required by 42 Code of Federal Regulations, parts 489, subpart I, and To abide by the Indiana Health Coverage Programs Provider Manual, as amended from time to time, as well as all provider bulletins and notices. Any amendments to the provider manual, as well as provider bulletins and notices, communicated to Provider shall be binding upon receipt. Receipt of amendments, bulletins and notices < Page 16 of 30 > IHCP Provider Agreement

17 by Provider shall be presumed when mailed to the billing Provider s current mail to address on file with IFSSA or its fiscal agent. 13. To submit timely billing on Indiana Health Coverage Program approved claim forms, as outlined in the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages, in an amount no greater than Provider s usual and customary charge to the general public for the same service. 14. To be responsible and accountable for the completion, accuracy, and validity of all claims filed under the provider number issued, including claims filed by the Provider, the Provider s employees, or the Provider s agents. Provider understands that the submission of false claims, statements, and documents or the concealment of material fact may be prosecuted under the applicable federal and/or state law. 15. To submit claim(s) for Indiana Health Coverage Program reimbursement only after first exhausting all other sources of reimbursement as required by the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages. 16. To submit claim(s) for Indiana Health Coverage Program reimbursement utilizing the appropriate claim forms and codes as specified in the provider manual, bulletins and notices. 17. To submit claims that can be documented by Provider as being strictly for: a. medically necessary medical assistance services; b. medical assistance services actually provided to the person in whose name the claim is being made; and c. compensation that Provider is legally entitled to receive. 18. To accept payment as payment in full the amounts determined by IFSSA or its fiscal agent, in accordance with federal and state statutes and regulations as the appropriate payment for Indiana Health Coverage Program covered services provided to Indiana Health Coverage Program members (recipients). Provider agrees not to bill members, or any member of a recipient s family, for any additional charge for Indiana Health Coverage Program covered services, excluding any copayment permitted by law. 19. To refund within fifteen (15) days of receipt, to IFSSA or its fiscal agent any duplicate or erroneous payment received. 20. To make repayments to IFSSA or its fiscal agent, or arrange to have future payments from the Indiana Health Coverage Program withheld, within sixty (60) days of receipt of notice from IFSSA or its fiscal agent that an investigation or audit has determined that an overpayment to Provider has been made, unless an appeal of the determination is pending. 21. To pay interest on overpayments in accordance with IC , IC , and IC To make full reimbursement to IFSSA or its fiscal agent of any federal disallowance incurred by IFSSA when such disallowance relates to payments previously made to Provider under the Indiana Health Coverage Programs. 23. To fully cooperate with federal and state officials and their agents as they conduct periodic inspections, reviews and audits. 24. To make available upon demand by federal and state officials and their agents all records and information necessary to assure the appropriateness of Indiana Health Coverage Program payments made to Provider, to assure the proper administration of the Indiana Health Coverage Program and to assure Provider s compliance with all applicable statutes and regulations. Such records and information are specified in 405 IAC 15 and in the Indiana Health Coverage Programs Provider Manual, and shall include, without being limited to, the following: a. medical records as specified by Section 1902(a)(27) of Title XIX of the Social Security Act, and any amendments thereto; b. records of all treatments, drugs and services for which vendor payments have been made, or are to be made under the Title XIX or Title XXI Program, including the authority for and the date of administration of such treatment, drugs or services; c. any records determined by IFSSA or its representative to be necessary to fully disclose and document the extent of services provided to individuals receiving assistance under the provisions of the Indiana Health Coverage Program; d. documentation in each patient s record that will enable the IFSSA or its agent to verify that each charge is due and proper; e. financial records maintained in the standard, specified form; f. all other records as may be found necessary by the IFSSA or its agent in determining compliance with any federal or state law, rule, or regulation promulgated by the United States Department of Health and Human Services or by the IFSSA; and g. any other information regarding payments claimed by the provider for furnishing services to the plan. < Page 17 of 30 > IHCP Provider Agreement

