ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) CLINICAL NURSE

Transcription

1 LOUISIANA Department of HEALTH and HOSPITALS ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) CLINICAL NURSE SPECIALIST (Enrollment Packet is subject to change without notice) (PT93) Revised 10/06

2 Louisiana Medicaid Unisys Corporation Provider Enrollment Unit PO Box (225) To Whom It May Concern: Enclosed is the enrollment packet for the Louisiana Medical Assistance Program (also known as the Louisiana Medicaid Program) you requested. It contains a participation agreement, enrollment data and forms with instructions. You should carefully review these materials, including all instructions, before completing the necessary forms. The Medicaid Program requires all providers to be state certified for claims to be processed. After completing the enrollment packet materials, please return all forms to: Unisys Provider Enrollment Unit PO Box Please be sure to include any and all Medicare provider numbers you want linked to your Medicaid provider number. If you have applied for a Medicare provider number but have not received the number(s), please submit the number(s) to Provider Enrollment at the above address upon receipt. Claims will not automatically cross electronically from Medicare to Medicaid unless these provider numbers are linked in our system. If you have provided services to a Louisiana Medicaid recipient prior to the date you receive State certification, you must send a letter with your enrollment packet stating the earliest date that services were provided to a Louisiana Medicaid recipient. It will be necessary that all eligibility requirements are met at the time of service for Unisys to authorize retroactive eligibility. Any claims submitted prior to receipt of this letter must be resubmitted and returned with your application for enrollment. The Unisys Provider Enrollment Unit willl take the necessary steps to certify you as a provider and participant in the Louisiana Medical Assistance Program. Upon certification, you will be notified of your Medicaid provider number which must be used for billing. Also, Unisys Provider Relations will forward a provider manual to you. If manual is not received within two (2) weeks of notification, please notify Provider Relations at (800) or (225) If you have any questions concerning the completion of this enrollment packet, please contact the Provider Enrollment Unit at the above address or at (225) Thank you for your cooperation. Sincerely, Provider Enrollment Unit Louisiana Medicaid Project

3 CLINICAL NURSE SPECIALIST CHECKLIST OF FORMS TO BE SUBMITTED The following checklist shows all documents that must be submitted to the Unisys Provider Enrollment Unit in order to enroll in the Louisiana Medicaid Program as a Clinical Nurse Specialist provider: Completed Document Name 1. Completed Louisiana Medicaid PE-50 Enrollment Form* (Read instructions carefully before completing this form) 2. Completed PE-50 Addendum Provider Agreement* 3. Copy of printed document received from IRS showing Employer Identification Number (EIN) and official name as recorded on IRS records - W-9 forms are not accepted 4. If provider name in Section 1 of the PE-50 is: An entity completed LA Medicaid Entity Ownership Disclosure Information form (5 pages located in the Basic Enrollment Packet) An individual completed LA Medicaid Individual Disclosure Information form (2 pages, located in the Basic Enrollment Packet). 5. Completed Medicaid Direct Deposit (EFT) Authorization Agreement* 6. Copy of Voided Check for account to which you wish to have your funds electronically deposited. Deposit slips are not accepted 7. Copy of Registered Nurse License. If requesting retroactive coverage, license must be submitted that covers the retroactive period of coverage. 8. Copy of certification as a Clinical Nurse Specialist by the Louisiana State Board of Nursing 9. Verification that credentials have been filed with the Louisiana State Board of Nursing and that the area of specialization has been indicated. Note: The area of specialization must be verified in writing by the proper licensing Board. Areas of Specialization available for enrollment: Adult Psychiatric and Mental Health Nursing Acute and Critical Care, Neonatal Acute and Critical Care, Pediatric Child & Adolescent Psychiatric & Mental Health Nursing Community Health Nursing Gerontological Nursing Home Health Nursing Maternal Child Nursing Medical Surgical Nursing (known in prior years as Clinical Specialist in Adult Health) Oncology Pediatric Nursing 10. Must have Collaborative Practice Agreement available for review upon request. 11. Verification of Prescriptive Authority, if applicable. 12. To submit electronic claims, a Completed EDI contract* and Power of Attorney* (if applicable) must accompany this application. Refer to Basic Enrollment Packet for details. For Group Linkages: 1. Completed Group Linkage form (Review instructions in their entirety before completing form.) * Forms are included in the Basic Enrollment Packet PLEASE USE THIS CHECKLIST TO ENSURE THAT ALL REQUIRED ITEMS ARE SUBMITTED WITH YOUR APPLICATION FOR ENROLLMENT. FORMS MUST BE SUBMITTED AS ORIGINALS WITH ORIGINAL SIGNATURES (NO STAMPED SIGNATURES OR INITIALS) DO NOT SUBMIT COPIES OF THE ATTACHED FORMS. Please submit all required documentation to: Unisys Provider Enrollment Unit PO Box 80159

