Provider Qualifications & Requirements

Transcription

1 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Adult Care Home Ambulance Service Licensed by NC DHSR as a Family Care Home Home f the Aged and Disabled Group Home f Developmentally Disabled Adults Group Home f Mentally ill Adults Licensed by NC DHSR as an Emergency Medical Service Licensed as an Emergency Medical Service in Licensed as an Emergency Medical Service in Ambulaty Surgery Center Anesthesiologist Assistants Licensed by NC DHSR Licensed by the NC Medical Board as Anesthesiologist Assistant Licensed as Anesthesiologist Assistant in the applicant s state of practice Licensed as Anesthesiologist Assistant in the applicant s state of practice At-risk Case Management Behavial Health Managed Care Organization Birthing Center Certified as a Qualified Case Management Provider by NC Division of Aging and Adult Services DHHS approval letter Accredited by the Commission f Accreditation of Free-standing Birthing Centers Accredited by the Commission f Accreditation of Free-standing Birthing Centers Children's Developmental Services Agency Certified as an Infant-Toddler Program by the Division of Public Health Local ITP Service Plan/Agreement Amendment **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 1 of 30

2 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Cochlear Implant External Parts/Repairs NC Board of Pharmacy Permit Device and Medical Equipment (Dispensing) Permit NC Board of Pharmacy Permit Device and Medical Equipment (Dispensing) Permit NC Board of Pharmacy Permit Device and Medical Equipment (Dispensing) Permit Programs, CAP/C Case Management Home Mobility Aids Vehicle Modification Community Transition Funding Care Giver Training Medical Supplies Memo of endsement from DMA CAP/C supervis verifying agency designation f specific CAP services Approval from Head of DMA DME Program Programs, CAP/C Waiver Supplies Programs, CAP/C CAP/C Nursing Respite Care, Inhome (Nursing) Memo of endsement from DMA CAP/C supervis verifying agency designation f specific CAP services Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider Licensed by NC DHSR as a Home Care Service (Nursing Care must be indicated on the license) Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 2 of 30

3 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/C Personal Care Pediatric Nurse Aide Services Attendant Care Respite Care, Inhome (Aide) Licensed by NC DHSR as a Home Care Service (In-home Aide Care must be indicated on the license) Programs, CAP/C Respite Care, Institutional (Nursing Facility Hospital) Documentation verifying the facility's with NC Medicaid as a Nursing Facility Hospital Programs, CAP/C Palliative Care Documentation verifying the facility's with NC Medicaid as a Hospice Service **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 3 of 30

4 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Programs, CAP/Choice Care Advis Financial Management Services Home Modifications and Mobility Aids Medical Supplies Participant Goods and Service Personal Assistant Services Training and Education Services Transition Codination (MFP) Transition Services Programs, CAP/Choice Assistive Technology Programs, CAP/Choice Waiver Supplies Documentation verifying the facility's with NC Medicaid as a Nursing Facility, Hospital Home Health Agency Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 4 of 30

5 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/Choice Personal Care Aide, In-Home Aide Level II Personal Care Aide, In-home Aide Level III Non-Institutional Respite Services Programs, CAP/Choice Institutional Respite Services Programs, CAP/Choice Adult Day Health Care Programs, CAP/Choice Meal Preparation and Delivery Licensed by NC DHSR as a Home Care Service (In-home Aide Care must be indicated on the license) Documentation verifying the facility's with NC Medicaid as a Nursing Facility Hospital Certification by NC Division of Aging and Adult Services as Adult Day Facility Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Letter of approval from NC Division of Aging and Adult Services Copy of current review from NC Division of Aging and Adult Services **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 5 of 30

6 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Agency marketing materials (brochure) Programs, CAP/Choice Personal Copy of contract between provider agency and Emergency moniting station if the provider agency does not Response System directly provide the moniting service Copy of contract signed by the subscriber (recipient) Note: If the contract that is signed by the subscriber (recipient) indicates that the subscriber is responsible f monthly charges and/ states that subscriber is liable and responsible f the payment of any expenses costs incurred by any person responding to a call from the moniting center, an addendum must be submitted to indicate that these charges do not apply to the subscriber. Documentation on company letterhead indicating: who is responsible f 24-hour moniting where they are located who completes medical infmation who completes responder infmation who provides info to moniting staff verification that subscriber has not signed a contract because the provider does not use a contract Note: All documentation must confirm that the agency operates accepts responsibility f providing service 24/7. **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 6 of 30

