Government of the District of Columbia Department of Health Care Finance (DHCF)

Transcription

1 Government of the District of Columbia Department of Health Care Finance (DHCF) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME/POS) Medicaid Provider Enrollment Package APPLICATION PROCESS Step One New applicants and re-enrolling providers are required to first submit a completed application along with requested documentation. A separate application is required for each service location at which the applicant intends to provide DME/POS services. DHCF will review the application and make a determination within 30 business days as to whether the applicant can proceed to the next steps of the application process. Applicants not successfully completing Step One will be notified in writing. Completion of Step One, by itself, does not constitute acceptance into the Program. Step Two Applicants successfully completing Step One will be required to attend a mandatory provider orientation (specific staff from the applying company must attend, as appropriate) and sign a Provider Agreement along with accompanying documents. Step Three Applicants successfully completing Steps One and Two of the process will be notified of their acceptance or re-enrollment into the Program. Once notified of acceptance, providers will be permitted to bill and receive reimbursement for services rendered to District of Columbia Medicaid recipients. IMPORTANT FACTS TO REMEMBER Submission of an application does not constitute automatic acceptance or re-enrollment into the program. Anticipated time for DHCF s review of applications and determination of whether applicants can proceed to orientation is approximately 30 business days. Applications will be rejected and returned to sender if any information is omitted, requested documentation is not included, or the submitted package is not assembled as instructed. A National Provider Identifier (NPI) is mandatory. For information on the NPI, visit In-State DME/POS Providers are defined as entities whose service site is located inside the geographic boundaries of the District of Columbia. Out of-state DME/POS Providers are defined as entities whose service site is located outside the geographic boundaries of the District of Columbia. A separate application is required for each location at which the applicant intends to provide DME/POS services. Complete each section of the application, if applicable. Do not remove any pages from the application package. Electronic copies of the DME/POS Provider Enrollment Package can be found on the District of Columbia Department of Health Care Finance website at Last Revised: 04/01/2016 1

2 Direct questions to: District of Columbia Fiscal Agent Xerox State Healthcare Enrollment Division 8 A.M. to 5 P.M. EST, Monday through Friday (inside the District of Columbia) (outside the District of Columbia) Mail completed application package to: Provider Enrollment Xerox State Healthcare Provider Enrollment P.O. Box Washington, DC Last Revised: 04/01/2016 2

3 GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Care Finance All institutional providers will be required to pay a non-refundable application fee at the time of initial and re-enrollment. For newly enrolling providers, States must collect the applicable application fee prior to executing a provider agreement. The fee is set each year by CMS and increases each calendar year based on the consumer price index for all urban consumers. The application fee for calendar year 2016 is $554. This requirement does NOT apply to individual physicians, non-physician practitioners or providers that are enrolled in Medicare or another State's Medicaid program or to those that have already paid the fee to Medicare or another State Medicaid program or CHIP. The following provider types are defined as institutional providers: Freestanding Mental Health Hospital Dialysis Facility Home Health Agency Skilled Nursing Facility Ambulatory Surgical Center Portable X-ray Supplier Rehabilitation Agency DME Comprehensive Outpatient Rehabilitation Facility Federally Qualified Health Center Hospice Ambulance Service Supplier Independent Clinical Laboratory Independent Diagnostic Testing Facility Pharmacy Outpatient Rehabilitation Facility [Please note that providers with multiple sites, such as outpatient rehabilitation facilities must pay a fee for each site application.] The check for the application fees must be attached to the form. If the payment has already been made to another State Medicaid agency or Medicaid, then proof of payment must be attached. Proof may be a copy of a receipt or a screenshot. Failure to submit proof will delay the processing time of the provider application and result in a request for payment to District of Columbia Medicaid. HCOA-DPPPS September 2016

4 GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Care Finance DC Medicaid Institutional Provider Application Fee Submission Form Provider Name: Provider Tax Identification Number: Provider Address: Provider Type: Payment Details: (a) check number (b) date (c) amount (Submitting payment to District of Columbia Medicaid) ***No cash or credit cards are accepted. Checks should be made payable to DC Treasurer. *** For newly enrolling providers, States must collect the applicable application fee prior to executing a provider agreement. The fee is set each year by CMS and increases each calendar year based on the consumer price index for all urban consumers. The application fee for calendar year 2016 is $554. If previously submitted application fees payment, choose A or B and provide associated information. Provider Payment to: (A) Home State Medicaid Agency Date: Amount: (B) Medicare Date: Amount: Failure to submit proof will delay the processing time of the provider application and result in a request for payment to District of Columbia Medicaid For Official Use Only (DHCF) Payment Received by: Payment Verified by: Provider Number (if applicable): Application Tracking #: Application CR# Date: HCOA-DPPPS September 2016

