wv medicaid and wvchip provider … medicaid and chip joint...prescreening questions – determines...

WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION – GENERAL INSTRUCTIONS

DXC Provider Enrollment Unit

P.O. Box 625

Charleston, WV 25322-0625

WV Medicaid/WVCHIP Dual Provider Enrollment Application

Version 1.0 January 8, 2019

1

You should use this application if: You are an institution, ancillary facility, group of practitioners, individual or direct pay -to as a sole proprietor operating and billing under a unique TAX Identification Number; AND are applying to enroll as a WV Medicaid and/or WVCHIP provider. READ General Instructions, and complete all required sections of this application. Each page contains important information on completing this application, and requirements for submission of Provider Enrollment Application and participation information. ALL REQUIRED FIELDS ARE MARKED WITH AN ASTERISK (*). If you wish to enroll in WVCHIP, you must complete any

additional fields notated by a check -mark (√) . It is essential that ALL REQUIRED FIELDS MUST BE ANSWERED - IF NOT APPLICABLE FOR YOUR SPECIFIC PROVIDER TYPE, INDICATE N/A. Failure to submit a completed application with all supporting documentation will result in enrollment delays.

If you are a newly enrolling, or re-enrolling provider DO NOT SCHEDULE MEDICAID MEMBER APPOINTMENTS UNTIL YOU ARE NOTIFIED OF ENROLLMENT APPROVAL AND THE EFFECTIVE DATE OF ENROLLMENT. THE EFFECTIVE DATE WILL BE THE DATE OF ENROLLMENT APPROVAL and the first date claims will be eligible for claims processing and payment. WVCHIP providers may continue to serve WVCHIP members through the transition period of its provider enrollment and claims processing systems. This transition period is scheduled to end April 30, 2016. After this date, providers should not schedule any appointments for WVCHIP members if they have not yet been notified of an approved application by DXC Te.chnology.

The WV Medicaid and WVCHIP Provider Enrollment Application is comprised of the following sections:

Prescreening Questions – Determines provider’s eligibility to apply for enrollment as a WV Medicaid provider and specific questions for WVCHIP provider enrollment.

Type of Request – Indicates what type of request you are completing. Provider Checklist – Provider’s verification of all application requirements to ensure a completed application is being

submitted. Incomplete applications will delay the enrollment process. Documentation of criteria is required as indicated on the Provider Criteria Checklist.

P rovider Criteria Checklist —A separate checklist that identifies eligibility for enrollment based on provider type, and/or specialty. The Provider Criteria Checklist is included in the enrollment application. Supporting documentation (certificates, licenses, etc.) is required. If you have questions, please contact DXC Provider Enrollment toll free at 1-888-483-0793, or locally at 304-348-3360, enter your NPI and select option 4.

Provider Types – Provides the appropriate provider types, and identifies provider type risk levels for provider screening requirements.

Sections A -C – To be completed for ALL pay-to-providers . These are the providers that will receive payment from WV Medicaid and/or WVCHIP.

Section D – Rendering Providers – To be completed for all rendering service practitioners ( newly enrolling, re-enrolling, or revalidating).

Section E – Ordering/Referring/Prescribing(ORP)ONLY Providers – All ordering/referring /prescribing only providers must enroll. The ORP practitioners do not receive payment from WV Medicaid or WVCHIP, but can order, refer and/or prescribe for WV Medicaid and WVCHIP members. Provider types who are explicitly deemed as an ORP practitioner are: hospital resi- dents, pharmacists, physician assistants, social workers that are not licensed to practice independently, and licensed professional counselors. For WVCHIP Only: LPCs may enroll as rendering. BACB RBT and Front Line ABA Staff must be enrolled as servicing providers only.

WV Medicaid and WVCHIP Provider Signature Authorization – Required for all enrollment, re-enrollment, and revalidation. (NOTE: The owner or an authorized official of the business entity, directly or ultimately responsible for operating the business is the authorized signatory of this form. A delegated administrator may sign this form if it has been expressly indicated in writing on company letterhead signed by the authorized official on file or attached to this application. The authorization of a delegated signature of authority must be submitted with all new or revalidating pay-to providers.)

WV Medicaid and WVCHIP Provider Agreement – Required for newly enrolling, re-enrolling and revalidation of enrollment. Providers must complete a separate agreement for each program (WV Medicaid, WVCHIP) in which they wish to enroll. In addition, a completed provider agreement must accompany the application for each rendering provider affiliated at the group level. (NOTE: The owner or an authorized official of the business entity, directly or ultimately responsible for operating the business is the authorized signatory of this form for WV Medicaid and/or WVCHIP. A delegated administrator may sign this form if it has been expressly indicated in writing on company letterhead signed by the authorized official on file or attached to this application. The authorization of a delegated signature of authority must be submitted with all new or revalidating pay-to providers.)

WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION – GENERAL INSTRUCTIONS


P.O. Box 625


WV Medicaid/WVCHIP Dual Provider Enrollment Application


2

11. WV Medicaid and WVCHIP Statement of Rendering Practitioner Authorization (MPE-2) – Federal Medicaid Regulations, 42

CFR 447.10, require that payment be made to the individual practitioner providing the service, except that payment may be made to: a. The employer of the practitioner, if the practitioner is required as a condition of employment to turn over his fees to the

employer; or b. The facility in which the service is provided, if the practitioner has a contract under which the facility submits the

claim. c. In addition, such groups must comply with West Virginia Medicaid state laws applicable to group and corporate

practices.

The MPE-2 form is required to be signed by all rendering and ordering/referring/prescribing providers to authorize the group provider to receive payment from WV Medicaid or WVCHIP.

12. EEFT Form - All payments must be made through Electronic Funds Transfer. An EFT application is attached. If you have any questions, please contact DXC Provider Enrollment toll free at 1-888-483-0793 or locally (304) 348-3360, enter your NPI and select option 4. Your enrollment will not be approved unless this form is completed and returned with this application. The same EFT Information will be used for both WV Medicaid and WVCHIP payments.

NEXT STEPS – After completing this application, including all applicable agreements and signature forms and collecting the necessary supporting documentation, perform a quality check using the checklist on pages 5-7. The quality check helps to ensure your application can be processed and does not have to be returned forcorrections. Once you have completed the quality check-list, follow these steps:

-Make a copy of the entire application, agreements and documentation for your records -Mail the application, including all required documents to the following address:

Additional Information:

DXC Technology Attn: Provider Enrollment P.O. Box 625 Charleston, WV 25322-0625

If you have rendering providers (physician/non-physician practitioners) affiliated to your business, you must enroll as a group provider.

Facility and Group Providers can enroll in WV Medicaid and /or WVCHIP with one NPI, or multiple NPI’s for each location they want to receive payment for the services rendered at that facility.

Facility and group providers with multiple service locations will be enrolled under the facility Billing/Pay-To provider record. All services provided will pay to the primary facility’s billing and Pay-To provider record.

If a facility wants payment to be provided to individual facility locations, the facility locations must enroll independently and complete the facility application independently. For claims processing accuracy, a separate NPI for each service location is needed. Otherwise, payments can only be processed to the primary facility location.

Reminder: Your effective date is based on DXC Technology/WVCHIP Enrollment approval. Upon approved and completed review and credentialing of this application you will be notified by letter of the enrollment effective date.

Do not schedule WV Medicaid or WVCHIP member patient visits until notified of approved enrollment by DXC. (See Information regarding WVCHIP transition on page 1.)

You will receive a “Welcome Letter” that will provide program participation effective dates. You will be able to schedule member visits, and to submit claims for dates of service on and after your effective date. If after 30 days you have not received this “Welcome Letter,” contact the Provider Enrollment Unit toll free at 1-888-483-0793, or locally at 304-348-3360, enter your NPI and select option 4.

