USVI PROVIDER ENROLLMENT APPLICATION

Transcription

1 USVI PROVIDER ENROLLMENT APPLICATION DOH Facility, Group Provider Enrollment, FQHC, Hospitals You should use this packet if: You are an institution, ancillary facility, group of practitioners, or sole proprietor operating and billing under a unique Taxpayer Identification Number (TIN); either a sole practitioner s Social Security Number or a business entity s Federal Employer Identification Number (FEIN); AND Your business has no rendering providers linked to your TIN, or as a sole proprietor your TIN is not shared or used by any other practitioner, group, or facility; AND FOLLOW ALL INSTRUCTIONS AND COMPLETE ALL FIELDS AS APPLICABLE (indicate not applicable (N/A) as necessary) TO THE TYPE OF REQUEST BEING MADE TO AVOID ENROLLMENT DELAYS. THE APPLICATION WILL NOT BE PROCESSED WITHOUT A SIGNED PROVIDER AGREEMENT READ ALL GENERAL INSTRUCTIONS Contains important information on completing this packet, and requirements for submission of provider profile and participation information. DHS ENROLLMENT APPLICATION INSTRUCTIONS It is essential ALL FIELDS MUST BE ANSWERED WITHIN THIS PACKET - IF NOT APPLICABLE FOR YOUR SPECIFIC PROVIDER TYPE, INDICATE N/A. It is very important you read all contents on the pages of this application. The DHS Provider Enrollment Packet is comprised of the following sections: 1. Enrollment Application Instructions Provides instructions on completing the VI DHS Medicaid Provider Enrollment 2. Provider Quality Checklist Provider s verification of all application requirements to ensure a completed application is being submitted. Incomplete applications will delay the enrollment process. Where sections of the packet request supporting documentation (such as a copy of a certification), the required documentation must be included as an attachment to the completed packet. 3. Sections A through C Facility/Group Organization, Ownership and Legal Information, - is used when enrolling a facility, group or sole proprietor 4. Section D Rendering Providers, is used when enrolling a group, FQHC or RHC 5. Section E Provider Signature Adenda Required for newly enrolling and revalidation of enrollment. 6. DHS Medicaid Provider Agreement Required for newly enrolling and revalidation of enrollment. 7. EFT Addenda - All payments must be made through Electronic Funds Transfer. An EFT application is attached. Your enrollment will not be approved unless this form is completed and returned with this application. This form must include an original voided check. 8. Next Steps After completing this packet, including all applicable addenda, and collecting the necessary supporting documentation, perform a quality check using the checklist. Once you have completed the quality check-list, make a copy of the packet for your records and contact the DHS Medicaid provider enrollment representative. Page 1 of 16

2 GENERAL INFORMATION COMPLETE ALL FIELDS OF THIS PACKET Complete the enrollment quality check-list and double check all documentation is attached as indicated on the provider criteria checklist included with the application. Your effective date will be the date provided in your enrollment welcome letter. You will be able to submit claims from this date (date of service) forward. If you have rendering providers (physician/non-physician practitioners) affiliated your business, you must enroll as a group provider. A change in ownership cancels this enrollment agreement. A new enrollment agreement must be completed. If you are a group provider organization, you are required to enroll your rendering practitioners, in the DHS participating provider network. Incomplete packets, including packets that are missing the required addenda or supporting documentation, will be returned to the provider for completion and delay the process. Facility and Group Providers can enroll in DHS Medicaid participating provider network with one NPI, or multiple NPI s for each location they want to receive payment for the services rendered at that facility. o Facility and group providers with multiple locations will be enrolled under the facility Billing/Pay-To provider record. All services provided will pay to the primary facility s billing and Pay-To provider record. The Medicaid Management Information System (MMIS) is designed for direct payment of practitioner services to either the employing group or corporation, or the individual practitioner. The system will also accommodate those practitioners who are in solo practice and are also an employee of a group or medical corporation. The group practice requires at least two NPI numbers: one assigned to the group and one unique number for each individual practitioner. Federal Medicaid Regulations, 42 CFR , require that payment be made to the individual practitioner providing the service, except that payment may be made to: 1. The employer of the practitioner, if the practitioner is required as a condition of employment to turn over his fees to the employer; or 2. The facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim. 3. In addition, such groups must comply with USVI Medicaid Territory laws applicable to group and corporate practices. Page 2 of 16

