Provider Initial Enrollment Instructions Individuals n040513

1 _____ FA-31C-I: Provider Initial Enrollment Instructions ( Individuals ) Page 1 of 3 04/12/2013 Nevada Medicaid and Nevada Check Up This document provides Instructions for completing the Provider Initial Enrollment Application for Individual providers. Please answer all questions as of the current date. Attach additional sheets if necessary to answer each question completely. Each additional sheet must display the relevant question number from the application. These Instructions are designed to clarify certain questions on the application. Instructions are listed in question order for easy reference. No Instructions have been given for questions considered self-explanatory. Section 1: General Information Question 4 ( Enrollment Effective Date) Enter the date on which you wish the Provider Enrollment to begin. The date in this field may be backdated up to six months, but may not be prior to all Provider Enrollment requirements being met.

2 To exceed the six-month backdate limitation, provide a written explanation and supporting documentation. If you have already provided services, review the dates of service you will be billing and enter a date that will cover all of your back billing. If you have no back billing, enter the current date. Timely filing limits apply. (Timely Filing Limits: From the Date of Service or the recipient s date of eligibility, whichever is later, you have 180 days to submit in-state Provider claims when Medicaid is the only insurance or 365 days to submit out-of-state Provider claims and claims when the recipient has a primary health insurance carrier other than Medicaid.) Question 5 (Group Membership) If you would like to become a member of an existing Provider Group, enter the group s National Provider Identifier (NPI) and the date you would like to be affiliated with the group. You may enter a date in the past. Please note that timely filing limits apply. (See Question 4 above for timely filing limits.)

3 When the group s NPI is used as the billing Provider on a claim, payments will be made to the Provider Group. Group Enrollment is required for Provider types 14 and 82. Question 6 ( Provider Type) Nevada Medicaid has defined approximately 60 different medical service types, also referred to as Provider types. Enter the appropriate 2-digit Provider type number from the left column of Table E-2 found in the Provider Enrollment Information Booklet. Some providers provide more than one type of service. You must submit one complete set of Enrollment documents for each Provider type you are enrolling ( , Provider Enrollment Packet and documents listed on the relevant Enrollment checklist for that Provider type). For example, if you supply Durable Medical Equipment ( Provider type 33) as well as pharmaceutical drugs ( Provider type 28), complete two sets of Enrollment documents. The same NPI would be noted on each application. The difference between the two applications would be the Provider type number and the attachments required per the Enrollment checklists.

4 Question 7 (Specialties) Some Provider types require you to identify a 3-digit specialty code in Question 7 on the Application. The 3-digit specialty code is shown next to each bulleted item in Table E-2 found in the Provider Enrollment Information Booklet. Provider Initial Enrollment Instructions ( Individuals ) _____ FA-31C-I: Provider Initial Enrollment Instructions ( Individuals ) Page 2 of 3 04/12/2013 A specialty is required for Provider types 14, 17, 19, 20, 34, 38, 48, 57, 58 and 82. For Provider types 14, 17 and 82 only, enter one specialty code per Application. A Provider Enrollment Packet must be submitted for each specialty being enrolled. To assist in Medicaid tracking, we recommend that Provider types 22, 26, 54 and 76 identify a specialty when applicable. All other Provider types may leave Question 7 blank. Section 2: Tax and Business Information Question 17 (Electronic Health Records) Complete this question only if you are or will be providing services in an IHP, RHC or FQHC facility/clinic (PT 47 or PT 17) AND enrolling as a qualified eligible professional exclusively to receive incentives offered through the Electronic Health Records (EHR) program.

5 The EHR program is based on individual Enrollment ; therefore, the application is to be completed with the individual Provider s information, not the clinic or group the Provider may be associated with. Questions 18-20 (Legal Name, DBA, TIN/SSN) Must match the IRS records The legal name and Tax Identification Number or Social Security Number listed must match the information registered with the Internal Revenue Service (IRS), what is listed on your IRS Employer ID Number (EIN) confirmation letter and the W-9 form. Include with your Enrollment Packet a copy of the Internal Revenue Service (IRS) acceptance letter. Questions 21 and 22 (Secretary of State) Questions 21 and 22 are required for in-state providers only. These questions are not applicable for individual providers joining a group practice. #21: Enter the entity name listed on your business license or registered with the Secretary of State office. #22: Enter the Secretary of State issued NV Business ID number.

6 Question 31 (Electronic Funds Transfer) It is required that all providers must accept Nevada Medicaid and Nevada Check Up payments via Electronic Funds Transfer (EFT). Enter the business or personal bank account number along with the authorized signature. An original voided check or letter from your bank that contains your bank s routing number must accompany the application. Photocopied checks and bank deposit slips are not accepted. Section 3: Background, Ownership and Disclosure of Disclosing Entity Completion of this section is a condition of participation in the Nevada Medicaid program and is mandated by 42 CFR 106. Click here to view the full regulation. List the names of all Individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity.

7 A disclosing entity is defined as a Medicare Provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health-related services under the social services program. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: If A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A s interest equates to an 8 percent indirect ownership and must be reported. _____ FA-31C-I: Provider Initial Enrollment Instructions ( Individuals ) Page 3 of 3 04/12/2013 Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity ( , joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity.

8 The ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Other definitions: Agent means any person who has been delegated the authority to obligate or act on behalf of a Provider . Disclosing entity means a Medicaid Provider or a fiscal agent. Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency. Managing employee means 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 operation of an institution, organization or agency. Other disclosing entity means 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.

9 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 established under Title V or Title XX of the Act. 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.

10 Subcontractor means: a) 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 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. Supplier means an individual, agency or organization from which a Provider purchases goods and services used in carrying out its responsibilities under Medicaid ( , a commercial laundry, a manufacturer of hospital beds or a pharmaceutical firm). Declaration (Signature): The individual Provider must sign the application. FA-31C: Provider Initial Enrollment Application ( Individuals ) Page 1 of 5 02/18/2014 (pv04/12/2013) Nevada Medicaid and Nevada Check UpProvider Initial Enrollment Application ( Individuals ) This Provider Enrollment Application is to be used by individual providers.