7 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/DA Case Management Home Modifications and Mobility Aids Participant Goods and Service Training and Education Services Transition Codination (MFP) Transition Services Programs, CAP/DA Assistive Technology Programs, CAP/DA Waiver Supplies Programs, CAP/DA Personal Care Aide, In-Home Aide Level II Personal Care Aide, In-home Aide Level III Non-Institutional Respite Services Programs, CAP/DA Institutional Respite Services Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Documentation verifying the facility's with NC Medicaid as a Nursing Facility, Hospital Home Health Agency Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider Licensed by NC DHSR as a Home Care Service (In-home Aide Care must be indicated on the license) Documentation verifying the facility's with NC Medicaid as a Nursing Facility Hospital Documentation verifying the provider s with NC Medicaid as a Durable Medical Equipment provider **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 7 of 30

8 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/DA Adult Day Health Care Programs, CAP/DA Meal Preparation and Delivery Certification by NC Division of Aging and Adult Services as Adult Day Facility Memo from DMA Facility and Community-based Services Unit verifying agency designation as a Lead Administrative Agency Letter of approval from NC Division of Aging and Adult Services Copy of current review from NC Division of Aging and Adult Services **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 8 of 30

9 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Agency marketing materials (brochure) Programs, CAP/DA Personal Copy of contract between provider agency and Emergency moniting station if the provider agency does not Response System directly provide the moniting service Copy of contract signed by the subscriber (recipient) Note: If the contract that is signed by the subscriber (recipient) indicates that the subscriber is responsible f monthly charges and/ states that subscriber is liable and responsible f the payment of any expenses costs incurred by any person responding to a call from the moniting center, an addendum must be submitted to indicate that these charges do not apply to the subscriber. Documentation on company letterhead indicating: who is responsible f 24-hour moniting where they are located who completes medical infmation who completes responder infmation who provides info to moniting staff verification that subscriber has not signed a contract because the provider does not use a contract Programs, CAP/MR-DD Adult Day Health Care Programs, CAP/MR-DD Crisis Respite Note: All documentation must confirm that the agency operates accepts responsibility f providing service 24/7. Certification by NC Division of Aging And Adult Services Licensed by NC DHSR as a Respite Care facility Certification by the Local Management Entity (Notification of Endsement Action Letter) **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 9 of 30

10 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Documentation verifying the provider s Documentation verifying the provider s Programs, CAP/MR-DD with NC Medicaid as a Durable with NC Medicaid as a Durable Waiver Supplies Medical Equipment provider Medical Equipment provider Programs, CAP/MR-DD No requirements Specialized Equipment and Supplies Programs, CAP/MR-DD Transptation Enrollment f transptation services is limited to emergency (ambulance) service providers only F additional infmation: NC DMA: Transptation Services **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 10 of 30

11 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/MR-DD Augmentative Communication Behavial Consultant Crisis Services Home and Community Suppt Home Modification Home Suppt Individual/Caregiver Training and Education Long-term Vocational Suppts Personal Care Services Respite Care, Noninstitutional Specialized Consultative Services Suppted Employment Vehicle Adaptation Certification by the Local Management Entity (Notification of Endsement Action Letter) **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 11 of 30

12 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/MR-DD Certification by the Local Management Entity (Notification of Endsement Action Letter) Residential Suppts Note: Services can be delivered in the community in a licensed facility not owned by the provider. However, if the service is rendered in a licensed facility that is owned by the provider, the facility must be licensed (accding to 10A NCAC 27G.5600) by NC DHSR as one of the following: (F) Supervised Living/Alternative Family Living Facility (C) Supervised Living f DD Adults (B) Supervised Living f DD Mins **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 12 of 30