3 SECTION PROVIDER QUALITY CHECKLIST DHS ENROLLMENT PROVIDER QUALITY CHECKLIST FACILITY/GROUP PROVIDER QUALITY CHECKLIST PROVIDER USE ONLY Double-check that all sections of this packet have been completed and signed. (Refer to Enrollment Required Documents Checklist). Verify that the name and address in the Legal Name and Home Office Address section of Section A matches the information on the Federal W-9 form. Verify that the Service Location name, or DBA name, in the Service Location Name and Address section of Section A matches the business name on the Federal W-9 form. Information provided must match the attached IRS information allowing the Medicaid 1099 Form to be issued to the correct provider for whom the Federal Employer Identification Number or Social Security Number belongs. You MUST SUBMIT a copy of an IRS Notification Form, such as CP-575 or W-9 form for verification to whom the FEIN belongs. THE APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION. Verify that the Provider Agreement has been signed by an authorized official who is listed on Schedule C. The date should match all other dates on the application. (The Provider Agreement must not be signed by a delegated administrator). Double-check that the required documentation as applicable, are completed and included with the packet: Provider Enrollment Checklist supporting documentation (certificates, licenses, etc.) is included in this packet. Ownership Disclosure Form Electronic Funds Transfer Set-up (New Provider). MUST INCLUDE VOIDED CHECK Federal W-9 form (all) USVI Medicaid Provider Agreement (all) Page 3 of 16

4 DHS PROVIDER ENROLLMENT SECTION A ORGANIZATIONAL STRUCTURE Section A Organizational Information If your business is chain affiliated, the information about the company or organization must be included in the disclosure information in Section C. If your business is operated by a management company or leased (in whole or in part) by another organization, information about the management company or organization must be included in the disclosure information in Section C. 1. Provider Entity legally organized and structured as (Check only one). This must match the information provided on the attached W-9: Individual/Sole Proprietor Partnership Corporation S Corporation Limited Liability Company; select tax classification OTHER, please explain (see instructions on Federal W-9 form): 2. Provide the type of organization: Private For Profit Private Not for Profit Public Entity State Government Owned Public Entity Non-State Government Owned 3. NPI Enumeration Type (NPPES Enumeration): Type 2 Enumeration Organizational Type 1 Enumeration Individual Business License Number: State: Effective Date: / / Term Date: / / (State Business License Number in the State of the physical location, or license issued in the USVI Territory (if applicable). Page 4 of 16

5 DHS PAY-TO PROVIDER INFORMATION and PRIMARY SERVICE LOCATION SECTION B Section B Provider Information and Service Location(s) FACILITY/GROUP PROVIDER INFORMATION PRIMARY SERVICE LOCATION LEGAL NAME and HOME OFFICE ADDRESS The home office is the PRIMARY SERVICE LOCATION, unless each Service Location is where payment is received. If multiple service locations and each Service Location receive separate payment, a separate Provider Enrollment Application must be completed for each Service Location. The legal name is considered to be the entity maintaining ownership of the named business(s). The legal name must be the current name on tax, corporation, and other legal documents. The legal name and home office address must match the information currently registered with the Secretary of State, if registered. Is not applicable to informal associations such as Sole Proprietorships and General Partnerships that are not registered. The legal name as well as the home office address and TIN must match the information on the W-9. The home office and service location must be a physical location. A post office box is a valid mailing address. Pay-To National Provider Identifier (NPI - 10 Digits): Pay-To Name (W9 Legal Name-PRIMARY SERVICE LOCATION): FEIN No.: - Exempt Payee? YES NO Pay-To Physical Street Address 1: Street Address 2: Pay-To Physical Location City: W9 Business Name (if different from above): Pay-To Correspondence Mailing Address: Mailing Address 1: Mailing Address 2: Pay-To Correspondence Mailing City: Pay-To Physical Location State and Zip Code + 4: STATE: ZIP CODE: - CONTACT INFORMATION Pay-To Correspondence Mailing State and ZIP Code + 4: STATE: ZIP CODE: - The contact name and relate to the person who can answer questions about the information provided in this packet. addresses will be used for DHS business only and will not be sold or shared for other purposes. Contact Name (if different from Home Office contact): Credentialing Specialist Office Manager Owner Other: Contact Address: Contact Telephone #: ( ) - Fax Number: ( ) - Have you had a site visit conducted by Medicare, or another State s Medicaid? YES NO (Risk level moderate and high provider types require an unannounced pre and post site visit) Page 5 of 16

