VERMONT MEDICAID PROVIDER ENROLLMENT & REVALIDATION FORM Billing and Servicing Providers

Transcription

1 VERMONT MEDICAID PROVIDER ENROLLMENT & REVALIDATION FORM Billing and Servicing Providers Please refer to the Green Mountain Care Instructions for Enrollment and Revalidation for instructions. All *asterisked sections must be completed. I. *Request Type New Enrollment Request (not currently enrolled) Requesting Enrollment as: Individual Facility Group Revalidation Request (enrolled, required to revalidate) Provider number as indicated on notification letter: Change (Specify what change is occurring, for example: add/remove service/billing address, specialty or group affiliation): Change applies to Medicaid Provider Number: 2. *Provider/Applicant Information Applicant Name (if individual providers, please format LAST, FIRST MI, Title. If group/institution, please format exactly as it appears on your license/professional certification) Provider/Group/Institution DOB (mm/dd/yyyy): Individual providers provide a Social Security Number. Business entities (groups, facilities and institutions) are to provide an Employer Identification Number (EIN), also known as a Federal Employer Identification Number. If provider has both an EIN and SSN, they must provide both and supply a W9 as proof of the EIN. SSN: FEIN: Medicare Enrolled?: Yes No If Yes, Medicare number: Taxonomy Number(s): Are you enrolled in other state Medicaid programs? Yes No If Yes, what states: Driver s license or other state issued identification number: Gender (M/F): DEA Number: Expiration Date (mm/dd/yyyy): DEAX Number: Expiration Date (mm/dd/yyyy): CLIA Number: Issue Date (mm/dd/yyyy): Pharmacist Certification: Issue Date (mm/dd/yyyy): NABP #: Please provide other applicable certification numbers that authorize us to process claims: 3. *Legal Address Street Name: Suite #: City: State: Zip Code: Telephone: Fax: 11/1/2017 1

2 4. *Licensing Information (list all current licenses held; attach additional sheets as needed) License/Certification #: State Issued: Date of Expiration: License/Certification #: State Issued: Date of Expiration: License/Certification #: State Issued: Date of Expiration: 5. *Type of Business Select one; must match information reflected on IRS Form W-9 Sole Proprietor (unincorporated) Individual Trust/Estate C Corporation Partnership Other (specify): S Corporation Limited Liability Company Specify the tax classification ( C = Corporation; S = S Corporation; P = Partnership): 6. *Type of Services to be Provided List the types of healthcare services you or your agency will provide (such as emergency transportation, psychiatric counseling, physician, pharmacy, personal care, dental, home health, respiratory care services, DME, laboratory, etc.): 7. *Proof of Professional Liability Insurance (Attach a copy of the face page of Malpractice Certificate or Professional Liability Insurance Certificate) Name of Insurance Company: Street Suite #: City: State: Zip Code: Telephone: Insurance Policy #: Date Issued (mm/dd/yyyy): Expiration Date (mm/dd/yyyy): 8. Medical/Dental/Clinical Specialties ** ** The following health care professionals are required to complete this section at time of application: physicians, nurse practitioners, dentists, doctoral-level psychologists & social workers and individual DME providers (includes prosthetics). Specialty: End Date: Board Certified (Yes or No): Specialty: End Date: Board Certified (Yes or No): Specialty: End Date: Board Certified (Yes or No): 11/1/2017 2

3 9. Hospital Privileges Do you have hospital privileges: Yes No If No, explain why: If Yes, provide the following hospital information (attach additional sheets, as needed) Name of Hospital: NPI #: Street Name: Suite #: City: State: Zip Code: Telephone Number: Name of Hospital: NPI #: Street Name: Suite #: City: State: Zip Code: Telephone Number: Name of Hospital: NPI #: Street Name: Suite #: City: State: Zip Code: Telephone Number: *Group Affiliation *Are you affiliated with any individuals or groups?: Yes No If yes, list all providers and medical entities with whom you are affiliated (attach additional sheets as needed): 11/1/2017 3

