Florida Medicaid Provider Enrollment Application

Transcription

1 Florida Medicaid Provider Enrollment Application Please type or print all information in blue or black ink: Applicant s Name: Applicant s Telephone Number: ( ) Area Code Contact Person: Contact Person s Telephone Number: ( ) Area Code Please return entire Enrollment Application. Make a copy of the Enrollment Application for your files. Mail this application and all required paperwork to: ACS State Healthcare Provider Enrollment P.O. Box 7070 Tallahassee, Florida Please note that the following applicants do not submit enrollment forms directly to ACS State Healthcare. If you are Early Intervention Provider Home and Community-Based Waiver Service Provider Home Health Agency School-based Services Provider (certified match programs) CMS Targeted Case Manager or Management Agency Transportation Provider applications are sent to Your District Children s Medical Services Office The Program or Agency that administers the waiver Agency for Health Care Administration Medicaid Provider Enrollment 2308 Killearn Center Boulevard, Suite 200 Tallahassee, Florida Agency for Health Care Administration Medicaid Health Systems Development 2727 Mahan Drive Mail Stop 20 Tallahassee, Florida Your District Children s Medical Services Office Your Area Medicaid Office Note: See the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for a complete list of required documentation. If you have any questions, please call ACS Provider Enrollment at AHCA Form (December 2002)

2 APPLICATION Page 2 AHCA Form (December 2002)

3 Any person or entity that wants to be paid for rendering medical, medical-related and waiver-related services to Medicaid recipients must complete this form. Please refer to the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for information regarding Florida Medicaid provider enrollment. Use only the current application form. If you are unsure about whether you have the most current form, call the Medicaid fiscal agent at Please type or print in blue or black ink. 1. Name of Business or Individual: 2. This item should be completed by a provider operating under a trade or company name, e.g., ABC corporation, doing business (D/B/A) as ABC pharmacy #1. A provider doing business under his or her own name should leave this section blank. Doing Business As (D/B/A): 3. You must enter the street address of the place where services will be rendered in this section. Post office box addresses are not acceptable for physical addresses. Your application will be returned to you if you enter only a post office box address for the physical address. If you are unable to receive mail at your physical address, enter the physical address first and the post office box address second. Medicaid allows certain providers to use an Application for New Location Code form if the provider has more than one physical location. Please see Application Page 22 for the form and a list of providers that can use the form. Pharmacy providers may submit a letter on their letterhead requesting activation of a Durable Medical Equipment locator code in lieu of the Application for New Location Code form. Up-to-date Medicaid Provider handbooks are available on the fiscal agent web site at no charge. Paper copies of the handbooks will not be sent to you unless requested below. Please access this important information from the Internet. The Medicaid Bulletin will be sent to the address in Item 3. Paper copies of the handbooks are requested: Reimbursement Handbook Coverage and Limitations Handbook Business Physical Address: P. O. Box (if applicable) City/State: Zip Code: Business address: Visit to register for Florida Medicaid s Alert System. These automated alerts will be used to keep providers informed of late-breaking Medicaid information. 4. Business Location Telephone Number: ( ) Area Code Business Location Fax Number: ( ) Area Code AHCA Form (December 2002) APPLICATION Page 3

4 5. Enter the county for the address shown in Item 3. County Name: 6. All DME providers and pharmacies must be located within 50 miles of Florida s border to be enrolled as in-state providers. Other provider types located in Georgia and Alabama that regularly serve Medicaid recipients may enroll as in-state providers. A freestanding clinical laboratory located outside Florida can enroll as an in-state provider if it is Clinical Laboratory Improvement Amendment (CLIA) certified and licensed by Florida. Are you an out-of-state provider? Yes, I am an out-of-state provider No, I am an in-state provider 7. Enter the address to which you want your Medicaid payment information (remittance vouchers) sent. If you leave this item blank, your remittance vouchers will be sent to your address in Item 3. Mailing address for payment: City/State: Zip Code 8. Enter the name and telephone number of the person who maintains your patient and financial records and the physical address of the location that each type of file is maintained, as requested below. The address cannot be a post office box. Medical Record Custodian Name: Financial Record Custodian Name: Phone Number: ( ) Phone Number: ( ) Area Code Area Code Physical Address of Medical File Location City/State: Zip Code: Physical Address of Financial File Location City/State: Zip Code: 9. Enter the Social Security Number of the individual applicant, if the individual applicant is not personally incorporated. Enter the Federal Employer Identification Number (FEIN) of a group applicant. These items are mandatory per Section 6109(a) of the Internal Revenue Code. Do not enter the group FEIN for an individual applicant even if the individual will be associated with a group. You must submit an IRS Form W9 with an original signature or a copy of the Social Security card with this application. Social Security Number: OR FEIN: APPLICATION Page 4 AHCA Form (December 2002)