6 DHS PROVIDER PAY-TO PROVIDER INFORMATION PRIMARY SERVICE LOCATION SECTION B (cont.) Provider Type Description Effective Date: Service Location/Provider Specialty(s): CLIA Number (if applicable): CLIA Type: Effective Date: / / (Required if you provide Lab Services that are not CLIA waived/exempt) Do you provide radiological services at this location? If YES, what radiological services are provided: YES NO Technical Professional BOTH OFFICE HOURS: Open Time Closed Time in HH:MM followed by AM OR PM EXAMPLE: 08:00AM 05:00PM OPEN-Time CLOSED-Time OPEN-Time CLOSED-Time Monday: CLOSED Tuesday: CLOSED Wednesday: CLOSED Thursday: CLOSED Friday: CLOSED Saturday: CLOSED Sunday: CLOSED Handicap Accessible: YES NO Patient Age: MAX MIN Gender Restrictions: NONE FEMALE MALE Accepting New Patients: YES NO Languages: If you are enrolled in the Medicare Program, enter your Medicare information below. This information is required certain provider types as defined by criteria (refer to the Criteria Sheet for your provider type), or for Medicare Crossover payment. Medicare Number(s) given must match the number(s) used for Medicare billing; otherwise, crossover claims will not crossover to Medicaid. ATTACH A COPY OF THE MEDICARE APPROVAL LETTER(S). Medicare Number: Number of Institutional Beds (as applicable)? (Hospital, Skilled Nursing Facility, Overnight Stay Facilities) Nationally Recognized Accreditation Survey (Hospital must have at least one of the following): Joint Commission (JCAHO) American Osteopathic Association (AOA) DET NORSKE VERITAS Healthcare (DNVH) Effective Date: / / Institutional Hospital Based Pharmacy (Hospital ONLY) Outpatient - Open to the Public Outpatient - Closed to the Public Accreditation Number: Page 6 of 16

