Dear Provider, Please complete this form if: You are new in the Medicaid network or You believe your Medicaid disclosure will expire soon or You have not submitted your Medicaid Disclosure to the state of West Virginia. In accordance with state laws, providers who obtain and maintain a contract with Highmark West Virginia (d.b.a. Highmark Blue Cross Blue Shield of West Virginia and/or West Virginia Family Health, Inc.) are required to maintain a Medicaid disclosure for all individual practitioners and groups. To complete the form here, please scroll down to view and print a pdf. Upon completion of the form, please return to Highmark via fax at 800-236-8641. Thank you, Provider Information Management
WEST VIRGINIA MEDICAID MOUNTAIN HEALTH TRUST PROVIDER DISCLOSURE FORM This form must be completed by each Provider that enters into a contractual relationship with Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield West Virginia ( Highmark WV ) and West Virginia Family Health Plan, Inc. ( WVFH ) for the provision of Medicaid services in West Virginia. The term Provider includes a practitioner, such as a physician or other individual licensed under State law to practice his or her profession and who bills under his or her own provider number ( Individual Provider ). Provider also includes an entity such as a hospital, laboratory, pharmacy or other provider that is organized as a corporation, partnership or other business entity ( Business Entity Provider ). Providers include both Individual Providers and Business Entity Providers, as well as providers that are in WVFH s network either directly or through subcontractors. Providers should identify all legal names under which they do business. Each separate Individual Provider or Business Entity Provider must fill out a separate statement. Individual Providers do not need to complete Section B of the form relating to ownership and control. This form must be submitted before beginning operations under a new contract and as changes in ownership or control occur; or respond via written notification no later than 35 days after a change has occurred. WVFH s request for information from Providers regarding ownership and control, business transactions, convictions or other matters does not confer or imply that the matter being requested is allowable or unallowable. Unless otherwise instructed, the completed form and exhibits should be submitted to Highmark WV as a doc file. The Attestation (Section E) must be submitted as a.pdf file showing written signature. Please fill in the date this form is submitted in the designated space at the top of Page 1 of the form. If the Business Entity Provider or Individual Provider prefers sending a paper copy of the form, please do so to the address below. Highmark WV may provide the information disclosed by the Provider to the West Virginia Department of Health and Human Services to fulfill its obligations set forth in 42 CFR 455. Per Federal regulations: A Medicaid agency shall not approve a contract, and must terminate an existing contract, if certain contractors fail to disclose certain ownership and control information (42 CFR 455.104). An MCO may not knowingly have a relationship of the type described in 42 CFR 438.610 (b). Please send all completed paper forms to: Provider Information Management PO Box 898842 Camp Hill, PA 17089-8842 Or fax to: 800-236-8641 Forms may be submitted electronically to: PDSmailbox@highmark.com Page 1 of 15
Definitions: Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Person with an ownership or control interest means a person or corporation that (a) Has an ownership interest totaling 5 percent or more in a disclosing entity; (b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; (c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity; (d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; (e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership. Indirect ownership interest means 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. Determining of ownership or control percentages (per 42 C.F.R. 455.102) Indirect ownership interest. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in 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. Person with an ownership or control interest. 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 A owns 10 percent of a note secured by 60 percent of the provider's assets, A's interest in the provider's assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider's assets, B's interest in the provider's assets equates to 4 percent and need not be reported. Subcontractor of a Provider means an individual, agency, or organization to which the Provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients. Page 2 of 15
Provider Medicaid Disclosure Statement Page 3 of 15 DATE SUBMITTED: Section A: Provider Identification - Both Individual Providers and Business Entity Providers who are contracting with WVFH or its subcontractors must complete this Section. 1. Full legal name of the entity or provider that contracts with WVFH: 2. Other names: Doing business as (DBA), trade name(s), abbreviation, acronym, former name(s), etc. (list any and all, if different from legal name): 3. Primary street (physical) address of provider, including sip code, area code and main phone number: Address City State Zip Phone 4. Primary mailing address of provider, if different from physical address: Address City State Zip Phone 5. Other business (physical) address locations: 6. Website address(es) (list any and all home-page URLs): 7a. State of Incorporation or other formation (if Business Entity Provider): 7b. SSN (if Individual Provider) or Employer Identification Number (EIN) (if Business Entity Provider):