In the event of changes to your provider information supplied within, notify the Provider Enrollment Unit within 30 days. Change of ownership or tax ID change for pharmacy providers requires the pharmacy to acquire a new National Association of

Boards of Pharmacy (NABP) number. All tax ID changes require submission of supporting documentation and a written request. The West Virginia Medicaid Management Information System (MMIS ) is designed for direct payment of practitioner

services to either the employing group or corporation, or the individual practitioner. The system will also accommodate those practitioners who are in solo practice and are also an employee of a group or medical corporation. The group practice requires at least two NPI numbers: one assigned to the group and one unique number for each individual practitioner.

Once you are enrolled as a WV Medicaid provider, if you are interested in enrolling as a provider with WV Medicaid Managed Care Organization, you must apply directly with one or more of the managed care entities. Please refer to the Managed Care Health Plan Contacts document at www.wvmmis.com for contact information.

http://www.wvmmis.com/

DXC Provider Enrollment Unit P.O. Box 625


WV Medicaid/WVCHIP Dual Provider Enrollment Application Version 1.0

January 8, 2019 3

WV MEDICAID PROVIDER ENROLLMENT APPLICATION – PRESCREENING QUESTIONS www.wvmmis.com

You must answer the following questions to determine eligibility to apply to be an enrolled provider with

WV Medicaid. *1. Are you physically located in the state of West Virginia?

If YES, skip questions 2 through 7 and continue to the next section.

⃝ Yes ⃝ No

2. Are you physically located within 30 aeronautical miles of the West

Virginia border?


⃝ Yes ⃝ No

3. Are you a provider that has a special agreement with the Bureau for Medical Services, an Out of Network Lab OR are affiliated with one of

these providers? Call DXC Provider Enrollment if you need assistance with this.

(If you are not one of these providers you must select NO. If you are affiliated, select "Yes", complete the application and submit a copy of your Delineation of Privileges)

⃝ Yes ⃝ No

If YES, Provider Name: TAXID:

4. Are you an out-of-state provider enrolling for a medically necessary emergency service?


⃝ Yes ⃝ No

5. Are you an out-of-state provider enrolling to provide medical care for a

child placed in foster care in your state or placed in a residential

treatment center in your state?


6. Are you an out-of-state provider enrolling as a result of a referral from a

West Virginia provider that has obtained authorization for services

unavailable in West Virginia?

⃝ Yes ⃝ No

⃝ Yes ⃝ No

If YES, skip question 7 and continue to the next section.

7. Are you an out-of-state Durable Medical Equipment, Prosthetics,

Orthotics, and Supplies provider servicing a West Virginia Medicaid

member who is Medicare primary?

If YES, continue to the next section.

⃝ Yes ⃝ No

IF YOU ANSWERED NO TO ALL OF THE ABOVE QUESTIONS, YOU ARE NOT ELIGIBLE TO ENROLL IN WEST

VIRGINIA MEDICAID. If you have any questions, please contact DXC provider enrollment at 1 (888) 483-

0793, enter your NPI and select option 4.





January 8, 2019

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WVCHIP PROVIDER PRE-ENROLLMENT APPLICATION – QUESTIONS

√ 1. Are you a WV Medicaid Provider that would also like to enroll in

WVCHIP?

If YES, skip question 2.

√ 2. Do you solely want to participate and enroll in WVCHIP?

√ 3. Are you a current WVCHIP Medical Home Provider or would you like to be a WVCHIP Medical Home Provider?

Family and General Practitioners, Internists, Pediatricians, FQHCs and RHCs can choose to be a Medical Home Provider. More information is available at www.chip.wv.gov

⃝ Yes ⃝ No

⃝ Yes ⃝ No

⃝ Yes ⃝ No

√ 4. If you wish to enroll in WVCHIP as a Behavioral Health Provider under one of the following specialties and are

already enrolled in WV Medicaid, please contact the DXC Provider Enrollment Department at

1 (888) 483-0793, enter your NPI and select option 4.

Licensed Professional Counselor (LPC)

Board Certified Behavior Analyst (BCBA)

Board Certified assistant Behavior Analyst (BCaBA)

Behavioral Analyst Technician (BAT)

Registered Behavior Technician (RBT)

Nationally Certified Addiction (SUD) Counselor

√ 5. If you are an out-of-state provider and are interested in continuing or

starting participation with WVCHIP, are you willing to accept in-state rates

for your services?

If YES, continue completing the application, if NO, please read below notification

prior to completion of the application for additional information.

⃝ Yes ⃝ No

Waiver for Out-of-State Prior Authorization Option

WVCHIP has a blanket Prior Authorization on services provided outside the state of West Virginia. (Primary Care in bordering counties and all emergency services are excluded.) The process evaluates whether services provided out-

of-state are available in-state within an area geographically accessible to the member. WVCHIP will waive this re- quirement when out-of-state providers agree to 1) accept in-state rates as payment in full and 2) not balance bill WVCHIP members for the difference between submitted charges for covered services and WVCHIP’s fees. NOTE:

Prior Authorization of some specialized services will still apply regardless of whether the services are provided in or out-of-state.) For more information on in-state rates, please email [email protected].

Out-of-state providers that wish to participate but do not wish to accept WVCHIP’s in-state rates will need to contact WVCHIP at [email protected] to negotiate rates for services provided to our members. Out-of-state prior

authorization requirements will apply. Providers must also agree not to balance bill WVCHIP members.

http://www.chip.wv.gov/

http://www.chip.wv.gov/

mailto:[email protected]


5 P.O. Box 625 Charleston, WV 25322-0625


WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION www.wvmmis.com

INDIVIDUAL DIRECT, FACILITY, OR GROUP PROVIDER QUALITY CHECKLIST

TYPE OF REQUEST & PROVIDER CHECKLIST

*PAY-TO PROVIDER NAME:

*NPI: DXC USE ONLY: CASE #

TAXONOMY:

This application is used for multiple purpose (s); select one (1) enrollment type that applies to this application:

⃝ Individual Direct ⃝ Group Practice ⃝ Ancillary Facility/Agency ⃝ Hospital

⃝ NEW ENROLLMENT – Enrolling in the WV Medicaid and/or WVCHIP Provider Network for the first time.

⃝ RE-ENROLLMENT – Previously enrolled provider with WV Medicaid and/or WVCHIP and no longer active

⃝ REVALIDATE ENROLLMENT - You received a letter indicating you must revalidate your WV Medicaid

and/or WVCHIP enrollment. Providers must revalidate every 5 years. ⃝ CHANGE OF OWNERSHIP – The ownership of the business has changed. A change in ownership

cancels the current enrollment agreement. A new enrollment agreement number must be requested Provide a copy of the purchase or sales agreement as an attachment to the application (does not have to include purchase amount) WV Medicaid and /or WVCHIP must be notified within 30 days of

change of ownership ⃝ Service Location – Adding an additional Service Location (additional physical location where services

will be provided) to a currently enrolled WV Medicaid and/or WVCHIP Provider Networks for the first time.

⃝ Rendering and/or Ordering/Referring/Prescribing – Adding a new rendering and/or ordering/

referring/prescribing practitioner to a currently enrolled WV Medicaid and/or WVCHIP pay-to provider

⃝ If you are enrolling for the first time, re-enrolling, submitting a change of ownership, or revalidating your

enrollment, double-check that all sections of this application have been completed and signed

⃝ Type of Request and Provider Checklist

⃝ Completed Application

⃝ Section A – Provider Business & Pay-To Information

Verify that the name and address in the Legal Name and Pay-To Address section of Section A matches

the information on the Federal W-9 form. Information provided must match W-9 information allowing the Medicaid 1099 Form to be generated to the correct provider for whom the Federal Employer Identification Number or Social Security Number belongs. You MUST SUBMIT a copy of an IRS Notification

Form, such as CP-575 or W-9 form. THE APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION.

