PROVIDER ENROLLMENT PROGRAM REQUIREMENTS

Listed below are the program names, provider types (which is the first two digits of the provider number for that program), program requirements, and required attachments for each provider type.

All providers using a federal tax ID number must attach a copy of a document PREPRINTED by IRS showing the tax ID number and legal name. Examples of acceptable forms are: CP 575 or 147C letter; 941 Employer's's Quarterly Federal Tax Return; 8109 Tax Coupon; or letter from IRS with the Federal Tax Identification Number and legal name. A W-9 is not acceptable.

Adult Day Health Care (ADH) (29)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll. Each licensed ADH provider must enroll and bill separately.

Must be currently licensed and maintain license as Medical type ADH program (not Social) through the Division of Senior Services. Must submit a copy of current license and written proposal.

Aged & Disabled Waiver Homemaker/Chore and Respite (28)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll. Must maintain an SSBG contract thru the Division of Senior Services, Quality Assurance. Each provider must enroll and bill separately.

Institutional Respite

Must submit a copy of the nursing home facility license.

Adult Day Basic

Must submit a copy of current license as a social-type program through Division of Senior Services.

Ambulance - Ground (80)

Required documentation must be submitted with the enrollment application. Missouri applicants must submit a copy of the Ground Ambulance Service license issued by the Department of Health & Senior Services, out of state applicants must submit a copy of the Ground Ambulance Service license issued by their state agency, and both must submit a copy of the Ambulance Medicare approval letter showing the provider name and Medicare number. Each ambulance provider must enroll and bill separately.

Out of State Applicants

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

· Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

· Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary payor;

· Provider of service is located in a BORDERING STATE OF MISSOURI**

· Services were provided to a FOSTER CARE CHILD not residing in Missouri**

· Services were provided by an INDEPENDENT LAB

· Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continue to require prior authorization and are subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

If your claim DOES NOT meet one of the specific conditions listed above, the recipient is responsible for the charges, and you DO NOT need to enroll as a Missouri Medicaid provider. If you determine your claim(s) meets one of the specific conditions listed above, you must request a paper application. All services must meet timely filing requirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.

It is your responsibility to verify the recipient eligibility for dates of service provided. If the recipient is enrolled with a Missouri MC+ Health Plan, you must contact the MC+ Health Plan concerning services provided, Missouri Medicaid is not responsible for those services. It is not necessary that you enroll with Missouri Medicaid unless you have provided services to recipients who ARE NOT enrolled with a MC+ Health Plan.

Air Ambulance (80)

Above Out of State rules also apply. Submit a copy of the Helicopter Service license and a copy of the FAA Air Carrier Certificate to operate a helicopter service. Fixed wing ambulance services cannot enroll. Separate provider numbers are issued for Air and Ground Ambulances. Each air ambulance provider must enroll and bill separately.

Ambulatory Surgery Center (ASC) (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Individual practitioners practicing at the ASC must enroll individually. The ASC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately. Each ASC provider must enroll and bill separately.

Must be licensed by the Department of Health & Senior Services and Medicare certified as an ASC. Must submit a copy of the license and Medicare ASC approval letter.

Audiologist/Hearing Instrument Specialist (33)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each provider must enroll separately.

Must have a current permanent license and submit a copy of the license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. If licensed as both an Audiologist and Hearing Instrument Specialist, submit a copy of both licenses.

Case Management (HCY)(18)

Must be in compliance according to 13.66 of the physician manual. This type of provider number can only be issued if there is not an active clinic/group provider number to add the case management specialty. Out of state (non-bordering) providers cannot enroll.

Clinic/Group (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each clinic/group provider must enroll and bill separately unless one or more locations are covered under the same clinic/group Medicare number.

A clinic/group is one or more individuals designated by Medicare as a clinic/group, or one or more individuals designated by Medicaid as a clinic/group.

If the clinic/group has a Medicare number, submit a copy of the clinic/group Medicare letter showing the clinic/group provider name, clinic/group Medicare number, and individual members of the clinic/group with the members Medicare numbers. All individual providers practicing at the clinic/group must be enrolled individually. If submitting individual applications at the same time as the clinic/group, attach a cover letter referencing the individual provider applications submitted. If the individual providers are already enrolled, attach a list of their names and provider numbers. The clinic/group and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Community Based MR (85)

Must be prior approved by the Department of Mental Health (DMH) and enroll with Medicaid as enrolled with DMH. Contact DMH if you are interested in providing services; the Provider Enrollment Unit cannot forward these forms to you. Out of state providers cannot enroll.

Community Mental Health Center (CMHC) (56)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be Medicare certified as a CMHC and submit a copy of Medicare certification as a CMHC. Must also be approved by Department of Mental Health as a CMHC. All individual providers practicing in the clinic must enroll individually. Attach a cover letter referencing individual provider applications submitted. If the individual providers are already enrolled, attach a list of their names and provider numbers. The CMHC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Community Psychiatric Rehabilitation Center (87)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll.

Must be currently certified by the Department of Mental Health (DMH) as a community psychiatric rehabilitation center, submit a copy of the current Certification from DMH, and enroll with Medicaid as certified by DMH.

Comprehensive Day Rehabilitation (76)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be currently accredited by CARF and submit a copy of current CARF Accreditation.

CRNA (Certified Registered Nurse Anesthetist) (91)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Graduates cannot enroll.

Must have a current permanent RN license and Document of Recognition as a CRNA. Must submit a copy of the current permanent license, Document of Recognition, and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. If applicant is located in a bordering state, a copy of the permanent RN license and current CCNA certification must be submitted. All CRNAs must enroll individually.

C-STAR (86)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll.

Must be currently certified by the Department of Mental Health and submit a copy of the current Certification and enroll with Medicaid as certified by DMH.

Dental Hygienist (74)

Required documentation must be submitted with the original signed agreement.

Out of state (non-bordering) providers cannot enroll.

Dental Hygienist services are for patients 20 and under ONLY.

A Dental Hygienist must be licensed for at least 3 years and employed by a public health department, Rural Health Clinic, or FQHC.

The Dental Hygienist must enroll using the payment name and tax ID of the public health entity, payment is not made directly to the dental hygienist. Each Dental Hygienist must enroll individually, bill under their individual provider number, and must apply for a separate provider number for each public health entity at which they are employed. Each application with its required attachments must be submitted separately.

Dentist (40)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must have a current permanent license and submit a copy of the license. If enrolled with Medicare must submit a copy of Medicare letter showing the individual provider name and Medicare number. If a CORP dentist, submit a copy of CORP Dentist orders and a copy of the current permanent license from the home state.

Only dental providers selecting a specialty of general anesthesia (DS), parenteral conscious sedation (PC) or enteral conscious sedation (EC) must have a current certificate/permit to perform DS, PC or EC and a copy of the certificate/permit must be submitted.

Dialysis Center (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be currently certified by Medicare as a Dialysis Center. Must submit a copy of the Dialysis Center Medicare certification approval letter. The medical director must be enrolled. Attach a cover letter stating the medical director's name. Each dialysis center that is Medicare certified must enroll and bill separately. The dialysis center and physician application cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Disease Management (35)

Required documentation must be submitted with the original signed agreement.

Within the Disease Management program is Diabetes Self-Management Training Services and Disease State Management Training Services. Please make sure you submit the appropriate documentation for the service you will be providing as indicated below.

Diabetes Self-Management Training Services

CDE applicants:

Must submit a copy of current certification by the National Certification Board for Diabetes Educators (NCBDE) for CDEs through the American Association of Diabetes Educators;

If CDE is a nurse or physician:

Submit a copy of current RN or physician license, and a copy of a current certification listed above.

Licensed Dietitian applicants:

Must submit a copy of your current license as a Licensed Dietitian (LD).

Pharmacist applicants:

Must submit a copy of current Pharmacist license AND a copy of appropriate certification from: the National Community Pharmacists Association (NCPA) "Diabetes Care Certification Program", OR the American Pharmaceutical Association (APhA)/American Association of Diabetes Educators (AADE) certification program "Pharmaceutical Care for Patients With Diabetes", OR completed the Drake University, College of Pharmacy and Health Sciences, certification program "Developing Skills for Diabetes Care".