5 10. Enter the two-digit code for the appropriate provider type from the list provided in the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at Enter only one code per enrollment application. Provider Type Code 11. Enter the appropriate two-digit code from the Specialty Code list in the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at Check board certified or board eligible for each specialty listed. If either is checked, then you must attach a legible copy of either the Board Certification, the current Board Eligibility and expiration date of eligibility, or Certificate of Residency Completion. Enter the date you were certified for your specialty in MM/DD/YY format. Enter the number, up to six digits, that was provided to you when you were certified for the associated specialty. a. Primary Specialty Code This is a mandatory field for home and community based services waiver providers, physicians, dentists, therapists, and therapeutic service providers. Check One Board Certified Board Eligible Certification Date Certification Number b. Secondary specialty code Check One Board Certified Board Eligible Certification Date Certification Number Attach additional sheets if more than two specialties. Be sure to include the same information for additional specialties. 12. Enter the appropriate two-digit code for your type of practice from the list provided in the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at Practice Type Code 13. Enter the appropriate two-digit code(s) to designate your category(ies) of service from the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at If you have questions about the appropriate category of service, call the fiscal agent at List category of service codes 14. List NPIN and UPIN, if applicable NPIN UPIN AHCA Form (December 2002) APPLICATION Page 5

6 15. Medicare Number 16. Include a current legible copy of the licenses listed below: a professional license, a facility license, a Clinical Laboratory Improvement Amendment (CLIA) license, or any combination of the three. An Internet screen print of your license from the Department of Health web site is also required. Note: All providers who perform laboratory services must submit a legible copy of their current CLIA Certification of Compliance or Accreditation and a legible, current state laboratory license with their application. Professional License Number: License Date: Expiration Date: Facility License Number: CLIA License Number: 17. Only individual providers should complete this item. Group appl icants should leave it blank. Enter the Medicaid provider number(s) assigned to any group practice with which you are affiliated. If you do not belong to a group practice, leave this item blank. The begin date is your effective date of enrollment in Medicaid or the date you became affiliated with the group, whichever is later. Enter the date you became a member of the group practice in MM/DD/YY format. Limit of 15 group affiliations. a. Group Membership Information Group Provider No.: Begin Date: b. Is a group enrollment pending with this application? Yes No APPLICATION Page 6 AHCA Form (December 2002)

7 18. Enter the appropriate ownership code from the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at Ownership Code 19. OWNERSHIP INFORMATION: If you are an individual or group applicant, list information below for the applicant, financial custodian of records and the Electronic Funds Transfer (EFT) authorized individuals and the information requested on each. List all shareholders (five percent or more ownership), partners of your business and subcontractors AND all individual officers, directors, managers, financial custodian of records and Electronic Funds Transfer (EFT) authorized individuals and the information requested on each. Officers are deemed to be officers of the corporation or company such as the President or Vice President. Directors are members of the company s board of directors. Managers are members of the company s management team. If you have a Director of Therapy Services or Director of Clinical Services, these persons would qualify as managers for Medicaid purposes. Special Instructions: 1) The applicant and all of the individuals listed below must complete a fingerprint card for the background screening requirement for enrollment as a Medicaid provider. 2) If the applicant or any of the individuals listed below has already completed a fingerprint card for enrollment as a Medicaid provider, please indicate Yes in the chart below. 3) If an individual had a state and national criminal history check completed within the past 12 months as part of employment requirements, attach proof to this application from the state department or agency that required the background screening. The proof should state the name of the individual who was screened, his/her social security number, the type of screening, and the date the screening was completed. 4) Physician (25, 26, 27 and 28) and nurse (30 and 31) provider types are not required to complete a fingerprint card or background screening for Medicaid as the Department of Health license meets the Medicaid requirement. Please submit an Internet screen print of your license from the Department of Health web site. 1. Name and Address Title SSN License # Check business relationship that applies: % Owner Background Screened Yes No owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 2. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling AHCA Form (December 2002) APPLICATION Page 7