5 Government of the District of Columbia Department of Health Care Finance (DHCF) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME/POS) Medicaid Provider Enrollment Package Read all instructions before completing the application. Type or print clearly, in ink. If you make corrections, please line through, date, and initial in ink. Return the completed application package and accompanying documentation in the format specified to: Xerox Provider Enrollment P.O. Box Washington, DC DISTRICT OF COLUMBIA DME/POS MEDICAID PROVIDER APPLICATION FOR (Insert the full legal name of your company) Section 1 ENROLLMENT ACTION Directions: Check ( ) ALL that apply. A National Provider Identifier (NPI) is mandatory for all new applicants and re-enrolling providers. A Medicare Provider Number is required for all applicants. If re-enrolling as a Medicaid provider, provide your DC Medicaid provider number. If changing/ updating information, indicate the type of change requested and the effective date of the change. THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable): o Coy of your NPI letter o CMS Medicare Supplier letter New provider National Provider Identifier (NPI): Medicare Provider Number: For any of the following actions, include current or previous DC Medicaid provider number: Re-Enrollment (required every three (3) years) Mail order company Change/Update (state the type of change/update and the effective date below). Last Revised: 04/01/2016 3

6 Government of the District of Columbia Department of Health Care Finance (DHCF) Required Application Supplement for NPI The National Provider Identifier (NPI) final rule, Federal Register 45CFR Part 162, was published on January 23, 2004 by the Department of Health and Human Services (DHHS) as part of the Health Insurance Portability and Accountability Act (HIPAA). The rule established the NPI as the standard unique identifier for health care providers to be used in HIPAA-covered transactions. The rule requires covered health care providers, clearinghouses, and health plans to use this identifier in HIPAA-covered transactions. All DC Medicaid healthcare providers must provide DHCF with their NPI information. Please complete the below information and return with your Medicaid Provider Enrollment Application. If you do not have an NPI yet, you may obtain one at If you do not meet the definition of healthcare provider as defined under HIPAA, this form is not required. If you are a healthcare provider please provide your NPI that was issued by National Plan & Provider Enumeration System (NPPES) in the space below. Please also provide your taxonomy code that is currently on file with NPPES. NPI Taxonomy Code X If this application is for an organization, please supply additional NPIs and taxonomy codes on a separate sheet. I certify this information to be true and accurate. Provider Signature or Authorized Representative Printed Name Date Last Revised: 04/01/2016 4

7 Section 2 BUSINESS/CORPORATE Directions: Check one box only. If Other is checked, write in type of entity. ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE: o Business License o Certificate of Occupancy o Applicable Permits o Legible copy of the partnership agreement (if Partnership is checked) TYPE OF ENTITY (check one) Sole proprietor Partnership (attach legible copy of agreement) Government Entity Corporation: Limited Liability Company (LLC): Nonprofit Corporation Other: State Registered/Filed: Last Revised: 04/01/2016 5

8 Section 3 APPLICANT/PROVIDER Directions: 3a) Company Name o Provide company name or corporate name as registered with the Internal Revenue Service (IRS) and under which business is conducted. o Provide primary business location address, telephone and fax numbers, website and address. 3b) Out-of-State Applicants ONLY o Providers located outside the District of Columbia must have a registered agent, be enrolled as a Medicaid provider in state where your business is principally located, and be registered in the District of Columbia to conduct business. o Provide information regarding your District of Columbia registered agent. o PO Boxes are prohibited ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable): o D.C. Certificate of Authority [Corporation] or D.C. Certificate of Registration [LLC] (Out-of-State providers ONLY) o Proof of Medicaid enrollment in your state (Out-of-State providers ONLY) o Description of ownership and a list of major owners (stockholders owning or controlling five (5) percent or more outstanding shares) o List of Board Members and their affiliations o Copy of the basic organizational documents of the provider, a roster of key personnel with titles, including an organizational chart 3a) Company Name, as listed with the IRS. (Note: Name indentified below should match name indentified on the IRS form included in this application package.) Name of Owner(s) Doing Business as Business Address City/State/Zip Telephone Fax Website 3b) Out-of-State applications ONLY 1. Registered Agent (PO Box Prohibited): Name (Last, First, Middle) Company Name Address City/State/Zip Telephone Website 2. Medicaid Provider Number in the state where your business is principally located (Attach copy proof of Medicaid enrollment in your State) Last Revised: 04/01/2016 6

