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.

Birthing Center (61)

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

Must have a current license from Department of Health & Senior Services and Medicare certification as a Birthing Center. Must submit a copy of the license and Medicare certification approval letter.

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.