8 19 OWNERSHIP INFORMATION, continued: Name and Address Title SSN License # 3. Check business relationship that applies: % Owner Background Screened Yes No owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 4. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 5. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 6. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 7. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 8. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling APPLICATION Page 8 AHCA Form (December 2002)

9 19. OWNERSHIP INFORMATION, continued Name and Address Title SSN License # 9. Check business relationship that applies: % Owner Background Screened Yes No owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 10. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 11. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 12. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 13. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling 14. Check business relationship that applies: owner shareholder partner subcontractor Check relationship to enrolling provider: spouse parent child sibling Attach additional sheets if necessary. AHCA Form (December 2002) APPLICATION Page 9

10 20. Please answer all sections (a - e) of this question. Have you or any of the individuals listed in Item 19 ever: a. Been convicted of a felony, had adjudication withheld on a felony, pled nolo contendere to a felony, or entered into a pre-trial agreement for a felony? Yes No If yes, list name(s) of individuals(s): If yes, please provide a copy of the administrative complaint and final disposition. b. Had any disciplinary action taken against any business or professional license held in this or any other state or surrendered a license in this or any state? Yes No If yes: Against whom? What action was taken? Who took the action? What date? If yes, please provide a copy of the final disposition. Attach documentation from the proper authorities that approved the reinstatement of the license. c. Been denied enrollment, been suspended or excluded from Medicare or Medicaid in any state, or been employed by a corporation, business or professional association that has ever been suspended or excluded from Medicare or Medicaid in any state? If yes, please provide a copy of the documentation. Yes No If yes, list name(s) and provider number(s) of individuals(s): Name: Provider Number: d. Had suspended payments from Medicare or Medicaid in any state, or been employed by a corporation, business or professional association that ever had suspended payments from Medicare or Medicaid in any state? If yes, please provide a copy of the documentation. Yes No If yes, list name(s) and provider number(s) of individuals(s): Name: Provider Number: e. Owes money to Medicaid or Medicare that has not been paid? Yes No APPLICATION Page 10 AHCA Form (December 2002)

11 21. Do you or any officers, directors or owners listed in Item 19 have ownership in any other Medicaid enrolled business? Yes No List other Medicaid enrolled businesses you own and the names of all owners of five percent or more of these other businesses. Attach additional pages if necessary. If yes, list the owner s names, the names of the other businesses and the Medicaid provider numbers of the other businesses. Name: Name of Other Business: Provider Number: 22. DEA Number Attach a legible copy of current DEA license. 23. Pharmacy applicants must complete the following information: 1. Enter the following information about the business as it is listed on the Board of Pharmacy permit. Business Name: Type of Pharmacy: License Number: Issuance Date: Expiration Date: Attach a legible copy of the current Board of Pharmacy permit. Attach a list of the pharmacy department hours and legible copies of financial statements and pharmacy department descriptive inventory. See the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for inventory format. 2. Enter the following information about the prescription department manager. Name: License Number Issuance Date: Expiration Date: Attach a legible copy of the prescription department manager s current pharmacy license. Note: The prescription department manager must complete a background screening and must be listed as a manager in Item Is this facility affiliated with or part of a chain? Yes No If YES, give chain s: Name Address Federal Tax ID AHCA Form (December 2002) APPLICATION Page 11