13 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Agency marketing materials (brochure) Programs, CAP/MR-DD Personal Copy of contract between provider agency and Emergency moniting station if the provider agency does not Response System directly provide the moniting service Copy of contract signed by the subscriber (recipient) Note: If the contract that is signed by the subscriber (recipient) indicates that the subscriber is responsible f monthly charges and/ states that subscriber is liable and responsible f the payment of any expenses costs incurred by any person responding to a call from the moniting center, an addendum must be submitted to indicate that these charges do not apply to the subscriber. Documentation on company letterhead indicating: who is responsible f 24-hour moniting where they are located who completes medical infmation who completes responder infmation who provides info to moniting staff verification that subscriber has not signed a contract because the provider does not use a contract Note: All documentation must confirm that the agency operates accepts responsibility f providing service 24/7. **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 13 of 30

14 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Programs, CAP/MR-DD Certification by the Local Management Entity (Notification of Endsement Action Letter) Day Suppts Licensed by NC DHSR as one of the following: Adult Day Developmental Vocational Program (in accdance with 10A NCAC 27G.2300) Sheltered Wkshop (in accdance with 10A NCAC 27G.5500) Day Activity (in accdance with 10A NCAC 27G.5400) Developmental Day Programs (in accdance with 10A NCAC 27G.2400) Programs, CAP/MR-DD Respite Care, Institutional (ICF/MR) Programs, CAP/MR-DD Respite Nursing Note: Services can be delivered by a licensed Adult Day Health Care Facility that is enrolled to provide CAP/MR-DD Adult Day Health Care Services, no additional certification, licensure, endsement is required to provide day suppt services. Letter of approval verifying the facility's with NC Medicaid Certification by the Local Management Entity (Notification of Endsement Action Letter) Licensed by NC DHSR as a Home Care Service (Nursing Care must be indicated on the license) **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 14 of 30

15 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Community Intervention Services Assertive Community Treatment Team Mobile Crisis Management Medically Supervised ADATC Detox/Crisis Stabilization Diagnostic Assessment Multisystemic Therapy Community Intervention Services Early Intervention Services Certification by the Local Management Entity (Notification of Endsement Action Letter) Letter of approval from the Children's Developmental Services Agency **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 15 of 30

16 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Certification by the Local Management Entity (Notification of Endsement Action Letter) Community Intervention Services Professional Treatment Services in Facility-based Crisis Program - Adult Professional Treatment Services in Facility-based Crisis Program - Child Partial Hospitalization Ambulaty Detox Substance Abuse Comprehensive Outpatient Treatment Non-hospital Medical Detox Substance Abuse Non-medical Community Residential Treatment Substance Abuse Medically Monited Community Residential Treatment Substance Abuse Intensive Outpatient Program Psychosocial Rehab Opioid Treatment Licensed by NC DHSR as a Mental Health Facility **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 16 of 30

17 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Certified Registered Nurse Anesthetist, Individual Licensed by NC Board of Nursing as a Registered Nurse Certified by Council on Certification of Nurse Anesthetists Council on Recertification of Nurse Anesthetists Licensed as a Registered Nurse by the licensure board in Certified by Council on Certification of Nurse Anesthetists Council on Recertification of Nurse Anesthetists Licensed as a Registered Nurse by the licensure board in Certified by Council on Certification of Nurse Anesthetists Council on Recertification of Nurse Anesthetists Certified Registered Nurse Anesthetist, Group Critical Access Behavial Health Agency Community Suppt Team Child and Adolescent Day Treatment Intensive In-home state of practice state of practice No requirements No requirements Letter of Certification as a Critical Access Behavial Health Agency from DHHS from DMH/DD/SAS Certification by the Local Management Entity (Notification of Endsement Action Letter) Dialysis Center Licensed by NC DHSR **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 17 of 30