9 Section 4 PROOF LIABILITY INSURANCE & SURETY BOND Directions: Certificate of Liability Insurance of at least $1M each and $3M annual Proof of Surety Bond of at least $50,000 ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE: 1) Copy of the Certificate of Insurance for the business address listed on this application 2) Copy of Surety Bond for the business address listed on this application Name of Insurance Company Insurance Policy Number Date Policy issued (mm/dd/yyyy) Expiration Date of Policy (mm/dd/yyyy) Insurance Agent s Name (Last, First, MI) Telephone Number ( ) Fax Number ( ) Address Last Revised: 04/01/2016 7

10 Section 5 BACKGROUND CHECKS Directions: In 5a, state whether or not any personnel providing services at this service site do now or will: 1) enter beneficiaries homes to deliver DME/POS products, to fit DME/POS products to patients, or for other purposes; or 2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics, wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical contact routinely made by a cashier or other personnel performing administrative activities. In 5b, list every person in your company at this service location who will have contact with DC Medicaid recipients in any of the ways described above. For each such person: o If he or she holds a current professional license as a health care provider, attach a copy of the license. o If he or she does not currently possess a valid license as a health care provider, provide evidence of a background check. If additional space is needed, attach separate sheet(s) of paper behind the next page. FOR EVERY PERSON LISTED IN 5b, ATTACH THE FOLLOWING DOCUMENTS BEHIND 5b: o o Copies of the professional license(s) of all personnel who are licensed as a health care provider and who have or will have physical contact with beneficiaries (as described above); and Copies of current (within the past 90 days) criminal background checks for each person who has or will have physical contact with beneficiaries as described above, and who does not currently have a valid professional license as a health care provider. 5a) Declaration of whether personnel have physical contact with beneficiaries. Please answer YES or NO to the following questions: Do (or will) any personnel providing services at this service site: 1) enter beneficiaries homes to deliver DME/POS products, to fit DME/POS products to patients, or for other purposes? YES NO 2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics, wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical contact routinely made by a cashier or other personnel performing administrative activities. YES NO If you answered YES to either of the above two questions, go to 5b. 5b) List of personnel with physical contact with beneficiaries. On the next page(s), list every person in your company at this service location who will have contact with DC Medicaid recipients in any of the ways described above. For each such person: o If he or she holds a current professional license as a health care provider, provide a copy of the license. o If he or she does not currently possess a valid license as a health care provider, provide evidence of a background check. State the number of copies of professional licenses that are included here: State the number of criminal background checks that are included here: Last Revised: 04/01/2016 8

11 Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Last Revised: 04/01/2016 9

12 THIS PAGE INSERTED AS A REMINDER TO INSERT HERE ALL BACKGROUND CHECKS AND COPIES OF PROFESSIONAL LICENSES FOR EVERY INDIVIDUAL LISTED IN 5b Last Revised: 04/01/

13 Section 6 SERVICE LOCATION AND HOURS OF OPERATION Directions: Provide the information below for the service location you intend to enroll or re-enroll in DC Medicaid. Post Office Boxes are prohibited 6a) Service Location Address City/State Zip Code Telephone Number Fax Number \WARD/COUNTY Address 6b) Hours of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6c) Does this location have 24-hour telephone coverage? Yes No Phone: ( ) 6d) Is this location accessible to public transportation?? Yes No 6e) Does this location meet the access requirements of the Americans with Disabilities Act?? Yes No 6f) Does the location have TDD? Yes No TDD Telephone Number Section 7 MAILING ADDRESS FOR PAYMENT OR REMITTANCES Directions: Provide the address to which you want payments sent. A Post Office Box is acceptable. Provide the address to which you want Remittance Advices sent. A Post Office Box is acceptable. Only one Remittance Address is allowed per provider number. Check whether you will use electronic or paper billing. 7a) Address to which payment should be sent: Address City/State ZIP Code 7b) Address to which Remittances should be sent: Address City/State ZIP Code (if difference from Pay to Address) 7c) How are you billing? Electronic Paper Last Revised: 04/01/

14 Section 8 MAILING ADDRESS FOR CORRESPONDENCE OTHER THAN PAYMENT OR REMITTANCES Directions: Provide the mailing address to which correspondence (manual updates, memoranda, etc.) should be sent. A Post Office Box address is acceptable. Only one Correspondence Address is allowed per enrollment application and provider number. Address to which correspondence should be sent: Address City/State ZIP Code Last Revised: 04/01/