12 24. This section must be completed by: Physician Assistant (PA), Advanced Registered Nurse Practitioner (ARNP), Registered Nurse (RN), or Certified Registered Nurse Anesthetist (CRNA). This section must be signed by both the enrolling practitioner and the doctor with whom the practitioner has an agreement. This is to certify that, PA ARNP RN CRNA (circle one) and, M.D. D.O. D.D.S. (circle one) will collaborate in the provision of medically necessary services provided to Medicaid recipients. Signatures: PA ARNP RN CRNA (circle one) License # M.D. D.O. (circle one) D.D.S. License # 25. Durable Medical Equipment (DME) applicants must read the following information: DME suppliers who are required to have a Home Medical Equipment (HME) license per , F.S. must submit a copy of their HME license with their Medicaid Provider Enrollment Application. DME suppliers who have multiple locations must submit the HME license and a Medicaid provider application for each location. DME suppliers who provide oxygen and oxygen-related equipment must submit a copy of their oxygen retailer permit issued by the Department of Health in addition to a copy of their HME license. The DME suppliers who meet certain exemptions are not required to have a Home Medical Equipment license. If you meet one of the exemptions, please check the box. Business that supplies only diabetic monitors and disposable supplies, e.g., diabetic, ostomy, urological or wound care supplies. Orthotics and prosthetic provider licensed under Chapter 468, part XIV, F.S., which sells only orthotics and prosthetics. DME business that is owned by a pharmacy licensed under Chapter 465, F.S. DME business that is owned by a nursing facility, assisted living facility, home health agency, hospice, intermediate care facility, home for special services, or transitional living facility licensed under Chapter 400, F.S. DME business that is owned by a hospital or ambulatory surgical center licensed under Chapter 395, F.S. APPLICATION Page 12 AHCA Form (December 2002)

13 A change of ownership (CHOW) occurs whenever the stock or assets/liabilities of a business are purchased or transferred by the existing owners to new owners. The following is a list of situations that generally are not considered a change of ownership: parent corporations absorb or merge with their fully owned sub-corporations; the owners and structure of the Medicaid-enrolled entity remain the same; and the name of a company changes, but neither the company owners nor the federal tax identification numbers change. New ownership of a Medicaid provider requires a new provider number. Medicaid provider numbers are not transferable. 26. This information will be used to determine whether a new Medicaid provider number will be assigned and to terminate the old provider number effective on the date of the transfer of ownership. a. Is this application based on a change of ownership? Yes No Note: A copy of stock transfer document or bill of sale is needed to document a change of ownership. If YES, give date of ownership change If YES, give previous owner s: Name Medicaid Provider Number Federal Tax ID 27. Billing Agent Agreement The following billing agent is authorized to submit claims to and follow up with Medicaid and the Medicaid fiscal agent on my behalf. I understand that all payments and payment information are in my name and that this agreement does not exempt me from responsibility for claims filed on my behalf or from established claim filing policies. I further understand that the billing agent must be enrolled in the Medicaid program and is held to the same requirements of confidentiality and access to records that I am, as reflected in my agreement with Medicaid. I will immediately notify the Medicaid fiscal agent of any change in this authorization. Billing Agent Name Billing Agent Provider Number - Required Billing Agent Address City State Zip ( ) Area Code and Telephone Number AHCA Form (December 2002) APPLICATION Page 13

14 Electronic Claims Submission and Pharmacy Point of Service Providers - Providers who choose to submit claims electronically, including pharmacies that use Point of Service (POS) devices, must be aware that payment of claims will be from federal and state funds and that any falsification or concealment of material fact may be prosecuted under Federal and State laws. Further, providers must understand and agree to the following: safeguard the Medicaid program against abuse in the use of electronic claims submission, including POS. correctly enter the claims data, monitor the data and certify that the data entered is correct. assure that the transmission of claims data is restricted to authorized personnel to prevent erroneous payments by the Agency s fiscal agent that might result from carelessness or fraud. have on file the applicable source data to substantiate the claim submitted to the Medicaid program. allow the Agency or any of its designees and representatives of the office of the Auditor General or the Attorney General to review and copy all records, including source documents and data related to information entered through electronic claims submission, including POS. abide by all Federal and State statutes, rules, regulations, and manuals governing the Florida Medicaid program. sign and adhere to all conditions of the Medicaid Provider Agreement and be officially enrolled in the Medicaid program to participate in electronic claims submission, including POS. In addition, Pharmacy providers who use POS devices to submit claims must understand and agree to the following: allow the Agency or its representatives to perform audit functions. the Provider must maintain the original prescription on file. the Provider shall reverse any claim adjudicated and then not dispensed to a Medicaid recipient. Claim reversals are limited in their use by Medicaid policy. Please review and check the blocks and complete the information requested in the following items that pertain to you: 28. Electronic Claims Submission - I plan to file my Medicaid claims electronically to the Medicaid fiscal agent. Telephone # used for claims submission: 29. Point of Service Agreement - I plan to submit pharmacy claims electronically through a Point of Service (POS) device. The system vendor is and the system vendor certification number is. APPLICATION Page 14 AHCA Form (December 2002)