18 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Durable Medical Equipment NC Pharmacy Board Permit Device and Medical Equipment (Dispensing) Permit A letter on the applicant s letterhead signed by the authizing agent attesting to the provision of thotics and prosthetics only NC Pharmacy Board Permit Device and Medical Equipment (Dispensing) Permit A letter on the applicant s letterhead signed by the authizing agent attesting to the provision of thotics and prosthetics only NC Pharmacy Board Permit Device and Medical Equipment (Dispensing) Permit A letter on the applicant s letterhead signed by the authizing agent attesting to the provision of thotics and prosthetics only Current National Clearinghouse Supplier letter from CMS verifying Medicare (cannot be me than 3 yrs from the date of approval indicated on the letter) Current National Clearinghouse Supplier letter from CMS verifying Medicare (cannot be me than 3 yrs from the date of approval indicated on the letter) Current National Clearinghouse Supplier letter from CMS verifying Medicare (cannot be me than 3 yrs from the date of approval indicated on the letter) Federally Qualified Health Center Ce Services Approval from Head of DMA DME Program Medicaid Agency s Notice of Rate Health Department No Requirements Hearing Aid Provider Licensed by the NC State Hearing Aid Dealers Licensed by the NC State Hearing Aid Dealers and Fitters Board and Fitters Board by the licensure board in the applicant's state of practice HIV Case Management Certified as a Qualified Case Management Provider by the Carolinas Center f Medical Excellence Home Health Service Licensed by NC DHSR as a Home Care Service **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 18 of 30

19 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Home Infusion Therapy Hospice Licensed by NC DHSR as a Home Care Service (Infusion Nursing Service must be indicated on the license) Licensed by NC DHSR as a Home Care Service Hospital Hospital, Critical Access Licensed by NC DHSR Hospital, (Specialty) Long Term Acute Care (LTACH) Licensed by NC DHSR Licensed by NC DHSR Hospital, Swing Bed Licensed by NC DHSR Hospital, Psych/Rehab Unit ICF/MR, Privately Owned Licensed by NC DHSR Licensed by NC DHSR ICF/MR, State-owned No requirements **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 19 of 30

20 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Independent Diagnostic Testing Facility Accredited through the American Registry of Diagnostic Medical Sonographers Cardiovascular Credentialing International American Registry of Radiologic Technologists Independent Labaty CLIA certification CLIA certification CLIA certification Independent Practitioner, Individual Occupational Therapist Independent Practitioners, Individual Physical Therapist Independent Practitioner, Individual Respiraty Therapist Licensed by the NC Board of Occupational Therapy Licensed by the NC Board of Physical Therapy Licensed by the Respiraty Care Board Licensed by the Board of Occupation Therapy in the applicant s state of practice Licensed by the Board of Physical Therapy in the applicant s state of practice Licensed by the Respiraty Care Board in the applicant s state of practice **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 20 of 30

21 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Independent Practitioner, Individual Licensed by the NC Board of Examiners f Speech and Language Pathologists and Licensed by the Board of Examiners f Speech and Language Pathologists and Audiologists in Speech Language Therapist Audiologists the applicant s state of practice Proof of ASHA Certificate of Clinical Competence (CCC) in Speech/Language Pathology Documentation indicating the completion of: requirements and wk experience necessary f the ASHA CCC in Speech/Language Pathology academic Master's degree program and is acquiring the supervised wk experience to qualify f the ASHA CCC in Speech/Language Pathology Proof of ASHA Certificate of Clinical Competence (CCC) in Speech/Language Pathology Documentation indicating the completion of: requirements and wk experience necessary f the ASHA CCC in Speech/Language Pathology academic Master's degree program and is acquiring the supervised wk experience to qualify f the ASHA CCC in Speech/Language Pathology Independent Practitioner, Individual Audiologist Licensed by the NC Board of Examiners f Speech and Language Pathologists and Audiologists Licensed by the Board of Examiners f Speech and Language Pathologists and Audiologists in the applicant s state of practice Independent Practitioner, Group Local Education Agency (Public Schools) Local Management Entity No Requirements No Requirements No Requirements Note: Only a State-constituted public board of education other public authity running a school system, elementary secondary school, public nonprofit charter school recognized by the State is eligible to participate as an LEA. No Requirements **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 21 of 30