15 Section 9 PRODUCTS AND SERVICES TO BE FURNISHED BY PROVIDER Directions: Complete the chart by placing a check ( ) in the box next to the specific products (listed in Column I) that your business will deliver to DC Medicaid recipients. In Column II, check the specific licensure and/or certification held by those persons who will deliver the products and services. If a specific licensure and/or certification that you hold is not listed below, write or type the name of the licensure, certification or other credential in the space provided in Column II for Other. If a product that you intend to deliver is not listed in the chart below, write or type the name of the product in the space provided at the end of Column I. COLUMN I PRODUCTS TO BE FURNISHED BY PROVIDER Diabetic Footwear Orthotics Devices-Custom- Fabricated COLUMN II QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS Fitters of therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Orthotic Devices (Custom-Fabricated) ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) ABC Registered Orthotic Technician (RTO) for individuals who under the direct supervision of an ABC certified practitioner administers orthotic services and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic (BOCO) (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Fitters of orthotics, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Pedorthic Devices Therapeutic Shoes - Customized Shoe Modifications Foot Orthoses Pedorthic devices (therapeutic shoes, shoe modifications, & foot orthoses) ABC Certified Pedorthist (C.Ped) (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC Pedorthist Certification (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Last Revised: 04/01/

16 COLUMN I PRODUCTS TO BE FURNISHED BY PROVIDER (Continued) Power Wheelchairs Prosthetics General * (i.e. non-customized therapeutic shoes) Specialty (i.e. Speech Generating Devices, Voice Prosthetics Mastectomy COLUMN II QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS (Continued) Customized Manual Wheelchairs and Complex Rehabilitative Wheelchairs & Assistive Technology RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Prosthetic Devices ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) ABC Registered Prosthetic Technician (RTP) for individuals who under the direct supervision of an ABC certified practitioner administers orthotic/prosthetic service and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Prosthetic (BOCP) (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Fitters of mastectomy prostheses, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) and/or BOC-Certified Mastectomy Fitter (CMF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Respiratory Equipment Bi-level Positive Airway Pressure Continuous Positive Airway Pressure Intermittent Positive Pressure Respiratory Assist Devices Wheelchairs Manual (Customized) Respiratory Equipment, Supplies, and Services Registered Respiratory Therapist (RRT) Certified Respiratory Therapist (CRT) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Customized Manual Wheelchairs, Power Mobility Devices and Complex Rehabilitative Wheelchairs & Assistive Technology RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Last Revised: 04/01/

17 COLUMN I PRODUCTS TO BE FURNISHED BY PROVIDER (Continued) Additional DME/POS Apnea Monitor Commodes Diabetic Equipment and Supplies Blood Glucose Monitors Dialysis Equipment and Supplies Heat/Cold Applications Hemodialysis Equipment and Supplies Hospital Beds Accessories Electric Manual Lymphoedema Pumps Mobile Assistive Equipment Mechanisms Walkers, Canes and Crutches Patient Lifts and Seat Lift Orthotics Devices Non-customized Oxygen Oxygen equipment Concentrators Reservoirs High-pressure cylinders Accessories & Supplies Conserving Devices Wound Care Supplies Other DME/POS COLUMN II QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS (Continued) Applicable licensure, certification and/or training. NOTE: Products in this section only may not require specific licensure, certification or training Last Revised: 04/01/

18 Section 10 Directions: QUALIFICATIONS OF THE DME/POS BUSINESS Check [ ] agencies where any accreditation is held by your DME/POS business. ATTACH PROOF OF ACCREDITATION BEHIND The Joint Commission (JC) National Association of Boards of Pharmacy (NABP) Board of Orthotist/Prosthetist Certification (BOC) Community Health Accreditation Program (CHAP) The Compliance Team, Inc. American Board of Certification in Orthotics & Prosthetics, Inc. (ABC) The National Board of Accreditation for Orthotic Suppliers (NBAOS) Commission on Accreditation of Rehabilitation Facilities (CARF) HealthCare Quality Association on Accreditation (HAQAA) Accreditation Commission for Health Care, Inc. (ACHC) Last Revised: 04/01/