⃝ Verify that the Service Location name, or Doing Business As (DBA) name, in the Service Location Name and Primary Address of Section A matches the business name on the Federal W-9 form.

⃝ Section B – Disclosure Information & Legal Questions

⃝ Section C – Service Location Information

⃝ Section D – Rendering Provider Information

⃝ Section E – Ordering, Referring or Prescribing (ORP) Provider Information

DXC Provider Enrollment Unit WV Medicaid/WVCHIP Dual Provider Enrollment Application



P.O. Box 625



January 8, 2019 6


PROVIDER ENROLLMENT CHECKLIST—CONTINUED

⃝ PROVIDER CRITERIA CHECKLIST is a separate checklist and identifies eligibility for enrollment based on provider

type and/or specialty. The Provider Criteria Checklist is included in this application. Supporting documentation (certificates, licenses, etc.) is required. If you have questions, please contact the Provider Enrollment Unit at

1-888-483-0793, or locally at 304-348-3360, enter your NPI and select option 4.

⃝ Provider Signature Authorization and WV Medicaid and/or WVCHIP Provider Agreement.

⃝ Verify that the Provider Agreement has been signed by an authorized official. If a delegate is permitted to sign on behalf of the authorized official, a written request on company letterhead signed by the authorized official must be attached to this application, or designation is already on file. The authorization of a delegated signature of authority must be submitted with all new pay-to providers. The date should be a current date.

⃝ Provider Agreements (all)

⃝ WV Medicaid and WVCHIP Statement of Rendering Practitioner Authorization (MPE-2) (required for all

rendering and/or ordering/referring/prescribing providers authorizing payment for their services to the pay-to group)

⃝ Specialty Provider Agreement (as applicable, Waiver, Physician Assured Access System (PAAS), Skilled Nursing Facility (SNF), Traumatic Brain Injury (TBI), etc.)

⃝ Change of Ownership documentation of transaction along with purchase agreement (if applicable).

⃝ Electronic Funds Transfer (EFT) Set-up (New Provider), or Maintenance form (Existing Provider) – (asapplicable). MUST INCLUDE VOIDED CHECK - NOTE: If you are one of the State approved 13

Comprehensive Behavioral Health Facilities with Charity Care, you are required to complete the specific

Behavioral Health & Health Facilities (BHHF) EFT forms.


WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION

ORGANIZATIONAL STRUCTURE - Business and Pay-To Information

www.wvmmis.com

Section A (Business and Pay-To Information)


P.O. Box 625



January 8, 2019 8

* 1. BUSINESS NAME: _

2. DBA NAME (If applicable):

* 3.TAX ID/FEIN: _ OR *TAX ID/SSN: _

* 4. Pay-To NPI: _ National Plan & Provider Enumeration System (NPPES):

*NPI Type: ⃝ Type 1 Enumeration - Individual

⃝ Type 2 Enumeration - Organizational

* 5. W9 Information:

W9 Name:

Address 1: _

Address 2: _ _City: _ _

County: _ _State: Zip Code: _ - _ _

* 6. Primary Physical Location Address:

Address 1: _

Address 2: _ _City: _ _ _

County: _ _ State: Zip Code: - _

* 7. Pay-To Correspondence Address:

Address 1: _

Address 2: _ _City: _ _

County: _ _State: Zip Code: _ - _ _

If your business is chain affiliated, the information about the company or organization must be included in the disclosure information in Section B.

If your business is operated by a management company or leased (in whole or in part) by another organization, information about the management company or organization must be included in the disclosure information in Section B.

* 8. Provider Entity legally organized and structured as: * 8a. Provide the type of organization:

(Check only one). This must match the information (Check those that apply)

provided on the submitted W-9: ⃝ Private—For—Profit (27) ⃝ Individual/Sole Proprietor (1) ⃝ Private—Not—For—Profi t (28) ⃝ Partnership (2) ⃝ Public Entity—State Government (5) ⃝ Corporation Owned (3) ⃝ Public Entity—Non State Government Owned (29) ⃝ S Corporation (24) ⃝ Limited Liability Company (25) ⃝ OTHER (26), please explain (see instructions on Federal W-9)

* 9. Business License Number: _ _ _ _ * State: ___ _ _ _ __

*Effective Date: _ _/ / Termination Date: / /

(State Business License Number as registered with the State of WV Tax Department or in the State of the physical location (if applicable)).



ORGANIZATIONAL STRUCTURE - Business and Pay-To Information

www.wvmmis.com

Section A (Business and Pay-To Information)


P.O. Box 625



January 8, 2019 9

CONTACT INFORMATION

The contact name and email address for the person who can answer questions about the information provided in this application packet. Providers will be enrolled to receive email notifications when new information is published to www.wvmmis.com. Provide the email address where these notifications should be sent. Email addresses will be used

for WV Medicaid and/or WVCHIP business only and will not be sold or shared for other purposes.

* 1.Contact Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

⃝ Credentialing Specialist ⃝ Office Manager ⃝ Owner ⃝ Other: _ __ _ _ _ _ __

*Contact Phone No: ( _)_ _ _ _ _ _

Contact Secondary Phone: ( __)_ _ _ _ _ _

Mobile Phone: (_ _ _)_ _ _ _ _ _

Contact Fax No: ( ) _ _ _ _ __

Contact Email Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _

* 2. Exempt Payee?

(Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.)

⃝ Yes ⃝ No

* 3. Has this person or entity ever been sanctioned, excluded, or convicted of a criminal offense related to

Medicare, Medicaid, CHIP or any Federal Agency or Program (42 CFR 455.106)?

⃝ Yes ⃝ No

If Yes: ⃝ Sanctioned ⃝ Excluded ⃝ Convicted (Check all that apply)

If yes, please provide a detailed explanation: __ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

* 4. Do you provide any free health related services? ⃝ Yes ⃝ No

If YES, please identify the service code (if applicable) and description: _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _




P.O. Box 625



January 8, 2019 10


Section B

(Disclosure Information)

*REQUIRED* - DISCLOSURE INFORMATION – OWNERSHIP AND CONTROL, PROVIDER ENTITY (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED)

Disclosure of Ownership and Control, Provider Entity - List any PERSON(s) or ENTITY(s) that has direct or indirect ownership interest to 5% or more of the value of the provider entity. Please note: At least one (1) MANAGING EMPLOYEE must be identified in B.1. List any PERSON(s) or ENTITY(s) that owns an interest of 5% or more in any mortgage, deed of trust, note or other obligation secured by the provider entity, if that interest equals 5% of the value of the property or assets of the provider entity.

**If each person or entity owns less than 5% direct and/or indirect ownership in the provider, you must select “YES”, and attest below that no

one owns 5% or more in the provider. NOTE: Government owned entities (e.g. municipal, county, or state agencie s) should also select “YES”. ⃝ YES ⃝ NO

If YES, complete fields 1.a and 3 in this section. Then use section B.1 to list the board of director (s), agent (s) and managing employee (s), etc.