15 30. Automatic Deposits and Payments (EFT) I authorize the fiscal agent for the State of Florida, Agency for Health Care Administration to make deposits to my checking or savings account and the depository bank indicated. You must attach to this application a letter from the bank on bank letterhead verifying the bank transit / ABA routing number, your account number and account name. ( ) DEPOSITORY NAME BRANCH BANK TELEPHONE # CITY STATE ZIP CODE BANK ACCOUNT NUMBER NAME ON BANK ACCOUNT LIST ALL INDIVIDUALS AUTHORIZED TO SIGN ON THIS ACCOUNT: Note: All individuals listed here must be listed in Item 19 Ownership. Print Name Signature Note: Any future changes to this EFT account will require a signature of an individual authorized as listed above. See the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for exceptions to EFT. 31. Surety Bond If you are a Durable Medical Equipment provider, an independent laboratory, a physicians group with more than 50% non-physician ownership, or a non-emergency transportation provider, you must submit a surety bond with your application. Home health agencies have special surety bond requirements that are explained in the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at Your application will be returned to you if the surety bond is not included. For more information regarding surety bonds and a sample surety bond form see the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at AHCA Form (December 2002) APPLICATION Page 15

16 CERTIFICATION Complete the signature portion below. The application must contain an original signature and date. Copies and signature stamps are not acceptable. Authorized agents are those individuals designated in a letter attached to this application by the organization to transact business on its behalf. Registered agents are those who are so designated in the Articles of Incorporation filed with the Florida Department of State. If a registered agent signs the application, a copy of the Articles of Incorporation must be included with the application to document the registered agent s status. If an authorized agent or registered agent will be signing your application, the organization and its owners will be held accountable for the contents of the application just as if they had signed for themselves. For the purposes of establishing eligibility to receive direct or indirect payment for services rendered to recipients of the Florida Medicaid Program, I understand that, under Section (2)(f), Florida Statutes, the filing of materially incomplete or false information with this enrollment request is a third degree felony and is sufficient cause for termination from the Florida Medicaid Program. I further understand that false claims, statements, documents, or concealment of material facts may be prosecuted under applicable federal and state laws. I understand that I am responsible for the information presented on this application and that the information is true, accurate, and complete. Furthermore, I agree to abide by the provisions of this provider agreement effective from the date that the services or goods were provided, pursuant to Section (11), Florida Statutes. I understand that it is my responsibility to notify Medicaid s fiscal agent of any change to the information on this application, including but not limited to, a change of address, group affiliation, ownership, officers, directors, tax identification number, or EFT bank account. Signature of Provider or Authorized Agent/Registered Agent Date Name of Provider or Authorized Agent/Registered Agent (Please Type or Print Legibly) Title Note: See the Guide for Completing a Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or conta ct the fiscal agent at for a complete list of required documentation. If you have any questions, please call ACS Provider Enrollment at APPROVAL: (Office use only - do not write below this line) Signature Print Name Approval Date Comments: APPLICATION Page 16 AHCA Form (December 2002)

17 Electronic Funds Transfer (EFT) Exception Request This form must be completed by each individual who will not be receiving Medicaid EFT deposits to his/her own account in his/her own name and under his/ her own individual (treating) provider number. If a group provider is to be paid for services of an individual provider and the individual will never be receiving direct payments, then the individual must complete this form. Do not complete this form if you work for a group and will also be billing separately for yourself. The group can file for its portion of the services and receive payments under the group number. The individual can file directly for those services he/she performs apart from the group and receive payments to his/her own EFT account indicated on the EFT Authorization Agreement. Electronic Funds Transfer Exception Request for Individual Provider Number (if provider number is pending, this will be added by the fiscal agent) Please process this request for an exception to the requirement of participating in the electronic funds transfer (EFT) program. I qualify for this exception because I work under group number provider number or transportation CTC number and all disbursements made for services performed by myself will be made directly to the group on my behalf. I understand that by requesting this exemption, I will not be able to receive direct disbursements from Medicaid for the services I render, and I will not be able to file Medicaid claims under my individual provider number. Additionally, I understand that in order to begin receiving Medicaid disbursements billed with my individual number, I will need to comply with the requirements of the EFT program. Print Name Title Signature Date AHCA Form (December 2002) APPLICATION Page 17