4 11. *Applicant/Provider Accommodations & Addresses Provide the physical address where health care services are rendered. Individual providers: complete for each service address (Include a separate sheet for each additional service address) Institutions: complete for primary service address only Name of Practice: Medicaid ID Number: NPI Number: Street: Suite #: City: State: Zip Code: Telephone: Fax: Handicap Accessibility None Partial (At least one building, office and examining room are accessible) Totally Accessible Alternate Methods of Access: The provider s office is not accessible, but he or she will see patient at an alternate site that is accessible. Languages Accommodated: English Other (specify all): Patient Age Limits All ages Newborn Age range only (Youngest) (Oldest) (Age range of patients that you will see; not the age range of your current patients). Established Patients Only Yes No (If not accepting new patients check Yes ; if accepting new patients check No ) *Pay to Address (Remittance Advice & Checks) Street: Suite #: City: State: Zip code: Telephone: Fax: *Mail to Address (Correspondence & Newsletters) Street: Suite #: City: State: Zip code: Telephone: Fax: *Prior Authorization Address (To be Used if Service Location Has No Mail Delivery) Street: Suite #: City: State: Zip code: Telephone: Fax: 11/1/2017 4

5 12. *Conviction/Sanction/Disclosure and Suspension/Debarment Information of the Provider Sanction is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action. Have you ever been sanctioned (as defined above) in any State or Federal program? Yes No If Yes, fully explain the details, include any applicable documentation (attach additional sheets as needed): Is your professional license or certification currently revoked, suspended or otherwise restricted? Yes No Have you ever had your professional license or certification revoked, suspended, or otherwise restricted? Yes No Are you currently, or have you ever been, subject to a licensing or certification board order? Yes No Have you voluntarily surrendered your professional license or certification in lieu of disciplinary action? Yes No Do you have any outstanding debt in relation to any other state s federally funded program? Yes No (You are subject to a license or certification verification/status check with your license or certification board.) If Yes was answered to any of the above questions, fully explain details, include any applicable documentation (attach additional sheets as needed): Convicted means that: (a) A judgment of conviction has been entered against an individual or entity by a Federal, State or local court, regardless of whether: (1) There is a post-trial motion or an appeal pending, or (2) The judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed; (b) A Federal, State or local court has made a finding of guilt against an individual or entity; (c) A Federal, State or local court has accepted a plea of guilty or nolo contendere by an individual or entity, or (d) An individual or entity has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld. Are you currently charged with or have you ever been convicted of a crime (excluding Class C misdemeanor traffic citations)? Yes No To answer this question, use the Federal Medicaid/Medicare definition of Convicted in 42 CFR as described above, and which includes deferred adjudications and all other types of pretrial diversion programs. All applicants are screened per the requirements 42 CFR Criminal Background Check Have you been arrested for a crime but not yet charged? Yes No Is there an outstanding warrant for your arrest? Yes No If Yes was answered to any of the above questions, fully explain details, include any applicable documentation: In accordance with 32 VSA 3113(b) I declare, under the pains and penalties of perjury, that I am in good standing with respect to (or in full compliance with a plan to pay) any and all taxes due. Yes No If No, supply explanation: 11/1/2017 5