Bordering state CDE, LD, or RPh applicants must be licensed by their state and/or certified by the above mentioned certifying boards. Out of state (non-bordering) providers cannot enroll.

Disease State Management Training Services

Physician applicants:

Must submit a copy of current physician license and a copy of your signed Disease State Management Training Agreement form.

Pharmacist applicants:

Must submit a copy of current pharmacist license and a copy of your signed Disease State Management Training Agreement form.

Out of State applicants are not eligible to enroll for this service.

DME (Durable Medical Equipment) (62)

Required documentation must be submitted with the completed enrollment application. Each DME supplier who has a Medicare number must enroll and bill separately. Representatives of the DME supplier are not eligible to enroll.

Out of state non-bordering applicants are not permitted to enroll unless pre-approved by DMS. Before enrollment forms are sent you must indicate the recipient name, DCN, and date of service that has been provided.

Missouri Medicaid recipients are required to obtain services from Missouri or bordering state providers. Missouri Medicaid considers enrollment of an out of state (non-bordering) provider only if Medicare coinsurance and/or deductible amounts on covered services are provided to patients who have both Missouri Medicaid and Medicare, or the item needed is NOT available in Missouri or a bordering state of Missouri. If prior authorization is approved and reimbursement is made for equipment, supplies, or services for a Missouri Medicaid patient who is not Medicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may be recouped on any amounts paid.

Must submit a copy of the Medicare approval letter for the location completed on the enrollment forms, a copy of the current Certificate of Incorporation (if a corporation), and a copy of the pharmacy permit if also registered as a pharmacy. DME providers must enroll with the same name and address as their Medicare number is issued.

Environmental Lead Inspector (39)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must have a current permanent license as a Lead Inspector or Lead Risk Assessor and submit a copy of the current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. Each inspector must enroll individually.

FQHC (Federally Qualified Health Center) (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each individual practicing at the FQHC must be enrolled. Attach a cover letter stating the individual provider names practicing at the FQHC. Each FQHC that is Medicare certified must enroll and bill separately. The FQHC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

For purposes of providing covered services under Medicaid, an FQHC must:

· receive a grant under Section 329, 330 or 340 of the Public Health Services Act or the Secretary of Health and Human Services (HHS) may determine that the health center qualifies by meeting other requirements and

· must be Medicare certified as a FQHC and submit a copy of the FQHC Medicare certification approval letter.

FQHC COVERED SERVICES

Medicaid covered FQHC services include core services, defined generally in Section 1861 (aa) (1)

(A)-(C) of the Social Security Act and any other ambulatory services provided for under the Missouri State Plan, which are furnished by the FQHC. FQHC services are subject to benefit limitations as described in the applicable Medicaid program manuals and bulletins. Reimbursement methods for these services are described in 13 CSR 70-26.010.

Covered services include, but are not limited to:

physician services;

services and supplies incident to physician services (including drugs and biologicals that cannot be self-administered);

pneumococcal vaccine and its administration and influenza vaccine and its administration;

physician assistant services (cannot enroll individually);

nurse practitioner services;

clinical psychologist services;

clinical social worker services;

services and supplies incident to clinical psychologist and clinical social worker services as would otherwise be covered if furnished by or incident to physician services; and

part-time or intermittent nursing care and related medical supplies to a homebound individual when the FQHC is located in an area designated by HCFA as a home health agency shortage area.

While dental, podiatry, optical and audiology services may be included as covered services in the FQHC, these services must be billed using the individual Medicaid provider number and using procedure codes specifically approved for that program, as opposed to billing with the clinic number. These providers are all subject to the co-payment requirement, which mandates that their services not be billed under a clinic number.

FQHC BILLING PROCEDURES

All FQHC services (except dental, podiatry, audiology and optical services) must be billed on the CMS-1500 using the FQHC clinic name and provider number in field 33 along with the performing practitioner provider number in field 24K.

Podiatry, audiology and optical services may not be billed under the FQHC number, but should be billed on a separate CMS-1500 claim form following the policies of the specific program. You must use the individual provider name (last name first) and individual Medicaid provider number in field 33.

Dental services must be billed on the American Dental Association (ADA) Dental Claim Form, using the individual dentist name and provider number, and using the dental procedure codes specifically identified for use by the Dental Program.

NOTE: Place of Service (POS) may not include settings inappropriate for the delivery of FQHC services (i.e. ambulance, home [for non-homebound], nursing home [for part-time or intermittent visiting nurse care]), and related medical supplies. Professional services provided in these settings should be billed under the individual provider Medicaid number.

FQHC RECORD KEEPING REQUIREMENTS

Health Center records must be sufficient to allow completion and audit of the Medicare FFHC

(HCFA 242) cost report and supplemental Missouri FQHC reporting forms. The supplemental Missouri forms include an income statement, a summary of Medicaid, Medicare and total charges by program, and a statistical schedule of Medicaid, Medicare and total encounters. A uniform charge structure must be established to ensure charges for Medicaid recipients are the same as charges assessed to all other recipients for similar services. Failure to maintain adequate accounting records results in recovery of all funds paid in excess of the established fee schedules. All providers are further required to maintain adequate fiscal and Medical records for a period of five years, to fully disclose services rendered to Title XIX Medicaid recipients.

Home Health Agency (58)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be currently licensed by the Department of Health & Senior Services and Medicare certified as a home health agency. Must submit a copy of the home health license and a copy of the home health agency Medicare approval letter showing the provider name and Medicare number. Must enroll with the name and address as Medicare certified and licensed.

Aids Waiver Services:

Must complete the Medicaid AIDS/HIV Waiver Program Addendum to Title XIX Participation Agreement for Home Health. This form is available at the DMS website under Medicaid Forms and is used for new applicants as well as current providers who elect to provide this service.

Physical Disability Waiver Services:

Must complete the Physical Disability Waiver Services Addendum to Title XIX Participation Agreement for Home Health, Private Duty Nursing, or Personal Care Provider. This form is available at the DMS website under Medicaid Forms and is used for new applicants as well as current providers who elect to provide this service.

Hospice (82)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be currently licensed by the Department Health & Senior Services and Medicare certified as a Hospice. Must submit a copy of the current hospice license, a copy of the Hospice Medicare approval letter showing the provider name and Medicare number, and a copy of the hospice rate letter. Must enroll with the name and address as Medicare certified and licensed.

Nursing Facility Contract:

If providing services to nursing home residents must complete a Hospice Nursing Facility Addendum Contract showing all contracted nursing homes. This form is available at the DMS website under Medicaid Forms. This form is used for new applicants as well as to update the provider records with new contracted nursing homes or nursing homes whose contract has ended.

Hospitals (01)

Required documentation must be submitted with the completed enrollment application.

Psychiatric hospitals may only enroll for services provided to patients under 21 and over 65, this does not affect the acute hospitals who have psych units.

Instate: Must be currently licensed by the Department of Health & Senior Services and Medicare certified as a hospital. Must submit a copy of the hospital license and Medicare certification letter.

Bordering State: Must be currently licensed in their state and Medicare certified as a hospital. Must submit a copy of the current hospital license and Medicare certification letter and a copy of the license and Medicare certification covering the date of service provided. Must have treated an eligible Missouri Medicaid recipient before enrollment is granted.

Out of State Non-Bordering: Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic/group, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary

payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services routinely require prior authorization or have other limitations continue to require prior authorization and be subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

If your claim DOES NOT meet one of the specific conditions listed above, the recipient is responsible for payment, and you DO NOT need to enroll as a Missouri Medicaid provider. If you determine your claim(s) meets one of the specific conditions listed above, you must request a paper application. All services must meet timely filing requirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.

The hospital must maintain and submit a current permanent hospital license and Medicare certification and must submit a copy of their license and Medicare certification covering the date of service. If not required to be licensed, the facility must provide current accreditation approval. Must be licensed and Medicare certified before enrollment forms are sent.