19 Section 11 BUSINESS INFORMATION Directions: 11a) -11i) Check Yes or No in response to the questions listed. 11j) If Yes is checked for #2, provide the name and telephone number of the person who holds ownership of the warehouse, along with the owner s complete address. 11k 11o) Check Yes or No in response to the questions listed. 11p 11r) Check Yes or No in response to the questions listed. If Yes is checked, please explain in the space provided in Section s) Check Yes or No in response to the questions listed. If Yes is checked provide the information requested in the space provided in Section a) Do you have the retail business open and available to the general public, and which meets all local laws and ordinances regarding business licensing and operations and is readily identifiable as a place in which you sell, rent, or lease durable medical equipment, prosthetics, incontinence medical supplies, and/or medical supply items? Yes No 11b) Do you have a visible sign and posted hours of operation? Yes No 11c) Do you have inventory or contracts with other companies to ensure the ability to fill orders? Yes No 11d) Do you advise customers that they may either rent or purchase DME/POS? Yes No 11e) Do you honor all warranties expressed and implied under State law? Yes No 11f) Do you have a written complaint resolution process? Yes No 11g) Will records be stored at the service location? Records must be maintained for 10 years If not, where are they stored? Provide Address: Address: City/State Zip Code Yes No 11h) Do you own the building in which your business is located? Yes No 11i) Do you lease the building in which your business is located? Yes No 11j) Is your equipment and/or supplies: #1) In stock on the premise, and/or #2) In a warehouse under the applicant s or provider s direct control (if checked provide the following information for the warehouse): Yes No Yes No Name of Person who holds ownership in the warehouse: Address: City/State Zip Code Telephone Number: 11k) Do you have the necessary equipment, office supplies, and facilities available to carry out your business, including storing and retrieving such records as are necessary to fully disclose the type and extent of services provided to Medicaid customers? 11l) Does you business involve the trade, sale, rental, or transfer of upholstered - furniture (including wheelchairs) or bedding? Yes No Yes No Last Revised: 04/01/

20 11m) Does your business involve the trade, sale, rental or transfer of medical devices or durable medical equipment/devices for use in the home to treat acute or chronic illness of injuries? Yes No 11n) Does your business involve the trade, sale, rental or transfer of dangerous or legend drugs and/or dangerous or legend medical equipment devices? Yes No 11o) Does the applicant/provider provide custom rehabilitative equipment and custom rehabilitative technology services to Medicaid customers? If Yes, does the applicant/provider have on staff, either as an employee or independent contractor, or does the applicant/provider have a contractual relationship with a qualified rehabilitation professional who was directly involved in determining the specific custom rehabilitation equipment needs of the patient and was directly involved with, or closely, supervised, the final fitting and delivery of the custom rehabilitation equipment? Yes No Yes No 11p) Has any officer and/or employee of the business ever been convicted of a felony? Yes No If Yes, please explain in Section 12 11q) Has the applicant/provider ever been rejected or suspended from the Medicare or Medicaid program, or has your participation status ever been modified (terminated, suspended, restricted, revoked, limited, cancelled or sanctioned)? Yes No If Yes, please explain in Section 12 11r) Within the last five (5) years, has the applicant/provider ever been sanctioned, reprimanded or otherwise disciplined in any manner by any state licensing authority or other professional board or peer committee? Yes No If Yes, please explain in Section 12 11s) Does applicant/provider own, have an investment in, manage, own stock in, participate in a joint venture, or act as a partner, contract consultant or medical/dental advisor in any medical/dental enterprise or medical/dental supplier outside of the business identified in this application where you would financially benefit directly or indirectly? Yes No If Yes, please explain in Section 12 Last Revised: 04/01/

21 Section 12 DETAILED EXPLANATIONS FOR SECTION 10 QUESTIONS Directions: If you answered YES to questions 11p, 11q, 11r and 11s, please provider an explanation or additional information for each. QUESTION 11p QUESTION 11q QUESTION 11r QUESTION 11s Name of Organization Type of Organization Mailing Address Telephone Number Tax ID Number Percent of Business Owned/Invested by You Nature of Business Investment (Owner, Partner, Investor, etc.) Last Revised: 04/01/

