Medical Transportation Program Provider Application

1 REV. XIMedical Transportation Program Provider Application Revised Date: 12/31/2019 | Effective Date: 01/01/2020 Table of ContentsIntroduction ..1 Application Contact Information ..6 Application Payment Form ..7 Medical Transportation Provider Enrollment Application ..8 Disclosure of Ownership and Control Interest Statement ..9 MTP Principal Information Form (MTP-PIF1) For Entities ..14 MTP Principal Information Form (MTP-PIF2) For Transportation Provider A: Additional Forms ..A-1 Corporate Board of Directors B: tmhp Contact -1Do not return this page Page 1 Introduction Revised Date: 12/31/2019 | EThective Date: 01/01/2020 IntroductionDear Applicant:Thank you for your interest in becoming a Medical Transportation Provider . Your participation in the Medical Transportation Program (MTP) is vital to the successful delivery of Texas Medicaid services, and we welcome your Application for Application must be completed in its entirety as outlined in the instructions below and will be reviewed by the Texas Health and Human Services Commission (HHSC) and the Texas Medicaid & Healthcare Partnership ( tmhp ).

2 Providers are encouraged to review the current Texas Medicaid Provider Procedures Manual for information about Provider responsibilities, benefits and limitations, and much more. The Provider manual is updated monthly, and the current and archived Provider manuals can be accessed on the tmhp web site at Select Medicaid Provider Manual from the Providers is no guarantee your Application will be approved for StatementWith a few exceptions, Texas privacy laws and the Public Information Act entitle you to ask about the information collected on this form, to receive and review this information, and to request corrections of inaccurate information. The Health and Human Services Commission s (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, 1 TAC questions concerning this notice or to request information or corrections, please contact Texas Medicaid & Healthcare Partnership ( tmhp ) Contact Center at 1-800-925-9126.

3 tmhp customer service representatives are available Monday through Friday from 7 to 7 , Central Standard Care Act (ACA) RequirementsIn compliance with the Affordable Care Act of 2010 (ACA), all providers are subject to ACA screening procedures for newly enrolling and re-enrolling providers. All providers must be screened upon submission of an Application , including, but not limited to: Applications for providers that are new to Texas Medicaid Applications for providers that are requesting new practice locations Applications for currently-enrolled providers that must periodically revalidate their enrollment in Texas Medicaid. Refer to: Code of Federal Regulations (CFR) Title 42 Ch. IV, Part 455, Subpart E- Provider Screening and Enrollment; and Texas Administrative Code (TAC) Title 1, Part 15, Chapter 352, for the statutory provisions for these ScreeningAll providers are categorized by the CMS-defined risk levels of limited, moderate, and high based on an assessment of potential for fraud, waste, and abuse for each Provider type.

4 Providers will be screened according to their risk level and are subject to various screening activities for each risk level. Risk level assignments may be increased at any time at the discretion of HHSC. In these instances, the Provider will be notified by HHSC, and the new risk level will apply to enrollment-related not return this page Page 2 Introduction Revised Date: 12/31/2019 | EThective Date: 01/01/2020 Provider RevalidationIn compliance with ACA, tmhp is required to revalidate the enrollment of all providers at least every three to five years depending on Provider type. Providers will receive notification that they are required to revalidate before their revalidation deadline. The ACA screening criteria applies during revalidation . Providers that do not revalidate their enrollment by the designated date will be disenrolled.

5 Application CorrespondenceAll correspondence related to this Application ( , enrollment denials, deficiency letters) will also be mailed to the physical address listed on your Application unless otherwise requested in the Contact Information section of this Application . Contact InformationFor information about Medicaid Provider identifier requirements or the status of your enrollment, call the tmhp Contact Center toll-free at you for applying to become an Medical Transportation not return this page Page 3 Application Instructions Revised Date: 12/31/2019 | EThective Date: 01/01/2020 Application InstructionsRequired Forms for Medical Transportation Provider EnrollmentTo avoid any delay of the enrollment process, use this sheet as a checklist. For assistance with completing these forms, call the tmhp Contact Center at : To complete the Medical Transportation Provider enrollment Application process, the following forms must be completed and mailed to tmhp for processing.