Laboratory - Independent (70)

Required documentation must be submitted with the completed enrollment application. The physicians working in the lab cannot enroll. All applicants must submit a copy of the current CLIA Certificate as an Independent Lab and a copy of the Medicare approval letter showing the provider name and Medicare number. Each Independent Lab must enroll and bill individually.

Out of State Non-Bordering: Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic/group, office or other

facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary

payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continue to require prior authorization and be subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

Nurse - Advanced Practice Nurse (42)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) nurses and graduates cannot enroll. Each advanced practice nurse must enroll individually.

Nurse practitioners and clinical nurse specialists must be currently licensed as registered professional nurses and recognized as an advanced practice nurse within a specific clinical specialty area and role by the Missouri State Board of Nursing pursuant to 4 CSR 200-4.100 Advanced Practice Nurse. Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe. The Collaborative Practice Agreement must meet the requirements of statutes 334.104.1, 334.104.2, state regulation 4CSR 200-4.200, and any other Board of Nursing or Healing Arts statutes or regulations that may apply.

Missouri applicant:

Must submit a copy of current permanent RN license and current Document of Recognition for specialty of practice. Submit a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare.

Bordering State Applicant - Certifying body documentation to be submitted:

American Academy of Nurse Practitioners (AANP), Capital Station, LBJ Building, PO box 12846, Austin, TX 78711, (512)442-4262 extension 14. Advanced Practice Nurse Specialty Area Certifications: adult nurse practitioner and family nurse practitioner.

American Nurses Credentialing Center (ANCC), 600 Maryland Avenue Southwest, Suite 100 West, Washington DC 20024-2571, (800) 284-2378 Advanced Practice Nurse Specialty Area Certifications: adult nurse practitioner, family nurse practitioner, gerontological nurse practitioner, pediatric nurse practitioner, clinical nurse specialist in adult psychiatric and mental health nursing or child and adolescent psychiatric and mental health nursing, clinical nurse specialist in gerontological nursing, clinical specialist in community health nursing, and clinical specialist in medical-surgical nursing.

National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC), PO Box 11082, Chicago, IL 60611-0082, (800) 367-5613 Advanced Practice Nurse Specialty Area Certifications: neonatal nurse practitioner, women's health care nurse practitioner.

National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N), 416 Hungerford Drive, Suite 222, Rockville MD 20850, (301) 340-8213 Advanced Practice Nurse Specialty Area Certification: pediatric nurse practitioner.

Nurse Mid-Wife (25)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) nurses and graduates cannot enroll. Each nurse mid-wife must enroll individually.

Must be currently licensed as a RN and have a current Document of Recognition for the specialty of practice if practicing in Missouri. Must submit a copy of current permanent RN license & current Document of Recognition. If enrolled with Medicare, submit a copy of Medicare letter showing the individual provider's name and Medicare number. Bordering state applicants must have a current permanent RN license and submit a copy of their current permanent RN license and ACNM Certificate. Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe. The Collaborative Practice Agreement must meet the requirements of statutes 334.104.1, 334.104.2, state regulation 4CSR 200-4.200, and any other Board of Nursing or Healing Arts statutes or regulations that may apply.

Nursing Facility (10)

Must be currently licensed by Department of Health & Senior Services (DHSS). Enrollment forms are not sent until the appropriate paperwork is received by the Provider Enrollment Unit from DHSS. Any changes to a nursing facility must be approved by DHSS prior to enrollment sending forms. Bordering state nursing homes are not enrolled unless the recipient has been prior authorized by DHSS to be placed in the bordering state facility. Recipients wishing to be placed in an out of state facility must apply for Medicaid in the state the facility is located. Out of state providers cannot enroll.

Occupational Therapy (47)

These services are for patients under 21 only. Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each occupational therapist must enroll individually.

Must be current and permanently licensed as an occupational therapist and submit a copy of the current license.

Optometrist (31)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each optometrist must enroll individually.

Must be current and permanently licensed and submit a copy of the current license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare.

Optician (32)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of Medicare letter showing the provider name and Medicare number if enrolled with Medicare.

Personal Care (26)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Personal Care - Residential Care Facility (RCF)

Must be currently licensed as an RCF and submit a copy of the current RCF license. If RCF will be providing services in the community RCF must receive approval from Division of Senior Services, Quality Assurance (QA) as a Social Services Block Grant (SSBG) provider BEFORE submitting enrollment forms.

Personal Care - SSBG Contract

Must receive and maintain enrollment with the Division of Senior Services, Quality Assurance (QA) as an SSBG provider. Must enroll with Medicaid using the same provider information as used with QA.

Personal Care - Department of Health and Senior Services (DHSS)

Must be pre-approved by DHSS and attach DHSS approval documentation.

Personal Care - Department of Mental Health (DMH)

Must be pre-approved by DMH and attach DMH approval documentation.

Advanced Personal Care (APC)

Must complete the Medicaid Advanced Personal Care Program Addendum to Title XIX Participation Agreement. This form is available at the DMS website under Medicaid Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Physical Disability Waiver (PDW)

Must complete the Physical Disability Waiver Services Addendum to Title XIX Participation Agreement for Home Health, Private Duty Nursing, or Personal Care Provider. This form is available at the DMS website under Medicaid Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Pharmacy (60)

Each licensed pharmacy must enroll and bill separately. Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of the current Pharmacy Permit if pharmacy is located in Missouri. If pharmacy is located in a bordering state and the scripts will be mailed to a recipient in Missouri, a copy of the current Missouri Non-Resident Pharmacy Permit and a copy of the current pharmacy permit for the state in which the pharmacy is located must be submitted. A physician is not issued a Pharmacy Dispensing provider number unless they are more than 15 miles from a Pharmacy.

Long Term Care

Must complete the Missouri Medicaid Long Term Care Pharmacy Dispensing Fee Provider Specialty form showing the nursing home name and type of packaging being dispensed before the specialty can be added. This form is available at the DMS website under Medicaid Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Physical Therapy (48)

Must submit a copy of current permanent license.

Physician (MD & DO - 20) (instate and bordering)

Required documentation must be submitted with the original signed agreement.

Physicians who work for a Rural Health Clinic (RHC) may only bill for NON-RHC services.

Must submit a copy of current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number (if enrolled with Medicare) with the original signed agreement.

Physician (MD & DO - 20) (out of state non-bordering)

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations will continue to require prior authorization and be subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

Must maintain and submit a current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. Each physician must enroll and bill separately. If enrolling clinic and physicians at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Planned Parenthood Clinic (52)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of the clinic Medicare letter showing the clinic provider name, clinic Medicare number, and individual members of the clinic and their Medicare numbers if enrolled with Medicare. Each individual practicing at the clinic must also be enrolled. Attach a cover letter stating the individual provider names practicing at the clinic. If enrolling clinic and physicians at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Podiatrist (30)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of the current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. Each podiatrist must enroll individually.

Private Duty Nursing Care (94)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll. Each PDN provider must enroll separately.

Must submit the Missouri Medicaid home health provider number, a written proposal, or a copy of JCAHO or CHAPS Accreditation. Must maintain bonding, personal & property liability and Medical malpractice insurance coverage on employees delivering services in client's homes.

Physical Disability Waiver Services

Must complete the Physical Disability Waiver Services Addendum to Title XIX Participation Agreement for Home Health, Private Duty Nursing, or Personal Care Provider. This form is available at the DMS website under Medicaid Forms. This form is used for new enrollees as well as providers who decide to provide this service after they are enrolled.

Psychologist, Professional Counselor, Social Worker (49)

Each Psychologist, Professional Counselor, and/or Social Worker must enroll and bill individually. Professional Counselor and Social Worker services are for patients under 21 only. Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Psychologist: must submit a copy of the current permanent license and a copy of their Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare.

Professional Counselor or Social Worker: must submit a copy of the current permanent or provisional license. If professional counselor or social worker is provisionally licensed, the applicant must have a license at each location of practice, and must send permanent license when it is issued. All providers whether permanent or provisionally licensed must enroll at each location of practice.