6 12. *Conviction/Sanction/Disclosure and Suspension/Debarment Information of the Provider (Continued) Within ten years of the date of this statement, has the entity or person been convicted of any felony or misdemeanor involving fraud or abuse in any government program? Yes No If Yes, provide the date of the conviction (mm/dd/yyyy): Details: Within ten years of the date of this statement, has the entity or person been found liable for fraud or abuse involving a government program in any civil proceeding? Yes No If Yes, provide the date of the conviction (mm/dd/yyyy): Details: Within ten years of the date of this statement, has the entity or person entered into a settlement in lieu of conviction for fraud or abuse involving a government program? Yes No Yes, provide the date of the settlement (mm/dd/yyyy): Details: 13. *Disclosure of Information Ownership & Control All entities and persons as defined below are required to complete the Vermont Medicaid Disclosure Form as part of a complete application packet for enrollment and revalidation. Submit a Vermont Medicaid Disclosure Form for each person listed below. A. PERSON/ENTITY WITH A DIRECT OR INDIRECT OWNERSHIP List all PERSON(S) OR ENTITY that has direct or indirect ownership interest equal to 5% or more of the value of the provider entity. List all PERSON(S) OR ENTITY that owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the provider entity if that interest equals 5% of the value of the property or assets of the provider entity. (Attach additional copies of this page as needed to report additional names) City: State: Zip Code: % Owned: City: State: Zip Code: % Owned: City: State: Zip Code: % Owned: Are any of the above related to each other or any other managing employee or subcontractor listed in Sections 13B and 13C? Yes No If Yes, check the appropriate box; list name of individual: Spouse Child Other (explain below) 11/1/2017 6

7 13. *Disclosure of Information Ownership & Control (continued) All managing individuals/employees as defined below are required to complete the Vermont Medicaid Disclosure Form as part of a complete application packet for enrollment and revalidation. Submit a Vermont Medicaid Disclosure Form for each person listed below. B. MANAGING INDIVIDUALS/EMPLOYEES A managing employee is a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of the provider entity. (Attach additional copies of this page as needed to report additional names) Are any of the above related to each other or any person/entity with a direct/indirect ownership or any subcontractor listed in Sections 13A and 13C? Yes No If Yes, check the appropriate box; list name of individual: Spouse Child Other (explain below): _ 11/1/2017 7

8 13. Disclosure of Information Ownership & Control (continued) All subcontractors as defined below are required to complete the Vermont Medicaid Disclosure Form as part of a complete application packet for enrollment and revalidation. Submit a Vermont Medicaid Disclosure Form for each person listed below. C. SUBCONTRACTORS A Subcontractor of the Provider is defined as follows: An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or 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. (Attach additional copies of this page as needed to report additional names.) Are any of the above related to each other or any person/entity with a direct/indirect ownership or managing employee listed in Sections 13A and 13B? Yes No If Yes, check the appropriate box; list name of individual: Spouse Child Other (explain below): Has the applicant/provider had any significant business transactions with any wholly owned supplier or subcontractor (not disclosed) during the 5- year period immediately preceding the date of this application? Significant business transaction means any business transaction or series of transactions that involve health care services, goods, supplies, or merchandise related to the provision of services to Green Mountain Care members that, during any one fiscal year, exceed the lesser of $25,000 or 5 percent of an applicant s or provider s total operating expenses. Yes No If Yes, provide the following (if there is more than one supplier/contractor attach additional sheets): Subcontractor/Supplier Full Legal Name: Phone #: Street: Suite: City: State: Zip Code: 11/1/2017 8