22 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Nurse Midwife, Individual Licensed by the NC Board of Nursing Certification from the Midwifery Joint Committee of NC Licensed by the Board of Nursing in the applicant's state of practice Certification from the Midwifery Joint Committee of NC the entity responsible f certification in Licensed by the Board of Nursing in the applicant's state of practice Certification from the Midwifery Joint Committee of NC the entity responsible f certification in Nurse Midwife, Group No Requirements Nurse Practitioner, Licensed by the NC Board of Nursing Licensed by the NC Board of Nursing the Individual entity responsible f licensure in the applicant's state of practice Licensed by the NC Board of Nursing the entity responsible f licensure in the applicant's state of practice Certification as a Nurse Practitioner by one of the following national credentialing bodies American Nurses Credentialing Center American Academy of Nurse Practitioners National Certification Cpation of the Obstetric and Gynecological and Neonatal Nursing Specialists Pediatric Nursing Certification Board NOTE: Per 21 NCAC (a) A nurse practitioner with first-time approval to practice after January 1, 2000, shall provide evidence of certification recertification as a nurse practitioner by a national credentialing body. NPs licensed pri to January 1, 2000 did not have to be certified by a national credentialing body. Copy of Statement of Approval Letter issued by the medical board other licensing entity with both the approval date and the name of the supervising physician Certification as a Nurse Practitioner by one of the following national credentialing bodies American Nurses Credentialing Center American Academy of Nurse Practitioners National Certification Cpation of the Obstetric and Gynecological and Neonatal Nursing Specialists Pediatric Nursing Certification Board NOTE: Per 21 NCAC (a) A nurse practitioner with first-time approval to practice after January 1, 2000, shall provide evidence of certification recertification as a nurse practitioner by a national credentialing body. NPs licensed pri to January 1, 2000 did not have to be certified by a national credentialing body. Copy of Statement of Approval Letter issued by the medical board other licensing entity with both the approval date and the name of the supervising physician Certification as a Nurse Practitioner by one of the following national credentialing bodies American Nurses Credentialing Center American Academy of Nurse Practitioners National Certification Cpation of the Obstetric and Gynecological and Neonatal Nursing Specialists Pediatric Nursing Certification Board NOTE: Per 21 NCAC (a) A nurse practitioner with first-time approval to practice after January 1, 2000, shall provide evidence of certification recertification as a nurse practitioner by a national credentialing body. NPs licensed pri to January 1, 2000 did not have to be certified by a national credentialing body. Copy of Statement of Approval Letter issued by the medical board other licensing entity with both the approval date and the name of the supervising physician **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 22 of 30

23 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Nurse Practitioner, Group Nursing Facility No Requirements Licensed by NC DHSR Copy of the state Medicaid agency's official notice of rate Copy of the state Medicaid agency's official notice of rate Nursing Facility, Vent Bed Approval from Head of DMA Nursing Facility Program Nursing Facility, Head Bed Licensed by NC DHSR Licensed by NC DHSR Optical Supplier Licensed by the NC Board of Opticians Licensed by the NC Board of Opticians the licensure board in **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 23 of 30

24 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Orthotics and Prosthetics Certified Ocularist Certified Fitter of Therapeutic Shoes Certified/Registered Mastectomy Fitter Certified Orthotist Certified/Registered Orthotic Fitter Certified Prosthetist Certified Pedthist Register Fitter Orthotics Mastectomy Certified Orthotist/Prosthetist Certified accredited by American Board f Certification in Orthotics and Prosthetics Board of Orthotist/Prosthetist Certification National Examining Board of Ocularists Board f Certification in Pedthics Board of Certification in Clinical Anaplastology The Compliance Team, Inc. Certified accredited by American Board f Certification in Orthotics and Prosthetics Board of Orthotist/Prosthetist Certification National Examining Board of Ocularists Board f Certification in Pedthics Board of Certification in Clinical Anaplastology The Compliance Team, Inc. Outpatient Behavial Health Provider, Individual Advanced Practice Psychiatric Clinical Nurse Specialist Licensed by the NC Board of Nursing Certification from the American Nurse Credentialing Center Advanced Psychiatric Nurse Association Licensed by the NC Board of Nursing the licensure board in Certification from the American Nurse Credentialing Center Advanced Psychiatric Nurse Association **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 24 of 30