Provisional licensed professional counselors and social workers are not permitted to have payment made to their individual name and are not permitted to have an independent practice. Provisional licensed individuals must complete the payment information on the enrollment application with either the supervisor or employer’s name and the tax ID number assigned to the payee. If you have questions regarding either of these issues contact your license board.

Public Health Dept. Clinic (51)

Required documentation must be submitted with the original signed agreement. Out of state providers cannot enroll. Each Public Health Department must enroll individually.

Must be listed by Department of Health & Senior Services as a Public Health Dept. One physician or each advanced practice nurse employed must be enrolled. If the physician is enrolled, all services provided at the health department, other than advanced practice nurse services, can be filed using his/her provider number as performing provider in field 24K of the claim form. If the advanced practice nurse is enrolled instead of a physician he/she is only permitted to be used as the performing provider for the services they actually perform, not for any other service provided by the health department. If enrolling clinic, physicians, and/or nurses at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Qualified Medicare Beneficiary (QMB) (75)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll. Each QMB provider who has a Medicare number must enroll individually.

Must submit a copy of the current permanent license and a copy of the Medicare approval letter showing the provider name and Medicare number. Applicants must accept assignment and must have seen a QMB eligible recipient before enrollment is granted. Only QMB eligible recipients are covered under this program, many Medicare recipients are not QMB eligible.

Rehabilitation Center - Outpatient (57)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be certified by Department of Health & Senior Services & Medicare. Submit a copy of the Medicare Rehabilitation approval letter showing the provider name and Medicare number.

Rural Health Clinic (RHC) (59)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each RHC that is Medicare certified must enroll and bill separately.

Must submit a copy of the RHC Medicare approval letter showing the provider name and Medicare number and the RHC rate letter. Individual practitioners may only bill for NON-RHC services.

Individual providers at a RHC may also maintain a clinic/group and individual provider numbers at the rural health location. However, per the Centers for Medicare & Medicaid Services (CMS) the following specific documentation must be maintained by the provider and made available to the state Medicaid agency, upon request, which includes:

A list of services that will be provided on site through the clinic/group and practitioner provider numbers;

Documentation of the costs associated with services provided through the clinic/group and practitioners; and

Contract between the provider and the RHC defining which services provided off-site will be provided through the clinic/group and practitioners and which will be provided as an employee of the RHC. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report.

Please note: The costs associated with services provided through the clinic/group and practitioners provider number, off and on-site, must be excluded from the cost report submitted to the Medicare intermediary for the RHC. The RHC rate is based on the actual costs associated with the RHC services only, therefore, any changes in the costs reported is reflected in the RHC rate. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report.

Speech/Language Therapy (46)

These services are for patients under 21 only. Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of current permanent Speech Language Pathologist license. If enrolling with a school you may submit a copy of the current permanent Teacher Certificate showing speech. Provisional license or provisional Teacher Certificate is not acceptable. Each therapist must enroll individually.

Teaching Institution Department (hospital based) (54)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

If each department has a clinic/group Medicare number then each department must enroll and all practitioners in each department must be enrolled individually. If one Part B clinic/group Medicare number is issued for the entire hospital then only one All Department number is issued. If enrolling the department, physicians, and/or other individual practitioners at the same time, the clinic/group and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Teaching Institution (not hospital based) (55)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must submit a copy of the clinic/group Medicare letter showing the department provider name, department Medicare number, and individual members of the department and their Medicare numbers. If the departments are not enrolled with Medicare separately they are not enrolled with Medicaid separately. All individuals practicing in each department must be enrolled individually. Attach a cover letter stating the individual provider names practicing in each department. If enrolling the department, physicians, and/or other individual practitioners at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

X-Ray – Portable X-Ray/IDTF (71)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be certified through the Department of Health and Senior Services as a Portable X-Ray or IDTF and must submit a copy of the Portable X-Ray or IDTF Medicare approval letter. Out of state (non-bordering) providers cannot enroll. Individuals working for a Portable X-Ray or IDTF cannot enroll since all services are covered under the Portable X-Ray or IDTF.

OUT OF STATE (NON-BORDERING) APPLICANTS/PROVIDERS

Enrollment requirements for out of state (non-bordering) applicants: Missouri Medicaid recipients are required to obtain services from Missouri or bordering state providers. If a Missouri recipient leaves the state of Missouri and requires services, one of the following conditions must be met before the services are considered for reimbursement:

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary

payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continues to require prior authorization and be subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

When the recipient is in Missouri and receiving services from an out of state provider: Missouri Medicaid considers enrollment of an out of state (non-bordering) provider only if Medicare coinsurance and/or deductible amounts on covered services are provided to patients who have both Missouri Medicaid and Medicare, or if the item/services needed are not available in Missouri or a bordering state of Missouri. If prior authorization is approved and reimbursement is received for equipment, supplies, or services for a Missouri Medicaid patient who is not Medicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may be recouped on any amounts paid.

If the recipient is enrolled with a Missouri MC+ health plan on the date(s) of service provided, the provider must contact the MC+ health plan concerning the services. It is not necessary to enroll with Missouri Medicaid unless the services are for recipients who ARE NOT enrolled with a MC+ health plan and one of the conditions stated above is met.

If the claim DOES NOT meet one of the specific conditions listed above, the recipient is responsible for the services, and enrollment is not granted.

If the claim meets one of the specific conditions listed above contact the Provider Enrollment Unit via email at: providerenrollment@dss.mo.gov for the proper enrollment forms, have the recipient ID and date of service available. All services must meet timely filing requirements.

Submitting enrollment forms does not guarantee enrollment and receiving a provider number does not guarantee reimbursement.

INSTRUCTIONS FOR COMPLETION OF MISSOURI MEDICAID

INTERNET ENROLLMENT FORMS

DO NOT USE HIGH LIGHTERS OR MARKERS ON ANY FORMS.

FOLLOW INSTRUCTIONS CAREFULLY.

The Provider Enrollment Application site is best viewed with the latest version of Internet Explorer, or Netscape Navigator. This site does not support the AOL browsing software. Please install the latest version of either Internet Explorer or Netscape Navigator before using this site.

Instructions for each field of the Medicaid Enrollment Application are listed on the bottom bar of the application screen. Use HELP for more detailed instructions on completing the enrollment application.

If you have problems faxing or using this site contact the Help Desk at 573-635-3559. General enrollment questions should be e-mailed to: providerenrollment@dss.mo.gov. Please fax the signature page and required attachments in an upright position to 573-634-3105. Make sure the forms and attachments are of good quality so when they are faxed they are legible. Illegible forms or attachments are automatically denied.

Altered forms are automatically denied. Forms completed by typewriter or hand written are automatically be denied. Fields cannot be blacked out, whited out or crossed out, writing information on the forms is not acceptable, however, the provider must sign with their original wet signature.

All forms must be completed while on the Internet before they can be submitted and printed. Applications printed prior to being completed on the Internet are denied. The signature page of the application and ALL REQUIRED ATTACHMENTS must be faxed in one transmission. Partial applications are not processed. The provider is responsible to retain printed pages of the enrollment application, including the signature page showing the original wet signature.

1) Once all fields on the first page of the application are completed, click on Continue; the screen to verify the information entered appears. After all fields are verified and correct, choose: Edit or Continue.

a) Edit: returns to the previous screen and allows changes to be made to any field on the current part,

or to enter information in fields that may have been missed.

b) Continue: takes applicant to the print page. Your choices from this screen are to:

i) Print for Your Records: allows applicants the opportunity to print their application and

retain for audit purposes. Each part must be printed before advancing to the next page.

The Back button CANNOT be used to go back and edit or print previous pages after

you have hit "Continue" on the review screen.

ii) Continue: takes the applicant to the next page.

iii) Finish Remaining Pages Later: one or more pages can be completed and retrieved

at a later date. In order to finish remaining pages later, the full page must be completed

before it can be it can be saved. The PIN number at the top of the page must be used to

retrieve the application in the event that all parts of the application are completed during the same session.