9 14. *Applicant/Provider Self Disclosure A. CONVICTIONS/FINANCIAL Please answer the following questions, check "Yes or No. If Yes, is answered to any of these questions, list names and addresses of the individuals or organizations under Remarks on the Vermont Medicaid Disclosure Form. (a) Are you, the applicant or provider, aware of any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations, in any of the programs established by Titles XVIII, XIX, or XX? Yes No (b) Does the applicant or provider have any current employees in the position of manager, accountant, auditor, or in a similar capacity and who were previously employed by this provider s fiscal intermediary or carrier within the last 12 months? Yes No Has there been a change in ownership or control within the last year? Yes No (if Yes, specify date): If Yes, has it been reported Yes No If No, indicate in section 13, and follow reporting directions. Do you anticipate any change of ownership or control within the year? Yes No (if Yes, specify date): Do you anticipate filing for bankruptcy within the year? Yes No (if Yes, specify date): Are any of the new owners related to any of the former owners? Yes No (if Yes, list below) Did any former owners transfer their ownership interest to any new owners in anticipation of/ or following the assessment of a civil monetary penalty? Yes No (If Yes, please list the name of the former owners) Does the provider identified above comprise or include a facility that is operated by a management company, or a facility that is leased in whole or in part by another organization? Yes No If Yes, effective date of change (mm/dd/yyyy): Name of Management Company or Lessor: B. BED CAPACITY (Hospitals are required to provide the following information) Current Bed Capacity: Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater, within the last two years? (This question only applies to hospitals) If Yes, specify Year of Change: # of Beds After Change: # of Beds Prior to Change: Are you a Swing Bed Facility? Yes No If Yes, # of Licensed Beds: # of Swing Beds: Note: If swing bed facility, attach copy of your CMS swing bed certification letter with application. 15. *Contact Information Please provide the name and contact information of the individual to contact in regards to this form. Title: Phone #: Fax: Backdating Enrollment Start Date For New or Reenrolling providers ONLY. If you wish to have your effective date backdated, up to a year from the date of receipt of a completed application, please indicate below the date requested and rationale. Backdates will only be approved if confirmation can be obtained that screening requirements are meet, as of requested effective date, under 42 CFR and (Currently enrolled providers, please use Enrollment backdate form.) Attachments accepted. Office Use Only Effective Date Backdate: PECOS Effective Date End Date 11/1/2017 9

10 17. *Declaration & Signature I have read the contents of this application. I declare under penalty of perjury under the laws of the State of Vermont that the information in this application and any attachments are true, accurate and complete to the best of my knowledge and belief. My signature legally and financially binds this provider to the laws, regulations, and program instructions of the Vermont Medicaid program and state/federal assisted healthcare programs. I declare that I have the authority to legally bind the provider(s) listed or I am the provider on this Application. If I become aware that any information in this application is not true, correct or complete, I agree to notify DXC Technology of this fact immediately (within 30 days of change) at (802) or (800) Individual Practitioner First Name : Middle: Individual Practitioner Last Name: Jr., Sr., M.D., D.O., etc.: Authorized Signature or Practitioner Signature: Date: Title of Authorized Signature: All signatures must be original and signed in blue ink. Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures are not accepted. STOP! As a reminder, the following is required to accompany this application for it to be considered complete. Failure to include the following will result in a returned application and a delay in your enrollment or revalidation. 1. All pages of the Provider General Agreement must be returned with this application, to include the last page with an original signature. 2. If you disclosed any entities in sections 13A-C, you must include a Disclosure Form for each entity. Note: If the owner(s) or manager is enrolled with Vermont Medicaid, or the provider on this form is the sole proprietor, you do not need to complete the Disclosure form. 3. Proof of Professional Liability Insurance - attach a copy of the face page of Current Malpractice Certificate 4. If you are one of the following provider types, you are required to complete Section 8: physicians, nurse practitioners, dentists, doctoral-level psychologists & social workers and individual DME providers (includes prosthetics). If your provider type is listed above and you do not complete the section, your application will be considered incomplete and your application will be return. 5. New and Re-Enrollment effective dates are based on the day the complete packet is received by DXC. If you wish your effective date to be up to a year earlier and you are Medicare enrolled, please complete section 16 of this application. For requests that are more than a year or for non-medicare enrolled providers, please complete the Enrollment Backdate Form located here: If, upon verification of Medicare enrollment, we find your Medicare enrollment has lapsed, your effective will be the date of receipt of your complete application, not your requested effective date. If the enrollment application is not complete upon receipt by DXC Technology, it will be returned to the provider. Return all completed forms to: DXC Technology, Attn: Enrollment Unit, P.O. BOX 888, Williston, VT If confirmation of delivery is requested, please return to: DXC Technology, 312 Hurricane Lane, Suite 101, Williston, VT /1/