22 Section 13 DISCLOSURE OF OWNERSHIP Directions: Follow the instructions found in this section to complete the document on the next page. Remember to sign the document DEPARTMENT OF HEALTH CARE FINANCE Provider Instructions and General Information Pertaining to Disclosure of Ownership and Control Interest Statement and Criminal Information Completion and submission of this form is a condition of participation, certification or recertification under any of the programs established by Titles V, XVIII, XIX and XX or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of the appropriate state agency under any of the above-title programs. A full and accurate disclosure of ownership and financial interest is required. Direct or indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the Provider. Failure to submit requested information may result in a refusal by the appropriate State agency to enter into an agreement or contract with any such institution or termination of existing agreements. This form must be submitted at the time a Provider is initially enrolling, or revalidating, or reenrolling, or whenever there is a change in ownership of a Provider, or a material change in the information required by this form and/or upon request by the Department of Health Care Finance (DHCF) or federal agencies. DIRECTIONS Please answer all questions as of the current date. If additional space is needed, please note on the form that the answer is being continued, and attach a sheet referencing the item number that is being continued (For example: Item II. (a) continued.). Return the original to DHCF and please retain a copy for your files. Completely answer the applicable questions. If a question is not applicable to your provider type, please answer not applicable for that question. NO QUESTIONS SHOULD BE LEFT BLANK. P.O. Box, website and addresses are not acceptable answers to any of the questions and should not be referenced in the statement. This form is submitted to DHCF for either of one (1) or two (2) of the following purposes: (1) to gather information about the provider/entity and (2) to gather personal information about the individual providers. If you are the only provider furnishing services in this entity you need to fill out only one form. It will contain both the information about the Provider entity (i.e. if you are an LLC you would list the fact that you are a corporation and that you are the 100 percent owner) [Purpose 1] and information about you personally [Purpose 2]. In all other cases there must be more than one form. The entity must have an authorized person (i.e. corporate president or a partner in a partnership) fill out the form on behalf of the entity [Purpose 1], while each rendering provider must fill out the form with the personal information applicable to that provider [Purpose 2]. Purpose (1): This form is submitted by all Provider types that are either enrolling or reenrolling as a DC Medicaid program Provider. The form is used for the purposes of capturing information about the Provider entity, such as, whether the business structure is a corporation, partnership or some other type of business organization. It also collects information about nonprovider people associated with the entity like members of Boards of Directors, non-provider owners and managing employees. This information must be collected whether the Provider is a profit or not-for-profit entity. All of the sections of the form must be filled out and updated whenever there is a change in the Provider s ownership or control or, upon request by DHCF or appropriate Federal agencies. Purpose (2): This form is submitted by a new provider in a Group of Practitioners or a Disclosing Entity, whose employment does not change the ownership or control structure of the Group of Practitioners or Disclosing Entity. The Group of Practitioners or a Disclosing Entity as a whole does not need to submit a new form under Purpose 1 of the form as long as the ownership and control functions of the entity have not been changed by the addition of the new Provider(s). The new Provider(s) are responsible for filling out Items I and IV of the form and signing the form. Please answer not applicable for the remainder of the form. DEFINITIONS Agent: any person who has been delegated the authority to obligate or act on behalf of a Provider. 42 C.F.R Convicted or Conviction: a judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending. 42 C.F.R Last Revised: 04/01/

23 Convicted of a Criminal Offense (for purposes of this form): 1. When a judgment of conviction has been entered against the individual or entity by a Federal, State or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged; 2. When there has been a finding of guilt against the individual or entity by a Federal, State or local court; 3. When a plea of guilty or nolo contendere by the individual or entity has been accepted by a Federal, State or local court; or 4. When the individual or entity has entered into participation in a first offender, deferred adjudication or other arrangement or program where judgment of conviction has been withheld. 42 U.S.C.A. 1320a-7(i) Disclosing Entity: a Medicaid Provider, such as a Home and Community Based Service (HCBS) Provider (other than an Individual Practitioner or Group of Practitioners) or a fiscal agent. Fiscal Agent: a contractor that processes or pays vendor claims on behalf of the Medicaid agency. Group of Practitioners: two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff or common equipment). 42 C.F.R Common location means Providers share physical office space, for example, 101 Main Street, Suite A. Indirect Ownership Interest: an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. 42 C.F.R The amount of indirect ownership in the Disclosing Entity that is held by another entity is determined by multiplying the percentage of ownership interest at each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the Disclosing Entity, A s interest equates to an 8 percent indirect ownership interest in the Disclosing Entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the Disclosing Entity, B s interest equates to a 4 percent indirect ownership interest in the Disclosing Entity and need not be reported. Individual Practitioner: solo physician or non-physician practitioner; who has not reassigned Medicare/Medicaid payments to a Group Practice or Disclosing Entity. Managing Employee: general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency. 42 C.F.R For purposes of this form DHCF requires that you list as managing employees the following persons: the heads of your entity s operating units or divisions (i.e. inpatient care, finance/billing department, personnel department, ambulatory care center, etc.). Other Disclosing Entity: any other Medicaid Disclosing Entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII or XX of the Act. This includes: (a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic or health maintenance organization that participates in Medicare (Title XVIII); (b) Any Medicare intermediary or carrier; and (c) Any entity (other than an Individual Practitioner or Group of Practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program under Title V or Title XX of the Act. 42 C.F.R Ownership Interest: the possession of equity in the capital, the stock or the profits of the Disclosing Entity. 42 C.F.R In order to determine percentage of ownership, mortgage, deed of trust, note or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the Disclosing Entity s assets used to secure the obligation. For example, if Dr. Smith owns 10 percent of a mortgage secured by 60 percent of Dr. Murray s assets, Dr. Smith s interest in Dr. Murray s assets equates to 6 percent and must be reported. Conversely, if Dr. Brad owns 40 percent of a mortgage secured by 10 percent of Dr. Jolie s assets, Dr. Brad s interest in Dr. Jolie s assets equates to 4 percent and need not be reported. 42 C.F.R Provider Person: person who will be billing DHCF for the provision of services to DC Medicaid program beneficiaries. Last Revised: 04/01/