2) The Thank You page has additional instructions. If changes are necessary, a new application must

be completed.

3) Clicking on attachment document on the last page will take you to the document that

explains what type of attachments your provider type is required to submit with the application.

Only one signature page and its required attachments is accepted per fax transmission. If sending multiple signature pages along with required attachments, each signature page along with its required attachments must be faxed separately. In order for the signature page along with required attachments to be submitted by fax separately, make sure that each time a fax is completed, the fax machine being used is not only finished moving the pages through the machine, but has finished the transmission and has disconnected from the fax number dialed. Then re-dial to submit the next signature page along with required attachments.

The enrollment fax database number (573-634-3105) is used exclusively for submitting enrollment applications. All other faxes are disregarded. This is the only number that may be used to fax a signature page along with its required attachments.

All communications regarding Provider Enrollment are now communicated via e-mail at providerenrollment@dss.mo.gov A valid e-mail address must be included with all correspondence and applications. The Provider Enrollment Unit also has an auto-responder that confirms the receipt of the e-mail. E-mails are processed in date order as they are received. Your patience is appreciated.

Missouri Medicaid Provider Enrollment Application Part 1 Help

Instructions for completion of Part 1 of the Provider Enrollment Application

NOTE: ALL mandatory fields have an * on the application and must be completed before the application can be finalized.

Field Name

Instructions For Completion

*Provider Name (Last, First, MI)

Enter the name of the applicant. If enrolling an individual practitioner, enter the individual's name and title as is on the license: last name first, then first name, middle initial, and title. If the applicant is enrolling as a clinic/group, hospital, optical company, DME company, pharmacy, etc., use license or Medicare certification name, if this is a requirement for the program. Use the business/DBA name if a license or Medicare certification is not required.

*2. Business Telephone Number

Enter the business telephone number for the applicant. This number is used by recipients, providers, Missouri Medicaid employees, etc. to contact the provider.

*3. Provider Address

A street address must be entered in this field, either alone or with a post office box or route number. A post office box number alone is not an acceptable address, since correspondence may be sent by a commercial carrier such as UPS. If DMS is unable to locate a provider, the provider is terminated from Medicaid participation.

If the applicant is a physician (20, 24), advanced practice nurse (42), or CRNA (91) and has one or more Medicare numbers, enter the applicant's primary location address. All Medicare numbers are placed on one provider file, since only one Medicaid provider number is issued to these types of providers.

If the applicant is other than a physician (20, 24), advanced practice nurse (42), or CRNA (91) and has one or more Medicare numbers, each physical location that is issued a Medicare number must enroll separately with Medicaid. If the Medicare number covers several practice locations, the applicant must enter the primary address used by Medicare.

If the applicant is other than a physician (20, 24), advanced practice nurse (42), or CRNA (91) and does not have a Medicare number, the applicant must enroll at each practice location.

If enrolling as a member of a clinic/group or department, enter the physical location street address where the clinic is enrolled and the Medicare number is issued.

If enrolling a private/individual practice (provider types 20, 24, 25, 30, 31, 33, 34, 35, 39, 40, 42, 46, 47, 48, 49, 75, 91) enter the street address of the individual's office.

If enrolling an individual (see above provider types) employed by a facility, clinic/group, or school, enter the street address of the employer. Applicants must enroll at each practice location if other than physician (20, 24), advanced practice nurse (42), or CRNA (91).

Individual provider types 20, 24, 30, 42, 75, 91, who only provider services in a hospital or nursing facility and not in an office setting, may enroll using their administrative office address, but must attach a cover letter stating the facility name and location where the services will be performed. The Provider Enrollment Unit staff determines if the enrollment at an administrative office is appropriate.

*4. City

Enter the city corresponding to the applicant's address.

*5. State

Enter the state corresponding to the applicant's address.

*6. Zip Code

Enter the zip code corresponding to the applicant's address.

*7. County

Enter the county name corresponding to the applicant's address.

*8. Social Security Number

Individual applicants must enter their SSN. This information is kept confidential and is not used for IRS reporting.

*9. Date of Birth

Individual applicants must enter their date of birth. This information is kept confidential.

*10. License Number

Enter the applicant's permanent state license number. Provisional license is only accepted for PLPC and PLSW applicants. PLPC and PLSW applicants must have a license for each practice location.

*11. Payee Name Registered with IRS (used to report income)

If using a Federal Tax ID number for a business/entity in field #13, enter the exact legal business name as registered with the IRS in field #11.

If an individual is enrolling as an employee, use the employer's Federal Tax ID number and exact name as registered with the IRS.

If using a social security number (SSN) in field #13, enter the exact name as registered with the Social Security Administration in field #11.

This information must be correct even if payment will be direct deposited. If the applicant is unsure of this information, contact the applicant's accountant/financial advisor before completing an application.

Submit a copy of a document PRE-PRINTED by the IRS, showing both the legal business name and the Federal Tax ID number, with EACH application. A W-9 is not acceptable documentation.

Doing Business As (DBA) Name (if applicable)

If the applicant uses a name other than the legal name listed above, enter that name here.

*12. Payee Address

Enter the address where a paper check (if not participating in direct deposit) and the 1099 should be sent.

*Payee City

Enter the city corresponding to the payee address.

*Payee State

Enter the state corresponding to the payee address.

*Payee Zip Code

Enter the zip code corresponding to the payee address.

*13. Tax ID# or Social Security#
as Registered with IRS (used to report income)

The number entered here is used for IRS reporting and must be 9 digits.

If using a Federal Tax ID number for a business/entity in field #13, enter the exact legal business name as registered with IRS in field #11.

If enrolling as an employee, use the employer's Federal Tax ID number and exact name as registered with the IRS. If using a social security number(SSN) in field #13, enter the exact name as registered with the Social Security Administration in field #11.

This information must be correct even if payment will be direct deposited. If the applicant is unsure of this information, contact the applicant's accountant/financial advisor before completing an enrollment application.

Submit a copy of a document PRE-PRINTED by the IRS, showing both the legal business name and Federal Tax ID number, with EACH application.

A W-9 is not acceptable documentation.

*14. Practice Type

Select the type of practice or business.

*15. Specialties (minimum of 1)

Choose all specialties that the provider is licensed/certified to perform. This information is needed for correct payment of claims.

15a. National Provider Identifier (NPI)

Enter the National Provider Identifier (NPI) number for the applicant. This is the HIPAA standard unique health identifier for health care providers.

15b. Enter Valid Taxonomy Codes

Enter the applicant's 10-digit HIPAA taxonomy codes. Up to 20 codes may be entered. These codes are composed of the provider type, provider specialty, provider number and a place holder. A list of valid codes may be found at http://www.wpc-edi.com/codes/taxonomy

16. CLIA Number

Enter the Clinical Laboratory Improvement Act (CLIA) identification number issued to the practice location of enrollment. CLIA numbers are obtained from the Centers for Medicare and Medicaid Services (CMS). Lab services cannot be reimbursed if the CLIA number is not indicated.

17. Certified by the Department of Health and Senior Services for the following:

Indicate whether the applicant is certified by the Department of Health & Senior Services to provide one or more of these services. This information is needed for correct payment of claims.

18. Optical and Audiology/Hearing Aid Services

If the applicant is an optical or audiology/hearing aid applicant, enter the type(s) of services the applicant will be providing.

19. Do you have a Collaborative Practice Agreement to Prescribe Drugs?

All advanced practice nurse and nurse mid-wife applicants must answer this question.

If advanced practice nurse or nurse mid-wife applicants wish to be reimbursed for prescribing drugs, they must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe. The Collaborative Practice Agreement must meet the requirements of statutes 334.104.1, 334.104.2, state regulation 4CSR 200-4.200, and any other Board of Nursing or Healing Arts statutes or regulations that may apply. This information is needed for correct payment of claims.