6 Please return only the pages necessary for proper processing. Do not include any pages marked as Do Not Return in the upper right corner of this Application . FA copy of the completed Applicant Contact Information page FA completed Application Payment Form (see the instructions below for additional information) FA completed Medical Transportation Provider Enrollment Application (page 8) FA completed MTP Principal Information Form (MTP-PIF) FA completed Disclosure of Ownership and Control Interest Statement Form FA signed Medical Transportation Provider Agreement. (Original signatures required; see instructions below for additional information.)If the enrolling Provider is incorporated, the following additional forms must be completed and returned for processing: FCorporate Board of Directors Resolution Form MUST BE NOTARIZED.

7 (original signatures required) FFor corporations formed prior to January 1, 2006: Articles or Certificate of Incorporation/Certificate of Authority/Certificate of Fact (required for in-state corporations; certificate can be obtained from the Office of Secretary of State) FFor corporations formed on or after January 1, 2006: Certificates of Formation or Certificate of Filing FFranchise Tax Account Status Page (Refer to the instructions table for additional information.)Important: Retain a copy for your records of all documents submitted for the Application and Other FormsComplete this enrollment Application using the following information:ItemInstructionsApplication Payment FormAn Application fee is required for enrollment. This Application cannot be processed if the fee is not submitted with the Application .

8 Approval of your Application for enrollment does not guarantee affiliation or participation as a subcontractor with a Medical Transportation Organization (MTO) or Full Risk Broker. Enrollment fees will not be refunded once the Application process has Enrollment as:Facility enrollment. Medical Transportation Providers are enrolled as facility providers. This type of enrollment applies to situations in which licensure or certification applies to the entity. Although individuals working for or with the entity may be licensed or certified in their individual capacity, the enrollment is based on the licensure or certification of the entity. Do not return this page Page 4 Application Instructions Revised Date: 12/31/2019 | EThective Date: 01/01/2020 ItemInstructionsType of EnrollmentSelect your Provider type from the following options: Full Risk Broker: A Transportation broker awarded a contract with HHSC operating under a capitated rate system who arranges for the provision of nonemergency Medical Transportation (NEMT) services for MTP eligible clients utilizing a Provider in their Provider Subcontractor (Demand Response): A profit or non-profit entity enrolled through the Texas Medicaid & Healthcare Partnership ( tmhp ) for participation status as an NEMT service Provider , that may be enlisted by a managed transporation Transportation Organization (MTO).

9 A Transportation broker awarded a contract with HHSC to provide NEMT services to MTP-eligible clients and their attendant as prior authorized by the with Fleet: An MTO that provides NEMT services to MTP-eligible clients either through an owned, operated, and maintained fleet of vehicles or by utilizing a Provider in their Provider without Fleet: An MTO that is operating under a capitated rate system, does not own, operate, or maintain a fleet of vehicles, and arranges for the provision of prior authorized NEMT services for clients and their attendant by utilizing a Provider in their Provider network. Section A Provider of Service InformationThis section is for Provider demographic information. Provide complete and correct information as required. To apply for a National Provider Identifier (NPI), applicants should go to Principal Information Forms (MTP-PIF1 and MTP-PIF2)A separate copy of the MTP Principal Information Forms must be completed in full for each Principal (Entity [PIF1] or Principal [PIF2]) prior to of Ownership and Control Interest StatementCompletion 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 appropriate state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required.

10 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 in termination of existing Transportation Provider AgreementComplete the required information at the beginning of the form, read the agreement information, and sign and date the agreement to indicate that you have read and agree with the terms of enrollment as required by the Texas not return this page Page 5 Application Instructions Revised Date: 12/31/2019 | EThective Date: 01/01/2020 Instructions for the additional attachments available in Appendix A: ItemInstructionsCorporate Board of Directors ResolutionThis form is required if the applicant is incorporated. This form must be notarized, and an original signature is required. This form cannot be faxed to following forms must be obtained from other sources and submitted with this Application as appropriate for the requested Provider type:Franchise Tax Status PageThis certificate must be obtained from the Texas State Comptroller s Office website at request is who answer yes to the question Do you have a 501(c) (3) Internal Revenue Exemption must submit a copy of their IRS Exemption Letter with submission of this Application s signature page.