25 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Outpatient Behavial Health Provider, Licensed by the NC Board of Nursing Licensed by the NC Board of Nursing the licensure board in Individual Certification from the Advanced Practice American Nurse Credentialing Center Certification from the Psychiatric Nurse American Nurse Credentialing Center Practitioner another specialty with 2 years of documented mental health experience another specialty with 2 years of documented mental health experience Outpatient Behavial Health Provider, Individual Licensed Clinical Social Wker Licensed by the NC Social Wk Certification and Licensure Board Master's degree in social wk from a school of social wk accredited by the Council on Social Wk Education Licensed by the Social Wk Certification and Licensure Board the licensure board in the applicant s state of practice Master's degree in social wk from a school of social wk accredited by the Council on Social Wk Education Outpatient Behavial Health Provider, Individual Licensed Professional Counsel Outpatient Behavial Health Provider, Individual Licensed Clinical Addiction Specialist Outpatient Behavial Health Provider, Individual Certified Clinical Supervis Licensed by the NC Board of Licensed Professional Counsels Licensed by the NC Substance Abuse Professional Practice Board Certified by the NC Substance Abuse Professional Practice Board Licensed by the Board of Licensed Professional Counsels the licensure board in the applicant s state of practice Licensed by the Substance Abuse Professional Practice Board the licensure board in the applicant s state of practice Certified by the Substance Abuse Professional Practice Board the licensure board in the applicant s state of practice **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 25 of 30

26 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Outpatient Behavial Health Provider, Individual Licensed by the NC Marriage and Family Therapy Licensure Board Licensed by the Marriage and Family Therapy Licensure Board the licensure board in the applicant s state of practice Licensed Marriage and Family Therapist Outpatient Behavial Health Provider, Individual Licensed Psychologist Outpatient Behavial Health Provider, Individual Licensed Psychological Associate Outpatient Behavial Health Provider, Group PACE Licensed by the NC Psychology Board Licensed psychologists must be doctate level Licensed by the NC Psychology Board No Requirements Certification from the NC Division of Aging and Adult Services Licensed by the Psychology Board the licensure board in the applicant s state of practice Licensed psychologists must be doctate level Licensed by the Psychology Board the licensure board in the applicant s state of practice Copy of PACE Program Agreement from CMS Personal Care Service Licensed by NC DHSR as a Home Care Service (In-home Aide Care must be indicated on the license) Pharmacy Permit from the NC Board of Pharmacy Permit from the Board of Pharmacy in the applicant's state of practice Permit from the Board of Pharmacy in the applicant's state of practice Physician, Individual Medical docts Physician, Individual Osteopaths Licensed by NC Medical Board Licensed by NC Medical Board Licensed by Medical Board in the applicant's state of practice Licensed by Medical Board in the applicant's state of practice Approval from Head of DMA Pharmacy Program Licensed by Medical Board in the applicant's state of practice Licensed by Medical Board in the applicant's state of practice **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 26 of 30