20. Are you part of a Rural Health Clinic?

If the applicant provides services in a rural health clinic (RHC), answer YES to this question. The applicant needs to enroll only if providing Non-RHC services. All RHC services must be billed using the RHC provider number. RHC and Non-RHC services must be documented. See the Rural Health Clinic Program requirements for additional information.

21. Medicare Provider Number

Enter the Medicare number(s) assigned to the applicant's physical location address listed on this application. This information allows Medicare claims to crossover automatically to Missouri Medicaid.

A copy of the letter from Medicare showing the Medicare number issued, the applicant name, and physical location(s) approved by Medicare must be sent to DMS. If unable to provide the initial letter received, the applicant must contact the Medicare carrier to request written documentation to submit.

If the applicant is a physician (20, 24), advanced practice nurse (42), or CRNA (91) and has one or more Medicare numbers, all Medicare numbers are placed on one provider file since only one Medicaid provider number is issued to these types of providers. The Medicare documentation for each Medicare number must be submitted with the signature page.

If the applicant is other than a physician (20, 24), advanced practice nurse (42), or CRNA (91) and has one or more Medicare numbers, each physical location that is issued a Medicare number must enroll separately with Medicaid. If the Medicare number covers several practice locations, the applicant is only required to enroll at the primary practice location used by Medicare.

If the applicant is other than a physician (20, 24), advanced practice nurse (42), or CRNA (91) and does not have a Medicare number, the applicant must enroll at each practice location.

If the applicant is a member of a clinic/group or department, enter the applicant's Medicare number associated with the clinic/group or department for the location indicated on this application.

If enrolling a private/individual practice (provider types 20, 24, 25, 30,31, 33, 34, 35, 39, 40, 42, 75, 91) enter the Medicare number of the individual's practice location as enrolled with Medicare.

It is the Provider's responsibility to file electronic claims for all Medicare/Medicaid claims that do not automatically crossover for any reason.

22. Do you provide case management services according to 13.66 of the Physician Manual?

Answer YES to this question if the applicant will be providing case management services according to the case management section (13.66) of the Physician Manual. The Physician Manual may be found at http://www.dss.mo.gov/dms/providers.htm . Review the manual reference before answering this question to ensure the applicant is eligible for these services.

23. Indicate your rural health rate and submit a copy of your rate letter.

If the applicant answered YES to question 20, enter the applicant's rural health rate. Submit a copy of the rate letter to Provider Enrollment along with the signature page.

*Provider's e-mail Address:

Enter the APPLICANT'S e-mail address here.

Click the "Continue" button to go to the next page.

The next page is a review page for the information entered. The applicant may choose to edit the information by selecting the "Edit" button or continue by selecting the "Continue" button.

If the applicant wants to print the form page, select the "Print For Your Records" button.

THIS IS THE ONLY TIME THE PROVIDER MAY PRINT THE APPLICATION PAGE.

After printing the form page, select the "Continue" button to go to Part 2.

NOTE: If the applicant wants to complete the rest of the form later, write down the PIN number EXACTLY as shown at the top of this page. The applicant can then go into the provider application by choosing the "Retrieve Draft Enrollment Application" option when returning to the Provider Enrollment web site.

Missouri Medicaid Provider Enrollment Application Part 2 Help

Instructions for completion of Part 2 of the Provider Enrollment Application

NOTE: * These fields are mandatory and must be completed before the application can be finalized.

If patients have already been treated the applicant must complete #15 or 16 with the appropriate information requested or the provider number will not be backdated.

If backdating is granted, all services must still meet the Missouri Medicaid timely filing requirements.

Field Name

Instructions For Completion

Applicant Name:

The applicant's name is carried over from the Enrollment Application Part 1.

Contact Person:

Enter the name of the contact person for the applicant. This is the person that will be contacted with any questions relating to the enrollment forms.

Phone:

Enter the contact person's phone number.

Contact Person e-mail:

Enter the contact person's e-mail address

*1.

If the applicant is practicing as a member of a clinic or other group (this includes school districts and other groups), submit a list of ALL the names and provider numbers of the members of the group or clinic.

Clinic/Group Medicaid Number:

Enter the clinic or group Medicaid number where the applicant is providing services.

*2.

Select 'Y', if the application is being made as a result of a change in ownership, a merger, a replacement facility, a change in corporate structure, a new clinic/group formed at the same location or another type of change. Otherwise select 'N'.

If 'Y' is selected, check (click in the box) all the types of change that apply.

If 'Y' is selected, list the former owner's name(s) and provider number(s) and/or clinic/facility name(s).

If 'Y' is selected, list the new owner's name(s) and provider number(s) and/or clinic/facility name(s).

*3.

Enter the names and addresses of individuals having direct or indirect ownership, controlling interest, or partnership interest; all officers and directors; or partnership interest; all officers and directors; or the name and EIN of the organization(s) having direct or indirect ownership or a controlling interest. School districts and similar entities may submit a list of their board members.

*4.

Check (click in the box) the settings in which the applicant sees clients or patients.

If "Other" was checked above, enter an explanation.

*5 through 12

Select "Yes" if any of the stated incidents apply to the applicant, If the answer is "Yes", give an explanation, which includes the date, state, city and county. Fax any necessary documentation to the Provider Enrollment Unit along with your signature page.

*13.

Select "Yes" if the applicant now holds a certificate to dispense controlled substances from the Federal Drug Enforcement Agency (DEA).

If the answer above was "Yes", enter the first DEA (federal) number and select the state that issued the certificate.

If the answer above was "Yes", enter the second DEA (federal) number and select the state that issued the certificate.

Select "Yes" if the applicant now holds a certificate to dispense controlled substances from the Missouri Department of Health and Senior Services, or any other state agency.

If the answer above was "Yes", enter the first BNDD number and select the state that issued the certificate.

If the answer above was "Yes", enter the second BNDD number and select the state that issued the certificate.

*14.

Select "Yes" if any of the DEA or BNDD certificates have ever been suspended, revoked, surrendered, or in any way restricted by probation or agreement.

If the answer above was "Yes", give an explanation, which includes the date, state, city and county. Fax any necessary documentation to the Provider Enrollment Unit along with the signature page.

*15.

Selected "Yes" if the applicant has rendered services to a Missouri Medicaid recipient in reference to this location.

If the answer is "Yes", complete the information below and submit a copy of the license or required documentation covering these dates of service IN ADDITION to the current license or required documentation.

If the answer above was "Yes", enter the Medicaid recipient's full name.

If the answer above was "Yes", enter the Medicaid recipient's Medicaid ID number.

If the answer above was "Yes", enter the Medicaid recipient's Social Security number.

If the answer above was "Yes", enter the date of service the services were rendered.

*16.

Selected "Yes" if the provider number needs to be backdated.

If the answer above was "Yes", enter the preferred effective date. The effective date may not be past timely filing and may not be prior to the issue date of the applicant's required documents for enrollment in the Missouri Medicaid Program. The timely filing regulation is 12 CSR 70-3.100.

Click the "Continue" button to go to the next page.

The next page is a review page for the information entered. The applicant may choose to edit the information by selecting the "Edit" button, or continue by selecting the "Continue" button.

If the applicant wants to print the form page, select the "Print For Your Records" button.

THIS IS THE ONLY TIME THE PROVIDER MAY PRINT THE APPLICATION PAGE.

After printing the form page, select the "Continue" button to go to Part 3.

NOTE: If the applicant wants to complete the rest of the form later, write down the PIN number EXACTLY as shown at the top of this page. The applicant can then go into the provider application by choosing the "Retrieve Draft Enrollment Application" option when returning to the Provider Enrollment web site.

Missouri Medicaid Provider Enrollment Application Part 3 Help

Instructions for completion of Part 3 of the Provider Enrollment Application.

NOTE: If the applicant chooses the direct deposit option, all fields on this page must be completed.

If the applicant does NOT choose the direct deposit option, click continue at the bottom of the page, without entering any information.

If any information is entered, then the entire form must be completed.

Field Name

Instructions For Completion

Routing Number:

Enter the financial institution's routing number. This number must be 9 digits. The routing number is generally the first set of digits on the lower left corner of the check. Reference the examples.