18 25. To cease any conduct that IFSSA or its representative deems to be abusive of the Indiana Health Coverage Program. 26. To promptly correct deficiencies in Provider s operations upon request by IFSSA or its fiscal agent. 27. To make a good faith effort to provide and maintain a drugfree workplace. Provider will give written notice to the State within ten (10) days after receiving actual notice that the provider or an employee of the provider has been convicted of a criminal drug violation occurring in the provider s workplace. 28. To file all appeal requests within the time limits listed below. Appeal requests must state facts demonstrating that: a. the petitioner is a person to whom the order is specifically directed; b. the petitioner is aggrieved and, or adversely affected by the order; c. the petitioner is entitled to review under the law. 29. Provider must file a statement of issues within the time limits listed below, setting out in detail: a. the specific findings, actions, or determinations of IFSSA from which Provider is appealing; b. with respect to each finding, action or determination, all statutes or rules supporting Provider s contentions of error. 30. Time limits for filing an appeal and the statement of issues are as follows: a. A provider must file an appeal of any of the following actions within sixty days of receipt of IFSSA s determination: (1) A notice of program reimbursement or equivalent determination regarding reimbursement or a year end cost settlement. (2) A notice of overpayment. (3) The statement if issues must be filed with the request for appeal. b. All appeals of actions not described in (a) must be filed within 15 days of receipt of IFSSA s determination. The statement of issues must be filed within 45 days of receipt of IFSSA s determination. 31. To cooperate with IFSSA or its agent in the application of utilization controls as provided in federal and state statutes and regulations as they may be amended from time to time. 32. To comply with the advance directives requirements as specified in 42 C.F.R. part 489, subpart I, and 42 C.F.R (d), as applicable. 33. To comply with civil rights requirements as mandated by federal and state statutes and regulation by ensuring that no person shall, on the basis of race, color, national origin, ancestry, disability, age, sex or religion, be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination in the provision of a Indiana Health Coverage Program covered service. 34. The Provider and its agents shall abide by all ethical requirements that apply to persons who have a business relationship with the State, as set forth in Indiana Code 426 et seq., Indiana Code 427, et seq., the regulations promulgated thereunder, and Executive Order 0408, dated April 27, If the Provider is not familiar with these ethical requirements, the Provider should refer any questions to the Indiana State Ethics Commission, or visit the Indiana State Ethics Commission Web site at <<< If the Provider or its agents violate any applicable ethical standards, the State may, in its sole discretion, terminate this Agreement immediately upon notice to the Provider. In addition, the Provider may be subject to penalties under Indiana Code 426, 427, , and under any other applicable laws. 35. To disclose information on ownership and control, information related to business transactions, information on change of ownership, and information on persons convicted of crimes in accordance with 42 Code of Federal Regulations, part 455, subpart B, and 405 IAC 119. Long term care providers must comply with additional requirements found in 405 IAC 120. Pursuant to 42 Code of Federal Regulations, part (c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law. 36. To submit within 35 days of the date of request by the federal or state agency full and complete information about ownership of subcontractors with whom the provider has had more than $25,000 in a twelve month hearing period, and any significant business transactions between the provider and any (1) wholly owned supplier or (2) subcontractor during fiveyear period ending with the date of request. 37. Long term care providers must comply with additional requirements found in 405 IAC 120. Pursuant to 42 Code of Federal Regulations, part (c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law. 38. To furnish to IFSSA or its agent, as a prerequisite to the effectiveness of this Agreement, the information and documents set out in Schedules A through I to this Agreement, which are incorporated here by reference, and to update this information as it may be necessary. < Page 18 of 30 > IHCP Provider Agreement

19 39. That subject to item 32, this Agreement shall be effective as of the date set out in the provider enrollment notification letter. 40. That this Agreement may be terminated as follows: a. By IFSSA or its fiscal agent for Provider s breach of any provision of this Agreement as determined by IFSSA; or b. By IFSSA or its fiscal agent, or by Provider, upon 60 days written notice. 41. That this Agreement has not been altered, and upon execution, supersedes and replaces any provider agreement previously executed by the Provider. 42. For long term care providers involved in a change of ownership, this agreement acts as an amendment to the transferor s agreement with IHCP to bind the transferee to the terms of the previous agreement; and any existing plan of correction and pending audit findings in accordance with 405 IAC For new owners of nursing facilities or intermediate care facilities for the mentally retarded, to accept the assignment of the provider agreement executed by the previous owner(s) as required by 42 CFR For any entity that receives or makes annual payments totaling at least $5,000,000 annually as described in 42 U.S.C. 1396a(a)(68), to establish written policies that provide detailed information about federal and state False Claims Acts, whistleblower protections, and entity policies and procedures for preventing and detecting fraud and abuse. In any inspection, review, or audit of the entity by OMPP or its contractors, the entity shall provide copies of the entity s written policies regarding fraud, waste, and abuse upon request. Entity shall submit to OMPP a corrective action plan within 60 days if the entity is found not to be in compliance with any part of the requirements stated in this paragraph. 45. To verify and maintain proof of verification that no employee or contractor is an excluded individual or entity with the Health and Human Services (HHS) Office of the Inspector General (OIG). Providers shall review the HHSOIG List of Excluded Individuals/Entities (LEIE) database for excluded parties. This LEIE database is accessible to the general public at THE UNDERSIGNED, BEING THE PROVIDER OR HAVING THE SPECIFIC AUTHORITY TO BIND THE PROVIDER TO THE TERMS OF THIS AGREEMENT, AND HAVING READ THIS AGREEMENT AND UNDERSTANDING IT IN ITS ENTIRETY, DOES HEREBY AGREE TO ABIDE BY AND COMPLY WITH ALL THE STIPULATIONS, CONDITIONS, AND TERMS SET FORTH HEREIN. THE UNDERSIGNED ACKNOWLEDGES THAT THE COMMISSION OF ANY INDIANA HEALTH COVERAGE PROGRAM RELATED OFFENSE AS SET OUT IN 42 USC 1320a7b MAY BE PUNISHABLE BY A FINE OF UP TO $25,000 OR IMPRISONMENT OF UP TO FIVE YEARS OR BOTH. Provider AgreementAuthorized Signature All Schedules and Applicable Addendums The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. In addition, all rendering providers must sign this section. Provider s Business Name (Please Print): Tax ID: Authorized Official s or Rendering Provider s Name (Please Print): Title: Authorized Official s or Rendering Provider s Signature: Date: < Page 19 of 30 > IHCP Provider Agreement