18 Agency for Health Care Administration Electronic Remittance Voucher Agreement Any provider planning to receive claim remittance vouchers (explanation of benefits) electronically must complete this form. If you sign this agreement, you will not receive remittance voucher (RV) banner messages when you receive payment information. If you have any questions regarding electronic remittance vouchers, please call the fiscal agent EDI technical support at This AGREEMENT made and entered into this day of,, by and between the Agency for Health Care Administration, hereinafter called the Agency, acting in its own right as the Agency responsible for administering the Medical Assistance Program (Title XIX and XXI), and by, hereinafter called Provider. (Provider Name) WITNESSETH: In consideration of the mutual promises and covenants contained herein and other good and valuable consideration, the parties hereto agree as follows: The Agency shall allow the Provider to receive remittance vouchers through Internet download from the fiscal agent s Internet web site. Please check who will be receiving your remittance vouchers. Yourself or Company Billing Agent (Vendor) Name Telephone Number Address Medicaid Provider Number City State ZIP Code BY: (Provider/Representative Signature) (Date) Medicaid Provider ID Number If not assigned, the fiscal agent will complete. APPLICATION Page 18 AHCA Form (December 2002)

19 Group Provider Application for Individual Membership in a Group Providers who will be submitting Medicaid claims under a group number, regardless of the group type, must complete this form. Please complete this page for all the members of your group. Each member must sign below the printed name. All signatures must be original. Signature stamps and copies are not acceptable. If your group has more members than spaces available on this form, please photocopy this form to make sure that all members are listed and enclose that additional list with the application. If you are applying as an individual provider, not affiliated with any group, disregard this form. Group Name (Please print) Group s Federal Employer Identification Number Number in Group Group Provider Number, if assigned Individual member s name and title (MD, DPM, etc.) Name (please print) Florida License Number (license numbers begin with two alpha characters) Individual Medicaid Number Signature: Name (please print) Effective Date: Signature: Name (please print) Effective Date: Signature: Effective Date: If applying for a group provider number, you must complete the Certificate of Ownership Form for Physician Groups. AHCA Form (December 2002) APPLICATION Page 19

20 Group Name (Please print) Group s Federal Employer Identification Number Number in Group Group Provider Number, if assigned Individual member s name and title (MD, DPM, etc.) Name (please print) Florida License Number (license numbers begin with two alpha characters) Individual Medicaid Number Signature: Name (please print) Effective Date: Signature: Name (please print) Effective Date: Signature: Name (please print) Effective Date: Signature: Name (please print) Effective Date: Signature: Effective Date: Attach additional sheets if necessary. If applying for a group provider number, you must complete the Certificate of Ownership Form for Physician Groups. APPLICATION Page 20 AHCA Form (December 2002)

21 Certificate Of Ownership Form for Physician Groups (print name of business) has applied to become a Medicaid provider or is currently a Medicaid Provider. (print address of business) (print Tax ID # or Medicaid #, if applicable) This business is certifying the ownership as follows: (Check all that apply) Located in or attached to a hospital. Owned by a For Profit Hospital $50,000 Surety Bond required if this box is checked Owned by a Not-For-Profit Hospital 50% or more owned by a physician(s). Is not 50% or more owned by a physician(s) $50,000 Surety Bond required if this box is checked Please list owner s full name(s), social security number and percentages of ownership (totaling 100%). If you are a physician, please include a copy of your license. Owner s Full Name Social Security Number % of Ownership (Attach additional sheet if necessary) Under penalty of perjury, I do hereby certify that meets one or more of the criteria specified above. (name of business) Signature & Title of Owner or CEO Date Print name of above signatory party AHCA Form (December 2002) APPLICATION Page 21