7 DHS Provider Enrollment Additional Service Locations SECTION B.1 ADDITIONAL SERVICE LOCATIONS GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES SECTION B.1 Provider Information and Additional Service Location(s) IF MORE THAN One ADDITIONAL SERVICE LOCATION COPY THIS PAGE AND COMPLETE WITH EACH SERVICE LOCATION For additional service locations, the name must be the Doing Business As (DBA) name registered with the Secretary of State. This does not apply to informal associations such as a Sole Proprietorship and General Partnerships that are not registered. The service location name must match the business name on the Federal W-9 form. The service location address must be a physical address. A post office box is not a valid service location address. Multiple service locations will be affiliated to the Pay-To record. If separate payment by service location is requested a separate enrollment application will need completed with a separate NPI. If you are using this packet to change your business name, you must include a revised W-9 form as an attachment to the packet. For a personal name change submit documentation showing proof of the name change. A provider s updated license or appropriate certification may be presented as proof of a name change. If a provider license does not show the new name, and official document showing the legal name change is required. If your legal name and business name change is the same, one set of attached documents will support both changes. Providers that provide services at a place of service site, such as a hospital, or ancillary facility, should enter their home/business office as their service location address. Pay-To National Provider Identifier (NPI - 10 Digits): Pay-To Name (W9 Legal Name-PRIMARY SERVICE LOCATION): FEIN No.: - W9 Business Name (if different from above): Exempt Payee? YES NO Pay-To Physical Street Address 1: Street Address 2: Pay-To Physical Location City: Pay-To Correspondence Mailing Address: Mailing Address 1: Mailing Address 2: Pay-To Correspondence Mailing City: Pay-To Physical Location State and Zip Code + 4: STATE: ZIP CODE: - CONTACT INFORMATION Pay-To Correspondence Mailing State and ZIP Code + 4: STATE: ZIP CODE: - The contact name and relate to the person who can answer questions about the information provided in this packet. addresses will be used for DHS business only and will not be sold or shared for other purposes. Contact Name (if different from Home Office contact): Credentialing Specialist Office Manager Owner Other: Contact Address: Contact Telephone #: ( ) - Fax Number: ( ) - Service Location/Provider Specialty(s): CLIA Number (if applicable): CLIA Type: Effective Date: Page 7 of 16

8 (Required if you provide Lab Services that are not CLIA waived/exempt) Do you provide radiological services at this location? If YES, what radiological services are provided: YES NO Technical Professional BOTH OFFICE HOURS: Open Time Closed Time in HH:MM followed by AM OR PM EXAMPLE: 08:00AM 05:00PM OPEN-Time CLOSED-Time OPEN-Time CLOSED-Time Monday: CLOSED Tuesday: CLOSED Wednesday: CLOSED Thursday: CLOSED Friday: CLOSED Saturday: CLOSED Sunday: CLOSED Handicap Accessible: YES NO Patient Age: MAX MIN Gender Restrictions: NONE FEMALE MALE Accepting New Patients: YES NO Languages: If you are enrolled in the Medicare Program, enter your Medicare information below. This information is required certain provider types as defined by criteria (refer to the Criteria Sheet for your provider type), or for Medicare Crossover payment. Medicare Number(s) given must match the number(s) used for Medicare billing; otherwise, crossover claims will not crossover to Medicaid. ATTACH A COPY OF THE MEDICARE APPROVAL LETTER(S). Medicare Number: Effective Date: / / Number of Institutional Beds (as applicable)? (Hospital, Skilled Nursing Facility, Overnight Stay Facilities) Institutional Hospital Based Pharmacy (Hospital ONLY) Outpatient - Open to the Public Outpatient - Closed to the Public Nationally Recognized Accreditation Survey (Hospital must have at least one of the following): Joint Commission (JCAHO) American Osteopathic Association (AOA) DET NORSKE VERITAS Healthcare (DNVH) Accreditation Number: Page 8 of 16

9 DISCLOSURE INFORMATION OWNERSHIP AND CONTROL, PROVIDER ENTITY (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED) SECTION C C.1 Disclosure Information Disclosure of Ownership and Control, Provider Entity List any PERSON or ENTITY that has direct or indirect ownership interest equal to 5% or more of the value of the provider entity. List any PERSON 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. **If the provider entity is a publicly held corporation and no person owns 5% or more of the corporation, you must select YES, and you must provide information for board members, agent(s) and managing employee(s). (Local, county and state government entities must select NO. ) YES NO If YES, a corporation is publicly held and no person owns 5% or more of the corporation, or if the corporation is a not-for-profit entity, complete Section C.3 to list the board of director(s), agent(s) and managing employee(s). DHS Provider Enrollment SECTION C.1 Title: FEIN: Social Security Number: Date of Birth: Title: FEIN: Social Security Number: Date of Birth: Title: FEIN: Social Security Number: Date of Birth: Title: FEIN: Social Security Number: Date of Birth: Title: FEIN: Social Security Number: Date of Birth: Page 9 of 16