Depositor Account Number:

Enter the depositor account number from the financial institution. The account number is generally the second or third set of digits on the lower left corner of the check. Reference the examples.

NOTE: Credit Union and Savings and Loan Associations may differ from the above examples. Please VERIFY the DEPOSITOR ACCOUNT NUMBER and ELECTRONIC ROUTING NUMBER with the financial institution.

The check number should not be included in the depositor account number.

Type of Account:

Select either "Checking" or "Savings."

Financial Institution Name

Enter the name of the financial institution for this account.

Address

Enter the address of the financial institution.

City

Enter the city of the financial institution.

State

Enter the state of the financial institution.

Zip Code

Enter the zip code of the financial institution.

Branch Number or Name

Enter the branch number or name of the financial institution.

Telephone Number

Enter the telephone number of the financial institution.

To participate in the direct deposit option, the applicant must select "Yes, I agree" beside each condition.

Please read the conditions carefully, upon selecting "Yes, I agree" to each condition, the applicant has agreed to abide to all the conditions.

If the applicant cannot agree to all of the conditions, the applicant must delete all information from the fields above and select "Continue" to complete the application without the direct deposit option.

Click the "Continue" button to go to the next page.

The next page is a review page for the information entered. The applicant may choose to edit the information by selecting the "Edit" button or continue by selecting the "Continue" button.

If the applicant wants to print the form page, select the "Print For Your Records" button.

THIS IS THE ONLY TIME THE PROVIDER MAY PRINT THE APPLICATION PAGE.

After printing the form page, select the "Continue" button to go to Part 4.

NOTE: If the applicant wants to complete the rest of the form later, write down the PIN number EXACTLY as shown at the top of this page. The applicant can then go into the provider application by choosing the "Retrieve Draft Enrollment Application" option when returning to the Provider Enrollment web site.

Missouri Medicaid Provider Enrollment Application Part 4 Help

Instructions for completion of Part 4 of the Provider Enrollment Application

To participate in the Vendor Payment plan for Missouri Medicaid, the applicant must select "Yes, I agree" beside all of the conditions. Please read the conditions carefully. Upon selecting "Yes, I agree", the applicant has agreed to abide by all the legal requirements of a Missouri Medicaid provider.

Click the "Continue" button to go to the next page.

If the applicant wants to print the form page, select the "Print For Your Records" button.

THIS IS THE ONLY TIME THE PROVIDER MAY PRINT THE APPLICATION PAGE.

After printing the form page, select the "Continue" button to go to the Missouri Medicaid Provider Agreement Signature Form.

Missouri Medicaid Provider Agreement Signature Form Help

Instructions for completion of the Missouri Medicaid Provider Agreement Signature Form

Print the agreement signature form page by selecting the "Print and Continue" button at the bottom of the form. Read the form carefully, sign with original signature, date, and fax it to the Provider Enrollment Unit at 573-634-3105. This is a fax database, not a regular fax machine. The applicant must submit the required documentation as listed on this page as well as any additional information needed from the completion of the provider application.

INSTRUCTIONS FOR COMPLETION OF MISSOURI MEDICAID

PAPER ENROLLMENT FORMS

DO NOT USE HIGHLIGHTERS OR MARKERS ON ANY FORMS

DO NOT PUNCH HOLES IN ANY FORMS;

FOLLOW INSTRUCTIONS CAREFULLY;

ANY MEDICAID ENROLLMENT FORM THAT HAS BEEN DUPLICATED OR ALTERED IN ANY MANNER IS AUTOMATICALLY DENIED.

PAPER PROVIDER QUESTIONNAIRE INSTRUCTIONS

1. PROVIDER NAME: Enter name of applying provider. If enrolling as a hospital, optical company, DME company, pharmacy, etc., use license or certification name (if applicable), or business/DBA name if not licensed or certified.

2. BUSINESS PHONE: Enter business telephone number for applying provider. This number is used by recipients, providers, and Missouri Medicaid employees, etc.

3. PRESENT MISSOURI MEDICAID PROVIDER NUMBER(s): Enter ALL existing Missouri Medicaid provider numbers for the applying provider.

4. PROVIDER ADDRESS: A street address must be entered in this field either alone or with a post office box or route number, a P.O. Box alone is not an acceptable address, as correspondence may be sent by a commercial carrier, such as UPS. If mail is returned to our office the provider number is made inactive. If you participate with Medicare each physical location that is issued a Medicare number must also enroll with a separate Medicaid number.

5-8. CITY, COUNTY, STATE, ZIP CODE: Enter appropriate information for provider address.

9. PAYMENT NAME(name as registered with IRS): Enter the name that the payment should be taxed to. If using a Federal Tax Identification Number to report income to the IRS, the name must be the exact same name as registered with IRS. If using a Social Security Number the name must be the exact same name as used with the Social Security Administration. This information must be entered correctly even if payment is direct deposited. The name completed in this field appears on the paper check (if you do not participate in direct deposit), the paper remittance advice, and the 1099 tax form at the end of the year. If there is a DBA name please enter it after the appropriate payment name. Name/number mismatches for this field results in the incorrect issuance of 1099 tax forms to the provider and may cause withholding of reimbursement. Corrected 1099 tax forms are NOT issued by the Division of Medical Services. If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification Number, contact IRS at 800-829-1040. When using a Federal Tax Identification Number, also submit a copy of one of the following PREPRINTED Federal documents to verify the legal name used with IRS: CP 575 or 147C letter; 941 Employer's Quarterly Federal Tax Return; 8109 Tax Coupon; or letter from IRS with the Federal Tax Identification number and legal name. A W-9 is not acceptable.

10-13 PAYMENT, REMITTANCE and 1099 ADDRESS: Enter the address that a paper check (if not participating in direct deposit), paper remittance advice, and 1099 should be sent to. Even if participating in direct deposit, your remittance advice must still be sent by mail to this address. Providers cannot have checks or remittances sent to a bank address. Remittances are not mailed to an address other than what is on the Provider Enrollment File. Provider Enrollment must be notified in writing of remittance address changes even if participating in direct deposit. Provider Enrollment sends the appropriate form(s) for each provider to complete.

14. TAX IDENTIFICATION NUMBER: Enter the Federal Tax Identification Number or Social Security Number that payment should be taxed to, the number assigned to the name listed in field 9.. This may be a Social Security Number or a Federal Tax Identification Number depending on how income is reported to IRS. If using a Federal Tax Identification number the tax number must match the name as registered with IRS. If using a SSN the number must match the name as you are registered with the Social Security Administration. This information must be entered correctly even if payment is direct deposited. The name completed in this field appears on the paper check if you do not participate in direct deposit, the paper remittance advice, and the 1099 tax form at the end of the year. If there is a DBA name please enter it after the appropriate payment name. Name/number mismatches in this field results in the incorrect issuance of 1099 tax forms to the provider and may cause withholding of reimbursement. Corrected 1099 tax forms are NOT issued by the Division of Medical Services. If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification number, contact IRS at 800-829-1040. When using a Federal Tax Identification Number, also submit a copy of one of the following PREPRINTED Federal documents to verify the legal name used with IRS: CP 575 or 147C letter; 941 Employer's Quarterly Federal Tax Return; 8109 Tax Coupon; or letter from IRS with the Federal Tax Identification number and legal name. A W-9 is not acceptable.

15. Individual applicants only.

16. MEDICARE NUMBER: (if applicable) Enter the Medicare number(s) assigned to the applying provider's physical location address listed in fields 4-8. This information allows Medicare claims to crossover automatically to Missouri Medicaid. Attach a copy of the Medicare letter received from Medicare showing the Medicare number issued, the provider name, and physical location(s) approved by Medicare (a PO Box or payment address is not acceptable). If the initial letter cannot be provided, contact the Medicare carrier to request written documentation to submit. If the Medicare number covers more than one office location, complete the forms with the physical location address the Medicare number is issued to. If there are separate Medicare numbers for different locations, each location must enroll with Medicaid as with Medicare. It is the provider's responsibility to file claims for all Medicare/Medicaid claims that do not crossover electronically for whatever reason.