1. (Print) First – Middle – Last Name or Legal Name 1.a Signature:

2. Title: 3. FEIN:

-

4. Soc. Sec. No.:

- -

5. Date of Birth:

/ /

6. Street Address: 7. Begin Date: Termination Date:

/ / / / 8. City: 8.a State: 8.b County: 8.c Zip + 4:

9. Has this person ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare, Medicaid, CHIP or any federal agency or program (42 CFR 455.106)? ⃝ YES ⃝ NO If YES, provide explanation:

10. (Print) First – Middle – Last Name: 10.a Signature:

11. Title: 12. FEIN:

-

13. Social Security No.:

- -

14. Date of Birth: / /


/ / / /

17. City: 17.a State: 17.b County: 17.c Zip + 4:

18. Has this person ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare, Medicaid, CHIP or any

fede ral agency or program (42 CFR 455.106)? ⃝ YES ⃝ NO If YES, provide explanation:

19. (Print) First – Middle – Last Name: 20. Signature:

21. Title: 22. FEIN:

-

23. Social Security No.:

- -

24. Date of Birth:

/ /


/ / / /


28. Has this person ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare, Medicaid, CHIP or any fede ral agency or program (42 CFR 455.106)? ⃝ YES ⃝ NO If YES, provide explanation:


WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION www.wvmmis.com Section B

(Disclosure Information—CONTINUED)


P.O. Box 625



January 8, 2019

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*REQUIRED* - DISCLOSURE INFORMATION – BOARD MEMBER/DIRECTOR, MANAGING INDIVIDUALS (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED)

List ALL agents, officers, directors and managing employees who have expressed or implied authority to obligate or act on behalf of the provider entity. Not-for- profit providers must also l ist their managing individuals. Complete all fields for each individual l isted.

An AGENT is any person who has express or implied authority to obligate or act on behalf of an entity.

An OFFICER is any person whose position is listed as an officer in the provider’s articles of incorporation or corporate bylaws or is appointed as an officer by the board of directors or other governing body. A DIRECTOR is a member of the provider’s board of directors , board of trustees, or other governing body. It does not necessarily include a person who has

the word “director” in his or her job title, such as director of operations or departmental director. A MANAGING EMPLOYEE is a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of the provider entity. Each Service Location must identify at least one managing employee.

1. Legal Name (Please Print): 2. Signature:

3. ⃝ AGENT ⃝ OWNER ⃝ OFFICER ⃝ BOARD MEMBER/DIRECTOR ⃝ SUB-CONTRACTOR ⃝ MANAGING EMPLOYEE

4. FEIN: - 5. Soc. Sec. #: - -

6. Date of Birth: / /


/ / / /





14. FEIN: -

15. Soc. Sec. #: - - 16. Date of Birth: / /


/ / / /





24. FEIN: - 25. Soc. Sec. No.: - - 26. Date of Birth: / /


/ / / /







P.O. Box 625



January 8, 2019

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*REQUIRED* - DISCLOSURE INFORMATION – RELATIONSHIPS AND BACKGROUND INFORMATION (ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED)

1. Indicate if any of the individuals listed in Section B or B.1 are related through blood or marriage as spouse, parent, child, or sibling. Nonprofit providers must also complete section 3 below. Use N/A as appropriate.

1.a Name of Person 1: Name of Person 2: Relationship:

1.b Name of Person 1: Name of Person 2: Relationship:

1.c Name of Person 1: Name of Person 2: Relationship:

1.d Name of Person 1: Name of Person 2: Relationship:

2. Has the provider had business transactions with any subcontractor totaling more than $25,000 during the preceding 12 month period? If yes, give the information below for each subcontractor. ⃝ YES ⃝ NO

2.a Name: Address:

2.b Name: Address:

2.c Name: Address:

2.d Name: Address:

3. Has the provider had any significant business transactions with any wholly owned supplier or with any subcontractor during the preceding five year period? If yes, give the information below for each wholly owned supplier or subcontractor. ⃝ YES ⃝ NO

4.a Name: Address: Description of Business Transaction:

4.b Name: Address: Description of Business Transaction:

4.c Name: Address: Description of Business Transaction:

4.d Name: Address: Description of Business Transaction:

Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the State agency.

Name of Provider or Authorized Representative (Please Print):

Signature of Authorized Representative: Title:





P.O. Box 625



January 8, 2019

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*REQUIRED* - DISCLOSURE INFORMATION – LEGAL QUESTIONS AND BACKGROUND INFORMATION

(ATTACH ADDITIONAL COPIES OF THIS PAGE IF SPACE FOR ADDITIONAL NAMES IS NEEDED)

* 1. Have you or any owner or employee identified in this application ever had:

a. An assessment taken against you? ⃝ YES ⃝ NO

b. An administrative sanction taken against you? ⃝ YES ⃝ NO

c. A suspension of payment taken against you? ⃝ YES ⃝ NO

d. A restitution order taken against you? ⃝ YES ⃝ NO

e. A program exclusion taken against you? ⃝ YES ⃝ NO

f. A program debarment taken against you? ⃝ YES ⃝ NO

g. A pending criminal judgment taken against you? ⃝ YES ⃝ NO

h. A pending civil judgment taken against you? ⃝ YES ⃝ NO

i. A judgment pending under False Claims Act taken against you? ⃝ YES ⃝ NO

J. A criminal fine taken against you? ⃝ YES ⃝ NO

k. A civil monetary penalty taken against you? ⃝ YES ⃝ NO

* 2. Do you, any owners or employees owe money to Medicare, Medicaid, or CHIP ⃝ YES ⃝ NO

that has not been paid?

* 3. Have you or any owner or employee identified in Section B ever been: ⃝ YES ⃝ NO

a. Convicted of any health related crimes? ⃝ YES ⃝ NO

b.

Convicted of a crime involving the abuse of a child or elderly adult?

⃝ YES

⃝ NO

C. Do you, any owners or employees as identified in Section B have ownership interest

in any entity that provide services to Medicaid and/or CHIP

⃝ YES ⃝ NO

* 4. If you answer ‘yes’ to any of these questions, please complete the explanation box below & identify the owner, or

employee as indicated in Section B. Attach any court proceedings, documentation, etc.

*I attest the provider, all of its owners, managers, employees and contractors are not excluded from participation in Medicare, Medicaid, CHIP or other federal health care programs, by searching the Office of Inspector General List of Excluded Individuals/Entities (LEIE) at the time of enrollment, before hiring new employees or entering into a contract with a contractor, and monthly to see changes since the last search. I agree to immediately report any exclusion information discovered to the West Virginia Bureau for Medical Services or its fiscal agent. (Initial Here)



P.O. Box 625



January 8, 2019

14


Section C (Service Location Information)

*REQUIRED* - Copy Sections C through C.2 and complete for EACH Service Location LEGAL NAME & ADDRESS – The pay-to address is the PRIMARY SERVICE LOCATION, unless each service location is enrolled under its own

NPI. If multiple service locations and each service location have a separate NPI, a separate Provider Enrollment Application may be completed

unless all the service locations are affiliated with the primary service location’s NPI.

The legal name is considered to be the entity maintaining ownership of the named business (s). The legal name must be the current

name on tax, corporation, and other legal documents.

The legal name and pay-to address must match the WV Tax Department information currently registered with the WV Secretary of

State, if registered. Is not applicable to informal associations such as Sole Proprietorships and General Partnerships that are not

registered.

The legal name as well as the home office address and Taxpayer Identification Number (TIN) must match the information on the W-9.

The pay-to service location must be a physical location. A post office box cannot be used as a physical address.