27 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Physician, Individual Licensed by the NC Board of Chiropractic Licensed by the Board of Chiropractic Examiners Licensed by the Board of Chiropractic Examiners Chiropracts Examiners in in Physician, Individual Licensed by the NC Board of Examiners in Licensed by the Board of Examiners in Licensed by the Board of Examiners in Optometrists Optometry Optometry in Optometry in Physician, Individual Licensed by the NC Board of Podiatry Examiners Licensed by the Board of Podiatry Examiners in Licensed by the Board of Podiatry Examiners in Podiatrists Physician, Individual Licensed by the NC Board of State Dental Licensed by the Board of State Dental Examiners Licensed by the Board of State Dental Examiners Dentists Examiners in in Physician, Group No requirements No requirements No requirements Physician Assistant, Individual Physician Assistant, Group Successful completion of an accredited educational program accredited by the Committee on Allied Health Education and Accreditation (CAHEA) its predecess success entities Successful completion of Physician Assistant National Certifying Examination if licensed after June 1, Maintain a current and active license from State Medical Board (license renewed annually) and maintain an active registration with State Medical Board to practice in Nth Carolina Current Copy of Intent to Practice Acknowledgement Letter issued by the medical board other licensing entity No Requirements Licensed by State Medical Board (license renewed annually) and active registration with State Medical Board Successful completion of an accredited educational program accredited by CAHEA its predecess success entities Successful completion of Physician Assistant National Certifying Examination if licensed after June 1, 1994 Current Copy of Intent to Practice Acknowledgement Letter issued by the medical board other licensing entity Licensed by State Medical Board (license renewed annually) and active registration with State Medical Board Successful completion of an accredited educational program accredited by CAHEA its predecess success entities Successful completion of Physician Assistant National Certifying Examination if licensed after June 1, 1994 Current Copy of Intent to Practice Acknowledgement Letter issued by the medical board other licensing entity Not Eligible Planned Parenthood Agency Ptable X-ray Service Private Duty Nursing Certification from the Planned Parenthood Federation of America, Inc. Licensed by NC DHSR as a Home Care Service (Nursing Care must be indicated o the license) **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 27 of 30

28 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Psychiatric Hospital, State Owned (only f recipients under 21 and 65 years and older) Psychiatric Residential Treatment Facility, state-owned Psychiatric Hospital, privately owned, (only f recipients under 21 and 65 years and older) Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Licensed by the NC DHSR F Individuals under 21, Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Licensed by the hospital s state agency charged with licensure in F Individuals under 21,Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Licensed by the hospital s state agency charged with licensure in F Individuals under 21, Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 28 of 30

29 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** Psychiatric Residential Treatment Facility, privately owned Rural Health Clinic Ce Services School Based Health Center Sponsed by a Physician Group, a Nurse Practitioner Group, a Health Department School Based Health Center Sponsed by a Federally Qualified Health Center Licensed by NC DHSR as a Mental Health Treatment Facility Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Letter of Suppt from the Local Management Entity Copy of completed NC School-based Health Center Verification of Credentialed Status Fm from the N.C. Division of Public Health Copy of completed NC School-based Health Center Verification of Credentialed Status Fm from the N.C. Division of Public Health Health Resources and Services Administration (HRSA) Notice of Grant Award including Fm 5 Part B/Services Sites Licensed as a Mental Health Facility in the applicant s state of practice and location Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Be enrolled as a Medicaid provider in the state in which it is located. Licensed as a Mental Health Facility in the applicant's state of practice and location Accreditation from Joint Commission on Accreditation of Healthcare Organizations Council on Accreditation Commission on Accreditation of Rehabilitation Facilities Approval from Head of DMA Behavial Health Program Be enrolled as a Medicaid provider in the state in which it is located. Medicaid Agency s Notice of Rate **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 29 of 30

30 Nth Carolina Medicaid Management As of May 22, 2012 Infmation System (MMIS) Provider Type In-State Bder Out-of-State** F new applicants: Notice of Endsement from the Local Management Entity Targeted Case Management f Developmental Disabilities Targeted Case Management f Mental Health and Substance Abuse Therapeutic Family Services F providers currently billing f this service through the Local Management Entity: Notice of Endsement from the Local Management Entity and Letter of Attestation f TCM-DD from the Local Management Entity Letter of Certification as a Critical Access Behavial Health Agency from DHHS from DMH/DD/SAS Licensed by NC DSS as a Child Placing Agency Notice of Endsement from the Local Management Entity **Out-of-state providers are eligible f enrollment only f the reimbursement of services rendered to a N.C. Medicaid recipient in response to an emergency if travel back to the State would endanger the health of the eligible recipient; f reimbursement of a priapproved non-emergency service; f reimbursement of medical equipment and devices that are not available through an enrolled provider located within the State of Nth Carolina in the 40-mile bder area. Page 30 of 30