4 Medicaid Enrollment Procedures for Advanced Practice Registered Nurses Advanced Practice Registered Nurses (APRNs) are eligible to enroll in the Louisiana Medical Assistance Program (Medicaid) in the following ways: 1. Full Enrollment without Prescriptive Authority can provide services to the Louisiana Medicaid recipient population excluding prescriptive authority; 2. Full Enrollment with Prescriptive Authority can provide services to the Louisiana Medicaid recipient population including prescriptive authority; 3. Prescriber Only authorized with prescriptive authority only cannot provide any other services to the Louisiana Medicaid recipient population; and 4. Currently enrolled in Full Enrollment but requesting to add prescriptive authority The following steps are identified for new enrollments in the Medicaid program: A. Request an enrollment packet for your type of APRN by calling the Provider Relations Department at 800/ or 225/ The following information will be requested by the telephone representative: Provider Name, Provider Address, Provider Telephone Number, and Type of Enrollment Packet requested (Certified (Licensed) Nurse Practitioner, Nurse-Midwife, Certified Nurse Specialists, Certified Registered Nurse Anesthetist). B. Review packet carefully to ensure you understand what is required. Refer to listing at front of packet to familiarize yourself with the forms that must be included. An abbreviated list is also provided below. C. Complete the Enrollment Packet and return it to the Provider Enrollment Unit. All packets must be submitted in their entirety. Incomplete or incorrect enrollment packets will be returned to the provider for correction as Unisys cannot alter or change enrollment packet documents. -- Normal processing time for new applications is three to four business weeks The Provider Enrollment Unit must receive the following information before your request can be processed: 1. Full Enrollment without Prescriptive Authority the following forms are required to be submitted with your enrollment packet: ƒ Completed Form PE-50 (must be original two-sided document with original signature) ƒ Copy of Registered Nurse license ƒ Copy of license as an APRN by the Louisiana State Board of Nursing ƒ Verification that credentials have been filed with the Louisiana State Board of Nursing and that the area of specialization has been indicated ƒ Written documentation of formal collaborative practice agreement. The agreement shall be available for review upon request. ƒ Copy of a pre-printed IRS document verifying the taxpayer ID number or social security number ƒ Voided check (deposit slip not acceptable) 2. Full Enrollment with Prescriptive Authority same as number one above with the addition of the following forms: ƒ Copy of Certificate of Limited Prescriptive Authority from Louisiana State Board of Nursing granting limited prescriptive authority 3. Prescriber Only the following forms are required to be submitted with your enrollment packet: ƒ A letter addressed to the Provider Enrollment Unit requesting a Medicaid prescriber only number. Must include provider name, address, telephone number, social security number ƒ Verification of licensing from the appropriate State Licensing Board ƒ Copy of Letter of Notice of Limited Prescriptive Authority issued by the Louisiana State Board of Nursing ƒ Written documentation of formal collaborative practice agreement. The agreement shall be available for review upon request. 4. Enrolled Currently with Full Enrollment but adding Prescriptive Authority - the following forms are required ƒ A letter addressed to the Provider Enrollment Unit including: provider number, provider name, physical address, telephone number, social security number and request to add prescriptive authority indicator to provider file ƒ ƒ Copy of Letter of Noticie of Prescriptive Authority issued by the Louisiana State Board of Nursing. Use your Medicaid Provider Number when writing prescriptions not physician s number. If you have additional questions, please call the Provider Enrollment Unit at 225/

5 LNK01- INT Revised 5/02 Louisiana s Medicaid Program Provider Enrollment Form Group Linkage/Unlinkage Form Instructions PURPOSE This form is used by providers to supply identifying data to the Unisys Provider Enrollment Unit to link or unlink individual Medicaid provider numbers to group Medicaid provider numbers on the Medicaid Management Information System (MMIS). This form can be used only if the individual already has a Medicaid provider number. Linkages of individuals requesting new provider numbers require a complete Enrollment Packet. INDIVIDUAL PROVIDER NUMBER The individual provider number is the exclusive Medicaid number assigned to an individual or entity that is to be used to bill Medicaid for services rendered to Medicaid recipients: By an individual or entity; or As an Attending Provider in a group setting. GROUP PROVIDER NUMBER The group provider number is the exclusive Medicaid number assigned to a group that is to be used to bill Medicaid for services rendered to Medicaid recipients. This group number is used to bill all services rendered and an individual provider number is entered onto the claim as the Attending Provider. ADDITIONAL INFORMATION The address for the individual provider number does not have to be the same as the group address in order for the group to receive payments and/or remittance advice for services that are billed under the group s provider number. Those payments will automatically be sent to the Pay To address on the group s provider file. For claims submitted by the group to process correctly, the individual provider number used as the Attending Provider must be linked to the group number. This is accomplished by completing the attached form and returning it to the Unisys Provider Enrollment Unit. This form is also used to notify Unisys Provider Enrollment of an unlinkage meaning that an individual Medicaid provider no longer provides services under the group affiliation. PREPARATION Complete the form in its entirety and mail the original to the Provider Enrollment Unit at the address on the bottom of the form. The completed form may be photocopied for your records. Incomplete forms will be returned to you for completion. The following fields must be completed: Individual Provider Number: enter the seven- (7) digit Medicaid provider number for the individual to be linked to the group Individual Provider Name: enter the name for the individual provider number listed as it appears on the MMIS provider file Area Code and Telephone Number: enter the complete telephone number where the individual provider can be reached by the Provider Enrollment Unit should there be any questions Group Provider Name: enter the name of the group to which the individual provider wishes to be linked or unlinked Group Provider Number: enter the seven- (7) digit Medicaid provider number of the group indicated in the Group Provider Name Link / Unlink: check the appropriate box to indicate whether you are requesting a linkage or unlinkage Effective Date of Linkage: enter the date you wish to have the linkage of the individual provider number to the group provider number activated Termination Date of Unlinkage: enter the date the individual provider stopped performing services with the group

6 LNK01- INT Revised 5/02 Louisiana s Medicaid Program Provider Enrollment Form Group Linkage/Unlinkage Form Please review the instructions on the reverse side before completing the form. Individual Provider Number: Individual Provider Name: Area Code & Telephone Number: ( ) - Group Provider Name: Group Provider Number: LINK UNLINK Effective Date of Linkage: Termination Date of Unlinkage: Group Provider Name: Group Provider Number: LINK UNLINK Effective Date of Linkage: Termination Date of Unlinkage: Print Provider s Name Provider s Signature Date MAIL Completed Forms To: Unisys Provider Enrollment Unit PO Box For I nt er nal Use Only