* 1. SERVICE LOCATION NAME (If more than 1 service location, name should be unique). THIS NAME WILL BE PUBLISHED IN THE

PROVIDER DIRECTORY:

* 2. Is physical street address the same as the primary? ⃝ YES

If NO, complete the address information below:

Street Address 1:

Street Address 2:

* 3. Is mailing address the same as the primary? ⃝ YES

If NO, complete the address information below:

Mailing Address 1:

Mailing Address 2:

Mailing Address 3:

2.a Physical Service Location City:

2.b Physical Service Location State & Zip Code + 4:

STATE: ZIP CODE: -

3.a Service Location Mailing City:

3.b Service Location Mailing State & Zip Code + 4:

STATE: ZIP CODE: -

SERVICE LOCATION CONTACT INFORMATION

* 4. Is contact information different from the pay-to business contact information? ⃝ YES ⃝ NO (If yes, complete information below)

4.a Contact Name ( if different from Pay-To Office contact)

Contact Title:

Contact Email Address:

4.b Contact Telephone Number:

( ) - Fax Number

( ) -

* 5. Have you paid an enrollment application fee to Medicare, or any other State's Medicaid or CHIP program? ⃝ YES ⃝ NO (Refer to

provider type page of application, to determine if an application fee is required)

* 5a. Will you be requesting a Hardship Exception? ⃝ YES ⃝ NO (If YES, please contact Provider Enrollment for specific Hardship

Exception Criteria) All Hardship Exceptions will be sent to CMS. Until CMS approves/denies the request, enrollment will not be completed).

* 6. Have you had a site visit conducted by Medicare, or another State’s Medicaid or CHIP program? ⃝ YES ⃝ NO (Only required for Risk levels

2 & 3, moderate and high risk provider types – Refer to Provider Type, page 7 of application for more information)



P.O. Box 625



January 8, 2019

15

WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION www.wvmmis.com Section C

(Service Location Information CONTINUED)

* 1. Provider Type Description (refer to Provider Type on Page 7 of

this application):

* 2. Service Location Street

Address:

* 2a. Provider Specialty (s):

* 3. Effective date of provider type and specialty: / /

* 4. Are you currently enrolled in WV Medicaid?

⃝ YES ⃝ NO

If YES, provide WV Medicaid Provider ID Number:

* 5. Were you previously enrolled in WV Medicaid?

⃝ YES ⃝ NO

If YES, provide WV Medicaid Provider ID Number:

* 6. OFFICE HOURS: Open Time – Closed Time in HH (HOUR):MM (MINUTE). Circle AM or PM as appropriate.

OPEN AM/PM CLOSED AM/PM OPEN AM/PM CLOSED AM/PM

Monday: : AM/PM : AM/PM ⃝ CLOSED Friday: : AM/PM : AM/PM ⃝ CLOSED

Tuesday: : AM/PM : AM/PM ⃝ CLOSED Saturday: : AM/PM : AM/PM ⃝ CLOSED

Wednesday: : AM/PM : AM/PM ⃝ CLOSED Sunday: : AM/PM : AM/PM ⃝ CLOSED

Thursday: : AM/PM : AM/PM ⃝ CLOSED

* 7. Handicap Accessible: ⃝ YES ⃝ NO *7a. Gender Restrictions: ⃝ NONE ⃝ FEMALE ⃝ MALE * 7 b. Patient Age: MIN

MAX (112 Years) (NOTE: For newborns and infants less than 1 year old, specify 0 years.)* 7c. Accepting New Patients: ⃝ YES ⃝ NO

8. Additional Languages (other than English):

* 9. Do you participate in Medicare? ⃝ YES ⃝ NO ⃝ Enrollment Pending (If YES, provide your Medicare Provider ID Number and effective date below).

(NOTE: Some provider types are required to participate in Medicare to be eligible to participate in WV Medicaid. Refer to your provider

criteria for more information.)

10. Medicare Number: 10a. Effective Date:

/ /

* 11. Do you provide lab services in your office/facility? ⃝ YES ⃝ NO (If YES, complete CLIA information below)

12. CLIA Number (if applicable): CLIA Type (Numeric Level): Effective Date: / /

NOTE: If your lab performs moderate to high level testing as defined by CLIA you may have testing personnel that requires li censure through the WV Office of Laboratory Services (WVOLS). Please contact WVOLS or visit http://www.wvdhhr.org/lab services/compliance/licensure/faq.cfm.

* 13. Do you provide radiological services at this location? ⃝ YES ⃝ NO If YES, what radiological services are provided:

⃝ Technical ⃝ Professional ⃝ BOTH

(If technical services are provided, equipment registration/inspection documentation is required.)

* 14. Do you provide Advanced Diagnostic Services? ⃝ YES ⃝ NO If YES, see criteria sheet for additional documentation needed.

15. Do you participate in the 340B program? ⃝ YES ⃝ NO If YES, do you dispense your 340B stock to WV Medicaid members? ⃝ YES ⃝ NO

Begin Date: / / Begin Date: / /

16. NABP (Pharmacy No): 17. Pharmacy: Do you provide hemophilia services ⃝ YES ⃝ NO

18. Pharmacy Type: ⃝ Retail ⃝ Mail Order ⃝ Institutional

Do you also provide DME supplies? ⃝ YES ⃝ NO

19. Outpatient: ⃝ Open to Public ⃝ Closed to Public

* 20. Required for ALL Provider Types: Do you employ a certified Prosthetist? ⃝ YES ⃝ NO

*21. Required for ALL Provider Types: Do you employ a certified Fitter? ⃝ YES ⃝ NO

* 22. Required for ALL Provider Types: Do you employ a certified Orthotist? ⃝ YES ⃝ NO

23. Do you employ a Respiratory Therapist? If yes, license number (s):


http://www.wvdhhr.org/lab


P.O. Box 625



January 8, 2019

16

WV MEDICAID and WVCHIP PROVIDER ENROLLMENT APPLICATION www.wvmmis.com Section C

(Service Location Information CONTINUED)

*REQUIRED* - Copy Sections C through C.2 and complete for EACH Service Location

1. Hospital Certification #: (Nationally Recognized Accreditation Survey, Joint Commission (JCAHO), American Osteopathic Association (AOA), or Det Norske Veritas Healthcare (DNVH)

Effective Date: / /

2. Hospital, Skilled Nursing Facilities, Overnight Stay Facilities: Number of Institutional Beds (as applicable)?

3. Institutional Hospital Based Pharmacy (Hospital ONLY) ⃝ Outpatient - Open to the Public ⃝ Outpatient - Closed to the Public

4. Transportation: Emergency Medical Services (EMS) Certification Number (if applicable):

5. Air Transportation: What type of aircraft as certified by FAA?

Begin Date: / /

Non-Emergent Transportation: Specialized Multi-Patient Medical Transport (SMPMT) License Number from EMS agency: (if applicable)

Begin Date: / /

⃝ Rotary ⃝ Fixed Wing

Is aircraft medically dedicated? ⃝ YES ⃝ NO

6. Office of Health Facilities Licensure and Certification (OHFLAC) Number:

7. DME: Do you provide hearing aids? ⃝ YES ⃝ NO (Must provide documentation of current Hearing Aid Dispensing License.)

Begin Date: / /

(Issued by OHFLAC in State of WV – License/Certification Number applicable for Out-of-State Providers

8. Dental Only: Do you provide anesthesia services? ⃝ YES ⃝ NO

WV Medicaid Physician Assured Access System (PAAS) (Only Applicable to Primary Care Provider Specialties) 9. Do service location providers participate in the PAAS

program? ⃝ YES ⃝ NO

PAAS Number:

If No, is this service location interested in participating in the PAAS program? ⃝ YES ⃝ NO

10. If YES to either of the above questions, total number of PAAS members you will accept (MAX of 1,500 per Primary Care Provider—PCP):

Practice limited to:

⃝ OPEN PRACTICE: New Patients Accepted including Auto-Assignment of PAAS Enrollees

⃝ LIMITED PRACTICE: Accepting New Patients if Selected by Enrollee; Not Accepting Auto-Assignment of PAAS Enrollees

⃝ CLOSED PRACTICE: Not Accepting New PAAS Enrollees (Written or Verbal Notification Required)

Services limited to ages of:

YR TO YR NOTE: For newborns and infants less than 1 year old, specify 0 years. For maximum age, the greatest allowed value is 112 years.

