Authorized Provider Representative

Authorized Provider Representative The Division of Medicaid defines an authorized provider representative as an employee or agent of a provider designated by the provider to act for the provider with the provider’s knowledge and written consent in order to manage and submit claims to the Division of Medicaid for payment. A. An authorized provider representative must not have been convicted of or pleaded guilty to or nolo contendere to a felony or certain misdemeanors including, but not limited to, fraud, forgery, counterfeiting, embezzlement, identity theft, tax evasion, money laundering, or any other crime related to dishonesty or concealment. Reversal on appeal or a pardon granted for the conviction or plea of these crimes does not mitigate this requirement. B. A provider designating an authorized provider representative or agent must use the Appointment of Authorized Provider Representative or Agent Form included in the Mississippi Medicaid Provider Billing Handbook. This form must be kept on file at the provider’s main office and be available to the Division of Medicaid upon request.