Provider Medicaid Disclosure Statement Page 4 of 15 Section B: Ownership and Control Disclosures - To be filled out only by Business Entity Providers. 1. Legal status For-Profit Non-Profit 2. Type of ownership of entity or provider (select one): a. Privately held or controlled by one entity or individual or agency, b. Privately held or controlled by more than one entity or individual or partner, etc. (but not publicly traded or listed on a stock exchange). c. Governmental Entity (e.g. owned by a County Hospital District). d. Owned by multiple unaffiliated stock holders, where stock is listed and can be traded on a stock exchange, wherein no individual or entity, or affiliated group of individuals or entities, has control. e. Other. Describe/explain: 3. Please identify Ownership or Control Interests in the Business Entity Provider as described below: a. Does any entity or individual possess direct ownership interest in the Business Entity Provider totaling 5% or more? If yes, please identify entities in Exhibit A and individuals in Exhibit B. b. Does any entity or individual possess an indirect ownership interest in the Business Entity Provider equal to 5% or more? If yes, please identify entities in Exhibit A and individuals in Exhibit B. c. Does any entity or individual possess a combination of direct and indirect ownership interests equal to 5% or more in a Business Entity Provider? If yes, please identify entities in Exhibit A and individuals in Exhibit B. d. Does any entity or individual possess own an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the Business Entity Provider if that interest equals at least 5% of the value of the property or assets of the Business Entity Provider? If yes, please identify entities in Exhibit A and individuals in Exhibit B. e. If the Business Entity Provider is a corporation, identify all officers and directors of the Business Entity in Exhibit B (e.g., Chairman, CEO, President). f. If the Business Entity Provider is a partnership, identify all partners that are entities in Exhibit A and all partners that are individuals in Exhibit B.
Provider Medicaid Disclosure Statement Page 5 of 15 4. Please identify Family Relationships among individuals with an ownership or control interest in the Business Entity Provider identified in Exhibit B (see Family Relationships column and footnoted instructions in Exhibit B). 5. Please identify other disclosing entities with which the entities identified in Exhibits A and B have an ownership or controlling interest (See Other Disclosing Entities column and footnoted instructions in Exhibits A and B. 6. Please identify in Exhibit C all managing employees of the Business Entity Provider, as further described in Exhibit C. 7. Are there any Subcontractors of the Business Entity Provider in which the Business Entity Provider has an ownership interest of 5% or more ( Controlled Subcontractor ): If yes, please identify the Subcontractors: 8. Please identify Ownership or Control Interests in each Controlled Subcontractor as described below: a. Does any entity possess direct ownership interest in the Controlled Subcontractor totaling 5% or more? If yes, please identify entities in Exhibit D 1. b. Does any entity possess an indirect ownership interest in the Controlled Subcontractor equal to 5% or more? If yes, please identify entities in Exhibit D. c. Does any entity possess a combination of direct and indirect ownership interests equal to 5% or more in a Controlled Subcontractor? If yes, please identify entities in Exhibit D. d. Does any entity possess or own an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the Controlled Subcontractor if that interest equals at least 5% of the value of the property or assets of the Controlled Subcontractor? If yes, please identify entities in Exhibit D. e. If the Controlled Subcontractor is a partnership identify all partners that are entities in Exhibit D. 1 Create a new Exhibit D for each separate Controlled Subcontractor.
Provider Medicaid Disclosure Statement Page 6 of 15 9. For any Controlled Subcontractors as described above, are any individuals with an Ownership or Control Interest in the Controlled Subcontractor a spouse, parent, child or sibling of any individuals identified in Exhibit B as having a ownership or control interest in the Business Entity Provider? Such individuals include those: With a direct, indirect or combined direct and indirect ownership interest in the Controlled Subcontractor totaling 5% or more; Who possess or own an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the Controlled Subcontractor if that interest equals at least 5% of the value of the property or assets of the Controlled Subcontractor; Who, if the Controlled Contractor is a corporation, is an officer or director of the Controlled Subcontractor; Who, if the Controlled Subcontractor is a partnership, is a partner in the Controlled Subcontractor. If yes, please identify such individuals in Exhibit E. 10. Change of Ownership: In the last 12 months, has there been a change in the Business Entity Provider s ownership or control structure? If yes, please identify the changes and dates: Change Date Section C: Criminal Conviction Disclosures - Both Individual Providers and Business Entity Providers who are contracting with WVFH need to complete this Section. 1. Have you (if an Individual Provider) or any individuals or entities identified in Exhibits A-E (if a Business Entity Provider) ever been convicted of a crime related to the Medicare, Medicaid or Title XX SCHIP programs? If yes, please identify the individuals in Exhibit F. 2. Has your agent (defined as any person who has been delegated authority to obligate or act on behalf of an Individual Provider or Business Entity Provider) been convicted of a crime related to the Medicare, Medicaid or Title XX SCHIP programs? If yes, please identify the individuals in Exhibit F.