10 DISCLOSURE INFORMATION SUBCONTRACTOR OWNERSHIP, CONTROL, AND RELATIONSHIPS (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED) SECTION C C.2 Disclosure Information Disclosure of Subcontractor Ownership, Control, and Relationships List 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 5% or more. DHS Provider Enrollment SECTION C.2 Title: FEIN: Social Security No.: Date of Birth: Title: FEIN: Social Security No.: Date of Birth: Title: FEIN: Social Security No.: Date of Birth: Title: FEIN: Social Security No.: Date of Birth: Title: FEIN: Social Security No.: Date of Birth: Page 10 of 16

11 SECTION C C.3 Disclosure Information DISCLOSURE INFORMATION BOARD MEMBER, MANAGING INDIVIDUALS (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED) List ALL agents, officers, directors and managing employees who have expressed or implied authority to obligate or act on behalf of the provider entity. Not-for-profit providers must also list their managing individuals. An AGENT is any person who has express or implied authority to obligate or act on behalf of an entity. An OFFICER is any person whose position is listed as an officer in the provider s articles of incorporation or corporate bylaws or is appointed as an officer by the board of directors or other governing body. A DIRECTOR is a member of the provider s board of directors, board of trustees, or other governing body. It does not necessarily include a person who has the word director in his or her job title, such as director of operations or departmental director. 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. DHS Provider Enrollment SECTION C.3 AGENT OFFICER BOARD DIRECTOR MANAGING EMPLOYEE Title: FEIN: Title: FEIN: AGENT OFFICER BOARD DIRECTOR MANAGING EMPLOYEE Title: FEIN: Title: FEIN: AGENT OFFICER BOARD DIRECTOR MANAGING EMPLOYEE Title: FEIN: Title: FEIN: AGENT OFFICER BOARD DIRECTOR MANAGING EMPLOYEE Title: FEIN: Title: FEIN: AGENT OFFICER BOARD DIRECTOR MANAGING EMPLOYEE Title: FEIN: Title: FEIN: Page 11 of 16

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13 DISCLOSURE INFORMATION RELATIONSHIPS AND BACKGROUND INFORMATION (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED) SECTION C C.4 Disclosure Information DHS Provider Enrollment SECTION C.4 1. Indicate if any of the individuals listed in Schedule C, sections C.1, C.2, or C.3 are related through blood or marriage as spouse, parent, child, or sibling. Nonprofit providers must also complete section C.4. Use N/A as appropriate. 1.a Name of Person 1: Name of Person 2: Relationship: 1.b Name of Person 1: Name of Person 2: Relationship: 1.b Name of Person 1: Name of Person 2: Relationship: 2. Indicate if any persons or entities listed in Schedule C, Sections C.1, C.2, or C.3 or any secured creditors of the provider entity have ever been sanctioned either through criminal conviction or exclusion from participation in any program under Medicare, Medicaid, or Title XXI services since the inception of the program. 2.a Name: LPI or NPI: Date of Sanction: Type of Sanction: Date Sanction Ended (please attach supporting documentation) 2.b Name LPI or NPI: Date of Sanction: Type of Sanction: Date Sanction Ended (please attach supporting documentation) 3. Indicate if any persons or entities listed in Schedule C, Sections C.1, C.2, or C.3 or any secured creditors of the provider entity have ever been placed on pre-payment review. 3.a Name: LPI or NPI: 3.b Name: LPI or NPI: 3.c Name: LPI or NPI: 4. Indicate if any persons or entities listed in Schedule C, Sections C.1, C.2, or C.3 have an ownership or controlling interest in any other current or prospective IHCP provider. 4.a Name: LPI or NPI: 4.b Name: LPI or NPI: 4.c Name: LPI or NPI: 5. Indicate any former agent, officer, director, partner, or managing employee from Schedule C, sections C.1 through C4 who has transferred ownership to a family member related through blood or marriage (spouse, parent, child or sibling) in anticipation of or following a conviction or imposition of exclusion. 5.a Name: LPI or NPI: 5.b Name: LPI or NPI: 5.c Name: LPI or NPI: Page 13 of 16