11. After Regular Office Hours (Enter at least one)

⃝ Answering service contacts the site or covering Medicaid Provider

⃝ Answering machine directs patients to call a covering Medicaid Provider

⃝ Call forwarding transfers calls to another location where someone can contact the site or a covering Medicaid Provider

⃝ Alternate coverage arrangement – Explain in detail:

24-hour Phone Number: ( )



P.O. Box 625



January 8, 2019

17


Section D

* 1. Primary Specialty: * 2. Effective Date:

* 3. First Name: *MI: * 4. NPI:

* 5. Last Name: 6. Current Medicaid ID (if applicable):

* 7. Date of Birth: / /

* 8. Social Security Number:

- -

*9. Mailing Address 1:

Mailing Address 2:

* 10. Phone No.: ( ) - 10a. Fax No.: ( ) -

11. Email Address * 12. Gender: ⃝ Female ⃝ Male

* 13. Provider Type Description: (only 1 Provider Type allowed— Refer to PROVIDER TYPES on PAGE 7)

* 14. Primary Provider Specialty:

*Effective Date: / /

14a. Provider Subspecialty (s)

Effective Date: / /

14b. Provider Subspecialty (s)

Effective Date: / /

* 15. Are you Board Certified?: ⃝ YES ⃝ NO

If YES, Name of Certifying Body:

What is your Board Certification Specialty:

Board Certification Number:

Effective Date: / /

*15a. Are you Board Certified in a sub-specialty?: ⃝ YES ⃝ NO


What is your Board Certification Sub-Specialty:

Sub-Specialty Certification Number:

Effective Date: / /

Complete Section D for Each Rendering Provider

(Rendering Providers)



P.O. Box 625



January 8, 2019

18


Section D

(Rendering Providers—CONTINUED)

* 16. Current State License Number (Professional License) : *Effective Date: / /

* 17. Are you enrolled in Medicare?: ⃝ YES ⃝ NO ⃝ Pending

If YES, Medicare Number:

* 18. Do you have privileges at a Hospital or Ambulatory Surgery Center? ⃝ YES ⃝ NO ***If marked yes, submit delineation(s) of privileges as

indicated on criteria sheet***

* 19. Do you have prescribing privileges?: ⃝ YES ⃝ NO If YES, Drug Enforcement Agency (DEA) No.:

* 19 a. Do you prescribe addiction treatment drugs?: ⃝ YES ⃝ NO If YES, Drug Enforcement Agency (DEAX) No.:

* 20. Do you participate in the Medicaid Diabetes Education Program? ⃝ YES ⃝ NO If yes, submit CAMC certification

* 21. Dental Only: Do you provide anesthesia services? ⃝ YES ⃝ NO

* 22. Do you provide services in the nursing home and/or hospice setting?: ⃝ YES ⃝ NO IF yes submit Medicaid NF/Hospice agreement

23. TBI Providers ONLY: Do you have Level II or III Certification from the Society of Cognitive Rehabilitation?: ⃝ YES ⃝ NO Medicaid only

* 23. What service location (s) will you provide services at (indicate service location unique name—address): If additional space is needed you

may add an attachment

Begin Date: Termination Date:

NOTE: SUPPORTING DOCUMENTATION REQUIRED. REFER TO YOUR PROVIDER CRITERIA CHECKLIST FOR DOCUMENTATION

* 24. Have you or any entity you are or were an agent, owner, or managing employee of, ever been found to have violated federal or state laws, rules or regulations governing Medicare, Medicaid program or CHIP programs or any other publicly

funded federal or state health care or health insurance program? ⃝ YES ⃝ NO

If YES: ⃝ Sanctioned ⃝ Excluded ⃝ Convicted - Please provide an explanation:

WV Medicaid Physician Assured Access System (PAAS) (Only Applicable to Primary Care Provider Specialties) * 25. Do you participate in the Physician Assured Access System

Program?: ⃝ YES ⃝ NO PAAS Number:

26. If YES, is this rendering provider interested in participating in our Physician Assured Access System: ⃝ YES ⃝ NO

27. If Yes to either of the above questions, total number of PAAS members you will accept (MAX of 1,500 per PCP):

Practice limited to:


⃝ LIMITED PRACTICE: Accepting New Patients if Selected by Enrollee; Not Accepting Auto-Assignment of PAAS Enrollees ⃝ CLOSED PRACTICE: Not Accepting New PAAS Enrollees (Written or Verbal Notification Required)

Services limited to ages of: YR TO YR NOTE: For newborns and infants less than 1 year old, specify 0 years. For

maximum age, the greatest allowed value is 112 years.

28. After Regular Office Hours (Enter at least one) ⃝ Answering service contacts the site or covering Medicaid Provider ⃝ Answering machine directs patients to call a covering Medicaid Provider






P.O. Box 625



January 8, 2019

19


Complete Section E for EACH Ordering/Referring/Prescribing Provider Section E

(Ordering/Referring/Prescribing (ORP) Providers (Non-Billing Providers)

* 1. Primary Specialty: * 2. Effective Date:

* 3. First Name: *MI: * 4. NPI:

* 5. Last Name: 6. Current Medicaid ID (if applicable):

* 7. Date of Birth: / /

*8. Social Security Number:

- -

* 9. Mailing Address 1:

Mailing Address 2:

*City: *County *State *Zip Code + 4:

* 10. Phone No.: ( ) - 10a. Fax No.: ( ) -

11. Email Address * 12.Gender: ⃝ Female ⃝ Male

* 13. Provider Type Description: (only 1 Provider Type allowed— Refer to PROVIDER TYPES on PAGE 7)

* 14. Primary Provider Specialty:

*Effective Date: / /

14a. Provider Subspecialty (s)

Effective Date: / /

14b. Provider Subspecialty (s)

Effective Date: / /

* 15. Are you Board Certified?: ⃝ YES ⃝ NO


What is your Board Certification Specialty:

Board Certification Number:

Effective Date: / /

* 15a. Are you Board Certified in a sub-specialty?: ⃝ YES ⃝ NO


What is your Board Certification Sub-Specialty:

Board Certification Sub-Specialty Number:

Effective Date: / /



P.O. Box 625



January 8, 2019

20


Section E (Ordering/Referring/Prescribing (ORP) Providers (Non-Billing Providers)

* 16. Current State License Number (Professional License) : *Effective Date: / /

* 17. Are you enrolled in Medicare?: ⃝ YES ⃝ NO ⃝ Pending

If YES, Medicare Number:

* 18. Do you have privileges at a Hospital or Ambulatory Surgery Center? ⃝ YES ⃝ NO ***If marked yes, submit delineation of privileges as noted

in criteria*** *19. Do you have prescribing privileges?: ⃝ YES ⃝ NO If YES, Drug Enforcement Agency (DEA) No.:

* 19a. Do you prescribe addiction treatment drugs?: ⃝ YES ⃝ NO If YES, Drug Enforcement Agency (DEAX) No.:

* 20. Do you participate in the BMS Diabetes Education Program? ⃝ YES ⃝ NO If yes, submit CAMC certification Medicaid only

21. *Do you provide services in the nursing home and/or hospice setting?: ⃝ YES ⃝ NO IF yes submit Medicaid NF/Hospice agreement