24 Provider Entity: a business entity, such as, a solo practice, Group of Practitioners or Disclosing Entity. Responsible Party: an individual with legal authority to bind the Provider if the Provider is a Provider Entity - for example, a managing partner or corporate president. Significant Business Transaction: any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a Provider s total operating expenses. 42 C.F.R Subcontractor: (a) An individual, agency or organization to which a Provider Entity has contracted or delegated some of its management or administrative functions or responsibilities of providing medical care to its patients; i.e. billing, case management, utilization review, etc.; or (b) An individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies, equipment or services provided under the Medicaid agreement which is paid partially or in full by Medicaid funds. 42 C.F.R Supplier: an individual, agency or organization from which your organization purchases goods and services with Medicaid funds used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds or a pharmaceutical firm). 42 C.F.R Wholly owned supplier: supplier whose total ownership interest is held by a Provider or by a person, persons or other entity with an ownership or control interest in a provider. 42 C.F.R The following instructions are intended to clarify certain questions on the form. Instructions are listed in order of question for easy reference. ITEM I a. If you are filling this out as a Provider Person, specify the name of the Provider Person. Do not include a name of a contact person. List the Provider Person s national provider identifier(s) (NPI), social security number (SSN) and Medicaid ID number. b. List the Provider Entities doing business as (DBA) name, NPI(s), federal tax identification number(s) (TIN) and Medicaid ID number. This line is for the name of a Provider Entity (i.e. Family Medical Group of Anytown). This line would also be used for the DBA name of an Individual (i.e. John Smith Pediatrics P.C.). c. Specify whether your business is operated as: 1) an Individual by yourself; 2) in a group of Provider Persons at the same location or 3) in any other practice organization. d. Enter the address of both the Provider Person and the Provider Entity. P.O. Boxes are not acceptable addresses. All practice locations must be listed. ITEM II a. List the name, home address, date of birth (DOB), SSN and percentage owned for each person with a direct or indirect ownership or control interest of five (5) percent or more in the Provider Entity. If you are a Provider Person and own 100 percent of your practice then you would just list yourself. In addition, list the same information for any Subcontractor in which the Provider Person or Provider Entity has direct or indirect ownership or control interest of 5 percent or more. b. List whether any of the persons named in II(a) is related to another as a spouse, parent, child or sibling; and c. List the name, address and TIN of any other Provider Entity in which a Person with an Ownership or Control Interest in the Provider Entity also has an Ownership or Control Interest. 42 C.F.R ITEM III a. A Provider Entity must list the name, address, DOB, SSN and TIN for any Subcontractor with whom the Provider Entity has had singular business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and b. A Provider Entity must list any significant business transactions between the Provider Entity and any Subcontractor or Wholly Owned Supplier during the 5-year period ending on the date of the request. 42 C.F.R ITEM IV (if you are a sole Provider you will fill out both parts of this item --- a) is about your employees b) is about yourself a. If you are filling out this form for Purpose 1 (i.e. on behalf of the Provider Entity) please list the following: Last Revised: 04/01/

25 1. List the name, home address, DOB and SSN of each Person with an Ownership or Control Interest in the Provider Entity or is an Agent or Managing Employee of the Provider Entity; 2. Please list the name, home address, DOB and SSN of each Person with an Ownership or Control Interest in the Provider Entity that has been convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid or the title XX services program since the inception of those programs. 42 C.F.R Provider Entities shall search the List of Excluded Individuals/Entities (LEIE) each month for the names of the Providers Entities employees and contractors. b. If you are filling out this form for Purpose 2 (i.e. enrollment of a Provider Person) please fill out this section providing information only about yourself. Signature: If this form is being completed for a Provider Entity, the signature below MUST be the written signature of a Responsible Party for the business. If the form is being filled out for a Provider Person the person must sign the form. Last Revised: 04/01/