22 APPLICATION Page 22 AHCA Form (December 2002)

23 Application for a New Location Code Medicaid provider numbers consists of a base numbe r of seven digits with a two-digit suffix (location code) that can vary by physical location. To add a new location code to a base provider number, complete the reverse side of this form. INSTRUCTIONS You must submit a completed form for each physical location. (You may make photocopies of a blank form.) If the location has a different Federal Employer ID number than the base provider, you must complete and submit an entire enrollment application. If you have any questions, please call ACS Provider Enrollment at Only the following provider types can use the Application for New Location Code; all other provider types must complete and submit an entire enrollment application. Provider Type and Number 30 Advanced Registered Nurse 65 Home Health Agencies 83 Therapist (PT, OT, ST, RT) Practitioner 60 Audiologist 63 Optician 40 Ambulance 91 Case Management Agencies 62 Optometrist 41 Non-Emergency Transport 28 Chiropractor 29 Physician Assistant 42 Air Ambulance 05 Community Mental Health Services 26 Physician D.O. 43 Taxicab Company 77 County Health Departments 25 Physician M.D. 44 Government/Municipal Transport 35 Dentist 27 Podiatrist 45 Private Transportation 68 Federally Qualified Health Centers 31 Registered Nurse First Assistant only 61 Hearing Aid Specialist 07 Specialized Therapeutic Foster Care Provider 46 Non-Profit Transportation 47 Multi-Load Private Transport Note: Pharmacy providers may submit a letter on their letterhead requesting activation of a Durable Medical Equipment locator code in lieu of the Application for New Location form. Up-to-date Medicaid Provider handbooks are available on the fiscal agent web site at no charge. Paper copies of the handbooks will not be sent to you for this location code unless requested. Please access this important information from the Internet Paper Handbooks requested: Coverage and Limitations Handbook Reimbursement Handbook Where to mail forms: Home health agencies must mail completed forms and attachments to: Agency for Health Care Administration Medicaid Provider Enrollment 2308 Killearn Center Blvd., Suite 200 Tallahassee, FL All other provider types must mail completed forms to: ACS Provider Enrollment P.O. Box 7070 Tallahassee, FL See the Guide for Completing the Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for complete information regarding the license requirements for transportation providers and a list of the area Medicaid offices. AHCA Form (December 2002) APPLICATION Page 23

24 Application for a New Location Code 1. Provider Name: 2. Base Provider Number: Provider Type No. (see reverse for provider type numbers) 5. Physical Location: Enter the place where services are rendered. Post office boxes are not allowed for the physical address. If you are unable to receive mail at your physical address, enter the physical address first and the post office box address second. 4. Specialty Code No. (See the Guide for Completing the Medicaid Provider Enrollment Application, the web site listed at the bottom of the page, or contact the fiscal agent at for lists of codes) Billing Office Yes No 6. County: 7. Phone number: Do not abbreviate. 8. Pay to Address: (remittance vouchers will be sent to this address) 9. Financial Record Custodian s Name and Address You must attach an Authorization Agreement for Electronic Funds Transfer (EFT) with a letter from the bank verifying the bank transit / ABA routing number, your account number and account name. If the base provider number is for a group, you must attach a Group Provider Application for Individual Membership in a Group and the Certificate of Ownership Form For Physician Groups forms. Child Welfare Targeted Case Management Agencies Child Welfare Targeted Case Management Agencies are required to submit the Children s Certification for Child Welfare Targeted Case Management Form with this locator code application. Home Health Branches Must Complete this Section Branch License Number (attach copy) In addition to an Authorization Agreement for EFT, home health branches must also attach: Copies of the fingerprint cards submitted with the parent office s application and Surety bond, if applicable. Signature of Provider (or authorized agent if group provider) Date APPLICATION Page 24 AHCA Form (December 2002)

25 FDLE Criminal History Check and Fingerprinting Exemption Request (print name of organization or individual provider) attached application to become a Medicaid provider. is submitting the This organization is requesting exemption from the fingerprinting and criminal history check requirements under Chapter 409, Florida Statutes, on the following basis: (Check all that apply and include a copy of applicable licenses.) This organization is a School District, and is exempt under Section , Florida Statutes. This organization is a hospital licensed under Chapter 395, Florida Statutes. This organization is a nursing home licensed under Chapter 400, Florida Statutes. This organization is a hospice licensed under Chapter 400, Florida Statutes. This organization is an assisted living facility licensed under Chapter 400, Florida Statutes. This organization is a unit of local government. This organization derives more than 50% of its revenue from the sale of goods to final consumers AND 1. Is required to file a form 10K with the Securities and Exchange Commission OR 2. Has a net worth of $50 million or more. Documentation (annual report including audited financial statements and/or 10K form) must be submitted with any exemption request under this category. NOTE: If the organization is a contractor with a unit of local government, this exemption does not apply. Under penalty of perjury, I do hereby certify that (Name of Organization or Individual Provider) meets one or more of the criteria specified above. Signature of CEO of Organization or Superintendent of School District Date Print name of above signatory party AHCA Form (December 2002) APPLICATION Page 25