Provider Medicaid Disclosure Statement Page 7 of 15 Section D: Significant Business Transactions - Both Individual Providers and Business Entity Providers who are contracting with WVFH or its subcontractors must complete this Section. 1. Has the provider had business transactions with any Subcontractor totaling more than $25,000 during the preceding 12-month period? No If yes, please identify the name and address of the Subcontractor in the space provided below Name of Subcontractor Address (Street and P.O. Box, City, State, Zip Code) Section E: Suspensions, Revocations, Debarments, Exclusions - Both Individual Providers and Business Entity Providers who are contracting with WVFH or its subcontractors must complete this Section. 1. Has the Business Entity Provider or the Individual Provider making these disclosures, or its owners, persons with control interest, managing employees, partners, directors, or officers been excluded, suspended, debarred, revoked or any other synonymous action from participation in any program under Title XVIII (Medicare), Title XIX (Medicaid), or under the provisions of Executive Order 12549, relating to debarment or suspension from federal or state health care programs? No If yes, identify all applicable individuals or entities in Exhibit G. If no, the Provider must certify, through the individual signing the attestation in Section G, that no such individuals or entities described in this Section E have been excluded, suspended, debarred, revoked or any other synonymous action from participation in any state or federal health care program. WVFH recommends that the Provider use verification sources before making the above certification, including the Office of Inspector General List of Excluded Individuals and Entities (LEIE), the General Services Administration (GSA) Excluded Parties List System (EPLS), state exclusion lists, or any similar list. Section F: Other Disclosures - Both Individual Providers and Business Entity Providers who are contracting with WVFH need to complete this Section. 1. If the Provider believes that there is anything else that may be material to the disclosures, or that would be needed in order to avoid being possibly misleading, please provide information in the space below and, if more space is needed, in an attachment to this form. The Provider also may use the space provided in this Section to provide clarifications, explanations, additional information, etc., on any topic in this document. None Yes (explain):
Provider Medicaid Disclosure Statement Page 8 of 15 Section G: Signed Attestation I hereby attest that the information contained in this Medicaid Disclosure Statement, including the attached exhibits, is complete, comprehensive, accurate, and not misleading, to the best of my knowledge. I further certify that no such individuals or entities described in this Section E of this form have been excluded, suspended, debarred, revoked or any other synonymous action from participation in any state or federal health care program. Legal Signature: Printed Name: Date Signed: Title: (must be the Chief Executive Officer, or the entity s or provider s equivalent) On Behalf of: (Entity s or Provider s legal name) WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN A DENIAL OF A REQUEST TO PARTICIPATE, OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY. ALL INFORMATION IN THIS FORM, AS WELL AS THE EXHIBITS, WILL BE REQUESTED BY WVFH AT THE TIME OF PROVIDER APPLICATION, CREDENTIALING, RECREDENTIALING OR ANYTIME UPON REQUEST BY WVFH, DHHR, OR BMS. [ SEE EXHIBITS ATTACHED FOLLOWING THIS PAGE. ]
Provider Medicaid Disclosure Statement Page 9 of 15 EXHIBIT A Disclosures of Entities with Ownership or Control Interest in a Business Entity Provider Complete this Exhibit for all entities that are responsive to Section B, questions 3.a through 3.f. Continue on additional pages if needed. Sect. B Question (e.g., B.3.a ) Person s Name/Title Or Entity s Name Physical Address P.O. Box, if any Other business address locations (if any) EIN Other Disclosing Entities 2 2 If the person with an ownership or control interest in a Business Entity Provider also has an ownership or control interest in another entity that has to make disclosures because of the other entity s participation in Medicaid or in Title V, XVIII or XX federal programs, identify these other entities in this column.