22. TBI Providers ONLY: Do you have Level II or III Certification from the Society of Cognitive Rehabilitation?: ⃝ YES ⃝ NO Medicaid only

* 23. At what service location (s) will you provide services (indicate service location unique name, or location identifier): If additional space is needed you may add an attachment

Begin Date: Termination Date:

NOTE: SUPPORTING DOCUMENTATION REQUIRED. REFER TO YOUR PROVIDER CRITERIA CHECKLIST FOR DOCUMENTATION

* 24. Have you or any entity you are or were an agent, owner, or managing employee of, ever been found to have violated

federal or state laws, rules or regulations governing Medicare, Medicaid program or CHIP programs or any other publicly funded federal or state health care or health insurance program? ⃝ YES ⃝ NO

If YES: ⃝ Sanctioned ⃝ Excluded ⃝ Convicted - Please provide an explanation:

WV Medicaid Physician Assured Access System (PAAS) (Only Applicable to Primary Care Provider Specialties)

* 25. Do you participate in the Physician Assured Access System Program?: ⃝ YES ⃝ NO

PAAS Number:

26. If YES, is this order/refer provider interested in participating in our Physician Assured Access System: ⃝ YES ⃝ NO

27. If Yes to either of the above questions, total number of PAAS members you will accept (MAX of 1,500 per PCP):

Pr actice limite d t o:


⃝ LIMITED PRACTICE: Accepting New Patients if Selected by Enrollee; Not Accepting Auto-Assignment of PAAS Enrollees ⃝ CLOSED PRACTICE: Not Accepting New PAAS Enrollees (Written or Verbal Notification Required)

Services limited to ages of: YR TO YR NOTE: For newborns and infants less than 1 year old, specify 0 years. For

maximum age, the greatest allowed value is 112 years.

28. After Regular Office Hours (Enter at least one) ⃝ Answering service contacts the site or covering Medicaid Provider ⃝ Answering machine directs patients to call a covering Medicaid Provider






Form MPE-2 (Part 1) West Virginia Medicaid & WVCHIP

Statement of Practitioner Authorization

www.wvmmis.com





January 8, 2019 21

(To be COMPLETED for each GROUP’S Rendering, Ordering/Referring/Prescribing practitioners – Make cop-

ies as necessary) Please indicate which program this addition should apply:

⃝ WV Medicaid ⃝ WVCHIP ⃝ Both WV Medicaid/WVCHIP

I hereby declare myself solely and completely responsible for the accuracy and appropriateness of all West

Virginia Medicaid and/or WVCHIP Program documents submitted by:

Name of Employing Group or Corporation Group NPI:

Service Location Address

City State Zip Code (+ 4 - optional)

To the West Virginia Medicaid and/or WVCHIP Program in my name for services rendered by me. I hear-by authorize payment be made to:

Name of Employing Group or Corporation By the West Virginia Medicaid and/or WVCHIP Program for all such services provided on and after:

Below section for Rendering, Ordering/Referring/Prescribing and Individual Information:

Effective Date of Employment

Name - (Please PRINT) NPI Number

Signature Date Signed

(Do NOT use Black Ink)

Social Security Number License Number DO NOT FAX APPLICATION

Mail application to:






January 8, 2019 22


Form MPE-2 (Part 2) West Virginia Medicaid & WVCHIP

Statement of Practitioner Authorization

www.wvmmis.com

Disclosure Information (To be COMPLETED for each GROUP’S Rendering, Ordering/Referring/Prescribing practitioners – Make

copies as necessary):

* 1. Have you as a practitioner ever had (NPI) _:

a. An assessment taken against you? ⃝ YES ⃝ NO

b. An administrative sanction taken against you? ⃝ YES ⃝ NO

c. A suspension of payment taken against you? ⃝ YES ⃝ NO

d. A restitution order taken against you? ⃝ YES ⃝ NO

e. A program exclusion taken against you? ⃝ YES ⃝ NO

f. A program debarment taken against you? ⃝ YES ⃝ NO

g. A pending criminal judgment taken against you? ⃝ YES ⃝ NO

h. A pending civil judgment taken against you? ⃝ YES ⃝ NO

i. A judgment pending under False Claims Act taken against you? ⃝ YES ⃝ NO

J. A criminal fine taken against you? ⃝ YES ⃝ NO

k.

A civil monetary penalty taken against you? ⃝ YES ⃝ NO

* 2. Do you owe money to Medicare, Medicaid or WVCHIP that has not been paid? ⃝ YES ⃝ NO

* 3. Have you ever been:

a. Convicted of any health related crimes? ⃝ YES ⃝ NO

b.

Convicted of a crime involving the abuse of a child or elderly adult?

⃝ YES

⃝ NO

c. Do you, any owners or employees as identified in Section B have ownership interest

in any entity that provide services to Medicaid and/or CHIP

⃝ YES ⃝ NO

* 4. If you answer ‘yes’ to any of these questions, please complete the explanation box below. Attach any court proceedings, documentation, etc.

DO NOT FAX APPLICATION

Mail application to:


DXC Provider Enrollment Unit P.O. Box 625 Charleston, WV 25322-0625


January 8, 2019

23

7. *Date of Birth:

WV MEDICAID and/or /

CHIP PR /

IDER SIGNATURE AGREEMENT 7. *Date of Birth:

www.wvmmis.com WV OV

Signature Authorization

The WV Medicaid and/or WVCHIP effective date of participation is determined after DXC Technology has completed the credentialing and approved the application for enrollment. You will be notified by letter of enrollment approval. If th is application is being submitted for new enrollment, do not schedule Medicaid patient visits until notified of enrollment approval.

Submit the completed application within 60 days of the authorized official’s signature below. DXC Provider Enrollment must receive the application before the 60 days expires. Any delays of enrollment due to missing information required for submitting this application could require an updated application, or signature attesting to the validity and accuracy of current information submitted within this application.

The owner or an authorized official of the business entity, directly or ultimately responsible for operating the business is the authorized signatory of this form. A delegated administrator may sign this form if it has been expressly indicated in writing on company letterhead signed by the authorized official on file or attached to this application.

The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth therein. As of the date of signature, the information contained within this application is accurate and current.

* 1. Legal Name of Provider’s Business (please print): * 2. Taxpayer Identification Number (TIN):

* 3. Authorized Official’s Name (please print): * 4. Title:

* 5. Authorized Official’s Signature: * 6. Date:

* 7. Contact Name & Phone Number: * 8. Contact Email Address:


DXC Provider Enrollment Unit P.O. Box 625 Charleston, WV 25322-0625


January 8, 2019

24

WV MEDICAID / WVCHIP DUAL PROVIDER ENROLLMENT AGREEMENT and SIGNATURE www.wvmmis.com

A SEPARATE PROVIDER AGREEMENT MUST BE COMPLETED BY EACH RENDERING PROVIDER AND

A REPRESENTATIVE OR AUTHORIZED DELEGATE FOR THE GROUP/FACILITY.

1. The Provider hereby agrees to comply with all applicable laws, rules and written policies pertaining to the West Virginia

Medicaid Program (Medicaid) and/or West Virginia Children's Health Insurance Program (WVCHIP), including, but not limited

to, Title XIX and Title XXI of the Social Security Act, the Code of Federal Regulations, West Virginia State Laws the West Virginia

State Medicaid Plan, the West Virginia State CHIP Plan, the Department of Health and Human Resources, Bureau for Medical

Services' (Medicaid or Department/Bureau), written manuals, program instructions, policies and this document.