20 Overview Federal W9 Form Overview W9 Form Overview A W9 must be completed and submitted with each new enrollment and addition of new service locations. < Page 20 of 30 > Federal W9 Form Overview

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25 Overview IHCP Electronic Funds Transfer Addendum Overview Electronic Funds Transfer Overview The IHCP will establish a direct deposit account with your bank for claims payment. After you have established electronic funds transfer (EFT), the IHCP will electronically transfer payments into the account you specify on the following EFT Addendum. Please read the instructions on the EFT Addendum carefully and ensure that the appropriate signature and attachment are included. All claims processed by Friday at 4:30 p.m. will appear on the weekly remittance advice produced on the following Tuesday. EFT payment occurs each Wednesday. It takes approximately 18 days for the bank to process and completely establish your EFT account. If you bill claims prior to your EFT activation, paper checks are mailed to the Pay To address documented on Schedule A of the enrollment application. When your EFT account becomes active, direct deposits begin. Thank you for considering EFT as a payment option. < Page 25 of 30 > IHCP Electronic Funds Transfer Addendum, Overview

26 Addendum IHCP Electronic Funds Transfer Addendum General Information Complete all fields on form, and follow attachment instructions below. Confirm bank s ABA transit routing number. Account Belongs to Billing Agency: No Provider Name: Provider LPI Number: Service Location (alpha suffix): Provider Tax ID: National Provider Identifier: Provider Location ZIP + 4: Name on Bank Account: Bank Name: Tax ID of Account Holder: ABA Transit Routing Number: Bank Account Number: Bank Address: City: State: ZIP + 4: Bank Telephone Number: Type of Authorization: Start Cancel Change Type of Account Savings Due to Change of Ownership Checking ATTACHMENT: Please include one of the following documents with this form for verification of account owner and account numbers: voided check or a signed letter from your bank that lists the account holder s name, tax identification number, and the appropriate account and routing numbers. On behalf of the provider entity named above, I agree to keep, and disclose upon request to authorized agencies, records that fully disclose the extent of claim payments received from and services rendered to members of the Indiana Health Coverage Programs (IHCP). I accept, as payment in full, the amount paid by the IHCP for claims submitted with the exception of authorized cost sharing by members. I understand payment of IHCP claims is from state and federal funds and that any false claims, statements, documents or concealment of a material fact may be prosecuted under state or federal law. I ensure that this EFT request complies with the regulation set forth in 42 CFR , which prohibits State payments for any IHCP service to be made to anyone other than a Provider, a noncash member, or to one of the listed exceptions. I understand that an IHCP payment may be sent via EFT to an account held by the following only: (1) to the Provider; (2) a noncash member; (3) a government agency on reassignment by the Provider (IRS); (4) a third party by court order on reassignment by the Provider (child support); (5) a business agent (billing service, account firm) if three specific criteria are met (see page 2*); (6) the employer of the Practitioner (if a contract so requires); (7) a health care facility, or a health care delivery system (if a contract so requires) if the organization itself submits the claim directly to the IHCP. I authorize the electronic transfer of IHCP payments (including 590, Medicaid, and Package C) made to the above provider number. I understand that I am responsible for the validity of the above information. I agree to notify EDS within ten days of any change in any of the information included on this form. This section must be completed by an authorized officer or owner of the billing provider. Printed Name: Title: No Signature: Date: It will take approximately four weeks for this information to be processed by EDS and validated by your bank. Please send this form to EDS, Provider Enrollment, P.O. Box 7263,. < Page 26 of 30 > IHCP Electronic Funds Transfer Addendum