Provider Medicaid Disclosure Statement Page 10 of 15 EXHIBIT B Disclosures of Individuals with Ownership or Control Interest in a Business Entity Provider Complete this Exhibit for all individuals who are responsive to Section B, questions 3.a through 3.f. Continue on additional pages if needed. Sect. B Question (e.g., B.3.d ) Person s Name Address (physical and P.O. Box) Date of Birth SSN Family Relationships among Individuals 3 Other Disclosing Entities 4 3 Under Family Relationships, please identify each of the other individuals in Exhibit B to whom the individual is related as a spouse, parent, child or sibling and identify type of relationship (e.g., John Doe spouse; Jim Smith sibling). 4 If the person with an ownership or control interest in a Business Entity Provider also has an ownership or control interest in another entity that has to make disclosures because of the other entity s participation in Medicaid or in Title V, XVIII or XX programs, identify these other entities in this column.
Provider Medicaid Disclosure Statement Page 11 of 15 EXHIBIT C Disclosures of Managing Employees of Business Entity Provider A Managing Employee includes a 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 operations of the Business Entity Provider. (E.g., COO, (E)VP- Operations, Executive Director, Managing Director, General Manager, Chief Administrative Officer, Medical Director, Chief Medical Officer, CFO, (E)VP-Finance, Chief Accounting Officer, Controller, Director of Finance and/or Accounting, Finance Manager, Accounting Manager, Treasurer, Financial Functions Manager). Person s Name Title Address Date of Birth SSN
Provider Medicaid Disclosure Statement Page 12 of 15 EXHIBIT D Disclosures of Entities with Ownership or Control Interest in a Controlled Subcontractor Complete this Exhibit for all entities that are responsive to Section B, questions 8.a through 8.e. Continue on additional pages if needed. Sect. 8 Question (e.g., B.5.a ) Person s Name/Title Or Entity s Name Physical Address and P.O. Box Address Other business address locations (if any) EIN
Provider Medicaid Disclosure Statement Page 13 of 15 EXHIBIT E Disclosures of Individuals with Ownership or Control Interest in a Controlled Subcontractor who have a family relationship with individuals identified in Exhibit B Complete this Exhibit for all entities that are responsive to Section B, 9. Continue on additional pages if needed. Person s Name Address (physical and P.O. Box) Date of Birth SSN Family Relationships 5 5 Under Family Relationships, please identify each of the individuals in Exhibit B to whom the individual is related as a spouse, parent, child or sibling and identify type of relationship (e.g., John Doe spouse; Jim Smith sibling).
Provider Medicaid Disclosure Statement Page 14 of 15 EXHIBIT F Disclosures of Individuals or Entities with Criminal Convictions as Described in Section C Include any instance where any person described in Section C, questions 1 and 2, is or was convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid, or the Title XX SCHIP services program since the inception of those programs. A Business Entity Provider or Individual Provider is required to notify WVFH immediately after legal notice of conviction is received by the Provider. For purposes of this Form, convicted means (a) a judgment of conviction has been entered against a person 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. If no individual or entity described in Section C, questions 1 and 2 has been convicted of a criminal offense as defined above, check If you check none, no further action is necessary. If there has been a criminal conviction, please identify the information below. NONE Sect. C Question (1 or 2) Person s Name/ Title Indicate Type of Conviction Regarding what event conviction was entered Conviction(s) Date(s) Indicate Medicare, Medicaid, Title XX, or Other
Provider Medicaid Disclosure Statement Page 15 of 15 EXHIBIT G Excluded Individuals: Entity / Provider Owners and Managing Employees Complete this Exhibit for all persons or entities for whom or which you answered Yes in Section E, Suspensions, Revocations, Debarments, Exclusions. Person s Name/Title Or Entity s Name Physical Address DOB and/or SSN/EIN Indicate Action Taken 6 Regarding what event and when this action was taken Indicate Medicare, Medicaid, Title XX, or Other Program 6 Suspension, revocation, debarment, exclusion, etc.