17. MEDICARE CARRIER: Enter name(s) of Medicare carrier for Medicare number(s) listed in field 16 (i.e. Medicare Services, Blue Cross/Blue Shield, etc.).

18. STATE LICENSE NUMBER: Enter the State license number for the applying provider. Any provider that is issued a license to practice must submit a copy of current, permanent license unless otherwise requested.

19. NABP/NCPDP NUMBER: (Pharmacies only) Enter your NABP/NCPDP number. This number is used for DMS tracking purposes and must be included on all applications.

20. TYPE OF PRACTICE: Check box identifying type of practice/business. If box indicating City, Municipal, County, Dist. or State-owned is checked, underline the type of agency.

21. PROVIDER TYPE: Provider types and specialties are already indicated on the questionnaire.

22. CLIA: Enter Clinical Laboratory Improvement Act (CLIA) Identification number issued to the practice location of enrollment. CLIA numbers are obtained from CMS and documentation of this number is required to bill for laboratory services. (must also attach a copy of CLIA Certificate).

23. CRNA: Indicate if you employ or have any CRNAs under contract. All CRNAs must enroll individually via the Internet as individual Medicaid providers.

24. PROVIDER SPECIALTY: Circle all specialties licensed/certified to perform. This information is needed for correct payment of claims. ATTACH A COPY OF ALL APPROPRIATE LICENSES/CERTIFICATION TO SUPPORT SPECIALTIES INDICATED.

SECTION II: To be completed by Nursing Home Providers ONLY

25. NURSING HOME ADMINISTRATOR: Enter name of current nursing home administrator.

26. FISCAL YEAR END DATE: Enter the fiscal year month end date for the nursing home.

SECTION III: To be completed by Hospitals ONLY

27. CERTIFIED BEDS: Enter number of certified beds in the hospital.

28. FISCAL YEAR END DATE: Enter the fiscal year month end date for the hospital.

SECTION IV: To be completed by Pharmacies & DME (if also a Pharmacy) ONLY

29. PHARMACY OWNER: Enter name of Pharmacy owner.

SECTION V: To be completed by Home Health & Hospice ONLY

30. FISCAL YEAR END DATE: Enter the fiscal year month end date for Home Health or Hospice agency.

SECTION VI: To be completed by Nursing Homes ONLY

31. NURSING HOME ADMINISTRATOR SIGNATURE: Must be Nursing Home Administrator's ORIGINAL signature.

PAPER TITLE XIX PARTICIPATION AGREEMENT INSTRUCTIONS

(the back side of the Provider Questionnaire, blue form)

Read the agreement carefully.

The Title XIX Participation Agreement MUST contain the original wet signature of the person Medicaid has indicated to sign. An authorized representative of the owner may sign for a facility, clinic, or other entity. Billing agents etc. are prohibited from signing. Rubber stamp or other facsimiles are not acceptable.

Indicate the title of the person signing and the date signed.

PAPER MISSOURI MEDICAID PROVIDER ENROLLMENT APPLICATION INSTRUCTIONS

(white form, front and back)

All questions must be answered, NA is not an acceptable answer.

Field number 1: If you do not have any other provider numbers put none.

This form MUST contain the original wet signature of the person Medicaid indicates to sign, see Title XIX Participation Agreement. An authorized representative of the owner may sign for a facility, clinic, or other entity. All forms must be signed by the same person. Rubber stamps or other facsimiles are not acceptable.

Indicate the title of the person signing and the date signed.

CIVIL RIGHTS COMPLIANCE

All applicants are required to be in compliance with the Office of Civil Rights. Applicants are required to review the civil rights information via the Internet at www.dss.mo.gov/dms to ensure compliance is met. Click on Providers, under Provider Enrollment select civil rights.

Medicaid providers must enroll and bill Medicaid in the same manner they enroll and bill Medicare in order for Medicare/Medicaid claims to crossover electronically and be reimbursed appropriately. Medicaid providers must enroll at the physical practice location the Medicare number is issued.

Physicians, APNs, and CRNAs are no longer required to enroll at each Medicare or Medicaid practice location. However, they are still required to submit Medicare documentation so the claims can crossover automatically.

It is the provider's responsibility to file claims to Medicaid for any Medicare/Medicaid crossover claims that do not crossover automatically; wait 60-90 days before submitting claims. Duplicate billing of crossover claims is considered Medicaid fraud.

Missouri Medicaid has a contract with several carriers to automatically crossover Medicare/Medicaid claims. If you have a Medicare number with more than one carrier please submit documentation for all carriers, separate Medicaid provider numbers may be necessary in some cases.

Some Medicaid providers are only permitted to be reimbursed for crossover claims on QMB-ONLY recipients; therefore not all of their Medicare claims are paid.

If services are provided to Missouri Medicaid recipients at different office locations that have separate Medicare numbers for each location, separate Medicaid numbers must be issued for all providers and the providers must bill under the appropriate Medicare and Medicaid number for each location. This applies to all providers except: physicians, APNs, and CRNAs; these provider types are issued only one provider number.

If services are provided to Missouri Medicaid recipients at different office locations and all locations are approved by Medicare to use one Medicare number, then all providers must enroll with Medicaid in the same manner and bill with one Medicare and Medicaid number. Since all offices are permitted to use the same Medicare number in this instance, all providers must enroll at the physical location the Medicare number is issued even if they do not practice at that location.

Medicare/Medicaid services that have been issued a Clinic Medicare number must automatically crossover to a Clinic Medicaid provider number. If the clinic is not enrolled the Medicare/Medicaid claims does not crossover automatically. Physician, Advanced Practice Nurse, CRNA, Podiatrist, and Diabetes Self-Management individuals must enroll and bill as Medicaid performing providers. All other provider members must enroll and bill under their individual provider name and number.

When the clinic is issued a Medicare number, each individual provider is also issued a number as a member of the clinic. The clinic Medicare number is three digits followed by zeros and sometimes an alpha character. The member of the clinic is issued a performing provider number. The Medicare number will be the clinic's first three digits followed by at least four digits indicating their individual Medicare number with the clinic. The Medicare clinic and performing provider numbers are matched to the Medicaid clinic and performing provider numbers. The Medicare claims crossover automatically and are reimbursed under the Clinic Medicaid provider number. Therefore, if the clinic is not enrolled, an individual member of the clinic who is providing Medicare/Medicaid services is not enrolled, or, if the Medicare number is not showing on the Medicaid provider enrollment file, the Medicare numbers cannot be matched and crossover claims are not reimbursed.

When the clinic is issued a "Clinic or Group Medicare number" (i.e. 000012345), each individual is also issued a number as a member of the clinic, in this instance the clinic must enroll in order for the Medicare/Medicaid claims to crossover automatically. The Medicare claims crossover and pay under the clinic Medicaid provider number. The performing providers are not verified during this process, therefore, a list of all members must be submitted and all members of the clinic must be enrolled with Medicaid or a clinic Medicaid provider number is not issued. If the clinic enrolls but each member is not enrolled and the clinic receives Medicare/Medicaid payment for non-enrolled members of the clinic, it is considered Medicaid fraud. If any physicians, advanced practice nurses, CRNAs, or podiatrists refuse to enroll as performing providers and Medicaid pays for Medicare claims that automatically crossover, it is considered fraud. Medicaid claims must be billed using the clinic provider name and number in Field 33 of the HCFA-1500 claim form, and the individual physician, advanced practice nurse, CRNA, podiatrist, and diabetes self-management performing provider's number in Field 24K.

Medicare documentation to be submitted to Medicaid so the Medicare number can be added to the provider file: all providers must submit a copy of the letter received from Medicare, the letter must show the clinic name, Medicare provider number, and practice address if possible. The letter must include the names and Medicare numbers of all members within the clinic. If the letter is not available, request a letter from Medicare verifying the clinic Medicare number and the Medicare number of all members within the clinic.