14 DISCLOSURE INFORMATION RELATIONSHIPS AND BACKGROUND INFORMATION (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL INFORMATION IS NEEDED) DHS Provider Enrollment SECTION C.5 Have you or any owner or employee identified in Section C of this application ever had: SECTION C C.5 Legal Questions An assessment taken against you? YES NO An administrative sanction taken against you? YES NO A suspension of payment taken against you? YES NO A restitution order taken against you? YES NO A program exclusion taken against you? YES NO A program debarment taken against you? YES NO A pending criminal judgment taken against you? YES NO A pending civil judgment taken against you? YES NO A judgment pending under False Claims Act taken against you? YES NO A criminal fine taken against you? YES NO A civil monetary penalty taken against you? YES NO Have you or any owner or employee identified in Section C ever been: Convicted of any health related crimes? YES NO Convicted of a crime involving the abuse of a child or elderly adult? YES NO Do you, any owners or employees as identified in Section C have YES NO ownership interest in any entity that provide services to Medicaid provider(s)/supplier(s)? If you answer yes to any of these questions, please complete the explanation box below and identify the owner, or employee as indicated in Section C. Attach any court proceedings, documentation, etc. I ensure that provider, all of its owners, managers, employees and contractors are not excluded from participation in Medicare, Medicaid, or other federal health care programs, by searching the Office of Inspector General List of Excluded Individuals/Entities (LEIE) at the time of enrollment, before hiring new employees or entering into a contract with a contractor, and monthly to see changes since the last search. I agree to immediately report any exclusion information discovered to the. Page 14 of 16

15 DHS PROVIDER ENROLLMENT SECTION D (COMPLETE ALL FIELDS) First Name: NPI: SECTION D Rendering Providers Last Name: Current Medicaid Provider Number (if applicable): Date of Birth: / / Gender: FEMALE MALE Address 1: Social Security Number: - - Address 2: City: State: ZIP + 4 Phone No.: FAX No.: ( ) - ( ) - Address: Provider Type Gender: FEMALE MALE Provider Specialty(s): Effective Date: / / Are you Board Certified? YES NO If YES, American Board of: What is your Board Certification Specialty: Are you Board Certified in a sub-specialty? YES NO If YES, American Board of: What is your Sub-Board Certification Specialty: Board Certification Number: Effective Date: / / Current State License applicable to provider type: Effective Date: / / Term Date: / / Do you have privileges at a hospital or Ambulatory Surgery Center? YES NO If YES, name: Sub-Board Certification Number: Effective Date: / / Are you enrolled in Medicare? YES NO Pending If YES, Medicare Number: Do you have prescribing privileges? YES NO Do you prescribe addiction treatment drugs? YES NO DEA/DEAX NO.: Page 15 of 16

16 DHS Provider Enrollment Signature Addenda SECTION E Provider Signature Addenda Signature Authorization The DHS effective date of VI Medicaid Program provider participation is determined after the application for enrollment has been approved and credentialed. You will be notified by letter of enrollment approval. Submit the completed application timely on the date of signature below. Any delays of enrollment due to missing information required for submitting this application could require and updated application, or signature attesting to the validity and accuracy of current information submitted within this application. The owner or an authorized official of the business entity, directly or ultimately responsible for operating the business is the authorized signatory of this form. A delegated administrator may sign this form if it has been expressly indicated on a DHS Delegated Administrator Addendum/Maintenance Form, on file or attached. 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 therein. As of the date of signature, the information contained within this application is accurate and current. 1. Legal Name of Provider s Business (please print): 2. Taxpayer Identification Number (TIN): 3. Authorized Official s Name (please print): 4. Title: 5. Authorized Official s 6. Date: Page 16 of 16