26 PROVIDER DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT AND CRIMINAL INFORMATION FORM If additional space is needed, please note on the form that the answer is being continued, and attach a sheet referencing the item number that is being continued. For example, Item 11. (a) continued. Item I. Identifying information (a) Name of Provider Person, Personal National Provider Identifier(s) (NPI), Social Security Number (SSN), Date of Birth (DOB) and Medicaid ID Number(s) Provider Name(s) NPI SSN DOB Medicaid ID Number Add more rows if needed. (b) Provider Entities Name and DBA Name, National Provider Identifier(s) (NPI), Federal Tax Identification Number(s) (TIN) and Medicaid Number(s) Entity Name DBA Name NPI TIN Medicaid ID Number Add more rows if needed. Last Revised: 04/01/

27 (c) Check Business/Organization Type: (1) Are you the only provider person in your practice? (2) Do you all practice with other provider person(s) in all the same location(s)? (3) Are you any other practice type? (d) Address (P.O. Boxes are not permitted. List all practice locations.): Provider or DBA Name(s) Address City State Zip Code (5+4) Add more rows if needed. Last Revised: 04/01/

28 Item II. Ownership and Control Information 42 C.F.R and 42 C.F.R (a) List the name, home address (no P.O. Box addresses), Date of Birth (DOB), Social Security Number (SSN) and percentage owned for each person with a direct or indirect ownership or control interest of 5 percent or more in the provider entity. In addition, list the same information for any subcontractor in which the provider entity has direct or indirect ownership or control interest of 5 percent or more. If you are an individual AND you are a solo practitioner and you own 100 percent of your practice then you would just list yourself as 100% owner. Name SSN DOB % of Ownership or Control Address City State Zip (5+4) Add more rows if needed Last Revised: 04/01/

29 (b) List whether any of the persons named in II(a) is related to another as a spouse, parent, child or sibling. Name SSN Relationship Add more rows if needed. (c) List the name, address and TIN of any other provider entity in which a person with an ownership or control interest in this provider entity (named in Item II, section a) also has an ownership or control interest. Name TIN(s) Address (no P.O. Boxes) City State Zip (5+4) Add more rows if needed. Last Revised: 04/01/

30 Item III Business Transaction Information 42 C.F.R (a) List the name, address, DOB, SSN and TIN (if a business) for any subcontractor with whom the provider entity has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request. Name SSN DOB TIN(s) Address (no P.O. Boxes) City State Zip (5+4) Add more rows if needed. (b) List any significant business transactions between the provider entity and any subcontractor, or wholly owned supplier, during the 5-year period ending on the date of the request. Date of Transaction Person or Entity Name Amount of Transaction Add more rows if needed. Last Revised: 04/01/

31 Item IV Criminal Offense Information 42 C.F.R Purpose (1) On behalf of the provider entity (a) List the name, home address, DOB and SSN of each person with an ownership or control interest in the provider entity or is an agent or managing employee (please see definition s section for details) of the provider entity. If additional space is needed, please note on the form that this answer is being continued, and attach a sheet referencing this item number. Name SSN DOB Home Address City State Zip Role or Title Add more rows if needed. (c) List the name, home address, DOB and SSN of each person with an ownership or control interest in the provider entity or is an agent or managing employee of the provider entity, that has been convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs. Name Home Address SSN DOB Time Frame of the Offense Matter of the Offense Jurisdiction and Date of the Offense Program Area of the Offense Sanction Period of the Offense Add more rows if needed. Last Revised: 04/01/

32 Purpose (2) On behalf of the provider person have you ever been convicted of a criminal offense related to your involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of these programs. Yes No If Yes is checked, provide the name of the Federal District of conviction for a federal offense(s): and/or the County name of conviction for State offense(s):. If Yes is checked, provide the following information: Name Home Address SSN DOB Time Frame of the Offense Matter of the Offense Jurisdiction and Date of the Offense Program Area of the Offense Sanction Period of the Offense Add more rows if needed. The State or Federal Medicaid agency may refuse to enter into, renew or terminate an agreement with a provider if it is determined that a provider did not fully, accurately and truthfully make the disclosures required by this statement. Additionally, false statements or representations of the required disclosures may be prosecuted under applicable federal or state laws. 42 C.F.R The signature below MUST be the written signature of the provider, if being filled out by an individual practitioner. If the form is being filled out for a provider entity the signature below MUST be the written signature of a responsible party, an individual with legal authority to bind the provider. Name of Provider Person or Provider Entities Responsible Party Printed Title Signature of Provider Person or Provider Entities Responsible Party Date Last Revised: 04/01/