2. The Provider certifies that the care, services and supplies for which the Provider bills Medicaid and/or WVCHIP have been

furnished to eligible recipients and the amount listed will be due and, except as noted, no part has been paid. Provider

agrees to abide by the Medicaid "free- care" provisions. Payment for services made in conformance with established rates,

fee schedules and payment methodologies will be accepted by the Provider as payment in full. Provider understands that

WVCHIP cannot and will not make payment (s) on any claim (s) where any portion of the claim is payable by another entity or

person, and that Medicaid can only serve as the payer of last resort. To be eligible for WVCHIP, members cannot have any

other group health insurance.

3. The provider agrees to accept the WVCHIP and/or Medicaid payments as payment in full and will not balance bill the member or

member's family for the difference between the WVCHIP and/or Medicaid payments and the provider charged amount for the

service. 4. The Provider assures the Department/Bureau/WVCHIP that the Provider is an independent contractor and that neither the

Provider nor any of the Provider’s employees are employees of the Department/Bureau/WVCHIP under this enrollment form and

any subsequent amendments. The Provider is solely responsible for and shall meet all legal requirements, including payment of

all applicable taxes, workers compensation, unemployment and other premiums, deductions, withholdings, overtime and other

amounts which may be legally required with respect to the Provider and the employment of all persons providing services under

this enrollment form.

5. The Provider agrees to comply with the applicable advance directive requirements of §1902 (w) of the Social Security Act.

6. The Provider agrees to comply with those Federal requirements and assurances for recipients of federal grants provided in

OMB Standard Form 424B-(4-88) which are applicable to the Provider. The Provider is responsible for determining which

requirements and assurances are applicable to the Provider. The Provider shall provide for the compliance of any subcontractors

with applicable Federal requirements and assurances. The Provider, as provided by 31 U.S.C. §1352 and 45 CFR §93.100 et seq.,

shall not pay federally appropriated funds to any person for influencing or attempting to influence an officer or employee of any

agency, a member of the U.S. Congress, an officer or employee of the U.S. Congress in connection with the awarding of any

federal contract, the making of any cooperative agreement or the extension, continuation, renewal, amendment or

modification of any federal contract, grant, loan or cooperative agreement. 7. The Provider agrees to comply with the applicable provisions of the Civil Rights Act of 1964 (42 U.S.C.§200d, et. seq.), the

Age Discrimination Act of 1975 (42 U.S.C. §6101 et. seq.), the American with Disabilities Act of 1990 (42 U.S.C. §12101, et. seq.)

and §504 of the Rehabilitation Act of 1973 (29 U.S.C. §794 and 45 CFR Part85).

8. The Provider may not, on the grounds of race, color, national origin, creed, sex, religion, political ideas, marital status, age or

disability exclude persons from employment in, deny participation in, deny benefits to, or otherwise subject persons to

discrimination under the Medicaid and/or WVCHIP program or any activity connected with the provision of Medicaid and/or

WVCHIP services.

9. The Provider agrees to protect the confidentiality of recipient information pursuant to state and federal law including,

but not limited to, 42 USC 1396a (a)(7) of the Social Security Act; 42 CFR §431.300 et. seq.; 42 CFR §457.1110; and

42 USC 1320d et seq; W. Va. Code §16-29-1 et seq; W. Va. Code 27-3-1; and W. Va. Code 16-3C-3.

10. The Provider shall maintain records in accordance with federal and state regulations for a period of five (5) years from the date of

receipt of payment and/or three (3) years after audits, from the date of any and all exceptions having been declared resolved

by the Department/Bureau. Said records shall fully demonstrate the extent, nature and medical necessity of services and

items provided to Medicaid and/or WVCHIP members, support the fee or rate charged or payment sought for the

service and items, and demonstrate compliance with all applicable requirements related to such services or items.

11. Within thirty (30) days of the request, the Provider shall make any and all requested records and documentation available

upon request to the Department/Bureau, the United States Department of Health and Human Services, the

Medicaid Fraud Control Unit, WVCHIP and/or any other authorized governmental entity under applicable laws,

regulations and policies.





January 8, 2019

25

WV MEDICAID / WVCHIP DUAL PROVIDER ENROLLMENT AGREEMENT and SIGNATURE www.wvmmis.com

A SEPARATE PROVIDER AGREEMENT MUST BE COMPLETED BY EACH RENDERING PROVIDER AND

A REPRESENTATIVE OR AUTHORIZED DELEGATE FOR THE GROUP/FACILITY.

12. The Provider agrees to comply with the disclosure requirements as specified in 45 CFR part 455, subpart B, including,

but not limited to, disclosure of information regarding ownership and control, business transactions and

persons convicted of crimes. Upon request, the Provider agrees to provide to the Department/Bureau/WVCHIP,

the U.S Department of Health and Human Services the information requested in 42 in U.S.C. §1396b(s)

pertaining to imitation on certain physician referrals.

13. The Provider agrees to repay, subject to due process and procedures as set forth in the DHHR/Bureau Medicaid policy manual

and/or the Summary Plan Description (SPD) for CHIP, the Department/Bureau/WVCHIP the amount of any payment under

Medicaid and/or WVCHIP program to which to provider was not entitled, regardless of whether the incorrect

payment was the result of Department/Bureau/WVCHIP error or other cause, and the portion of any interim rate

payment that exceed the rate determined retrospectivey by the Department/Bureau/WVCHIP for the rate period.

14. The Provider agrees that all claims for services will be medically necessary to the health of the specific patient and will be

furnished personally by the Provider or an employee under his/her direction. The Provider agrees to comply with the

provisions of 42 CFR §447.10. The Provider further certifies that all information listed on a claim for

reimbursement from Medicaid and/or WVCHIP is true, accurate and complete. Provider understands that payment

of any claims will be from Federal and State funds, and that any falsification, or concealment of a material fact,

may be a crime to be prosecuted under Federal and State laws.

15. This Enrollment may be canceled by either party at any time, with or without cause, upon no less than thirty (30) working days’

written notice. 16. Notwithstanding 15. above, in the case of fraud, waste and/or abuse, payment may be suspended, or enrollment cancelled,

with less than thirty (30) working days’ written notice, so long as such suspension or termination is consistent with

applicable federal and state laws, regulations, rules and/or policies.

17. The Provider acknowledges that this enrollment is effective for the category of services as stated herein, and that a separate

provider enrollment form or a separate provider agreement may be necessary for certain services. The Provider further

certifies that all information listed on this and any application is true, accurate and complete.

18. If applicable, as a condition of entering into this agreement, provider agrees to assume the liabilities owed to the

Department/Bureau/WVCHIP by any predecessor provider, whether the provider is purchased through an asset

purchase, stock purchase, or another arrangement.

19. Within fifteen (15) business days, the Provider agrees to notify Medicaid and/or WVCHIP, in writing, of any changes in the provider information.

20. Pursuant to Section 6032 of the Deficit Reduction Act of 2005, any entity who receives or makes Title XIX (Medicaid) payments of at

least $5,000,000 annually must establish written or electronic policies and procedures for the education of employees of affected entities

regarding false claims recoveries.

I UNDERSTAND THAT PAYMENT OF CLAIMS WILL BE FROM FEDERAL AND STATE FUNDS AND THAT ANY

FALSIFICATION OR CONCEALMENT OF A MATERIAL FACT MAY BE PROSECUTED UNDER FEDERAL AND STATE LAW.

Provider Name (Please Print)

Provider NPI

Provider Signature

Mail applicaton to:

Date of Signature

TO SUBMIT (Choose one of the below options):

Email applicaton to:

DXC Technology Provider Enrollment P.O. Box 625 Charleston, WV 25322-0625

[email protected]

Upload with Application at: www.wvmmis.com




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