26 APPLICATION Page 26 AHCA Form (December 2002)

27 Organization Affidavit for Exemption from Medicaid Criminal History Checks Under penalty of perjury, I,, do hereby certify (Print Name) that, Medicaid Number, is (Print Name of Organization) a not-for-profit corporation or organization as defined in Florida Statutes. I further certify that the members of the board of directors of the organization listed above meet all of the following criteria: 1. Serves solely in a voluntary capacity for the above-named organization; 2. Receives no remuneration from the above-named organization; 3. Does not take part in the day-to-day operational decisions of the above-named organization; 4. Has no financial interest in the above-named organization; and 5. Has no family members with a financial interest in the above-named organization. Check here if the CEO meets any of the five requirements listed above. Please attach a list of board members containing the first and last names, and social security numbers. Under penalty of perjury, I do hereby certify that (Name of Organization or Individual Provider) meets one or more of the criteria specified above. Signature of CEO of Organization Date Print name of above signatory party AHCA Form (December 2002) APPLICATION Page 27

28 Jeb Bush Governor Rhonda M. Medows, MD, FAAFP Secretary 2727 Mahan Drive Tallahassee, FL

29 JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY Notice to Prospective Community Mental Health Services Provider Thank you for your interest in Medicaid s Community Mental Health Services program. Enrollment in the program is contingent upon compliance with the following: 1) Obtaining a contract with the Department of Children and Families, Substance Abuse and Mental Health (SAMH) district program office for the provision of community mental health or substance abuse services. 2) Employ or have under contract a Medicaid enrolled psychiatrist or other physician (provider type 25). 3) Score 85% or better in each domain reviewed during a pre-enrollment certification review to assure compliance with state and federal guidelines. The review includes: standards for facility/environment, leadership, management of human resources, staff credentials, records management, scope of and need for services provided, service area, access to care, quality improvement, services to be provided and records documentation. As part of the records documentation review, the facility seeking enrollment must provide a list of a minimum of client records from the facility to the Peer Review Contractor for a sample selection, 30 days prior to the onsite review. Note: Providers of Behavioral Health Overlay Services and Therapeutic Group Home Services are subject to additional certification requirements. The effective date for enrollment is the date that the Agency for Health Care Administration (AHCA) certifies in writing that the provider has met all the necessary standards for enrollment. Enrollment will not be retroactive to the application date. Enrollment will be no earlier than the effective date of the approval of the provider application. Medicaid will only reimburse for claims with dates of service effective on or after the enrollment date. Please direct questions regarding the pre-certification review to Ms. Nasreen Kabani at (850) , and questions regarding completion of the Medicaid provider application to ACS State Healthcare at Mahan Drive Mail Stop #20 Visit AHCA online at Tallahassee, FL

30 *MOST FREQUENT REASONS APPLICATIONS ARE RETURNED* PLEASE REVIEW YOUR APPLICATION FOR THE FOLLOWING: Question 8: Records Custodian (Application p.4) List an individual s name (Business name is not acceptable) Question 9: SSN or Tax ID 1. Attach a Social Security Card, SS-4, or W-9 2. Make sure an original (wet ink) signature is on W-9 Question 11: Specialty Certification Include documentation for requested specialty codes Question 19: Ownership (Application p.7) 1. List all required individuals: Applicant Financial Records Custodian EFT authorized individuals All individuals with 5 percent or more ownership 2. List all requested information (SSN, percent of ownership) Question 30: EFT or EFT Exception (Application p.15-17) 1. Complete all sections of the form(s) 2. Attach a bank letter (EFT) 3. Ensure information on the bank letter matches EFT form 4. EFT Exception - Provide a valid group link Fingerprint Cards 1. Include a $47 check for each card 2. Make checks payable to ACS State Healthcare 3. Complete all sections of the FP card (Application Guide p.37-42) Medicaid Provider Agreement 1. All associates listed in Question 19 are required to sign, or 2. CEO or President may sign for the entity 3. Make sure an original (wet ink) signature is provided Original Signatures Provide original signatures (No copies, faxes, signature stamps)