Definitions

Definitions A. Providers: All health care entities including individual practitioners, institutional providers, and providers of medical equipment or goods related to care that are currently enrolled in the Medicaid program. B. National Provider Identifier (NPI): A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers as noted in 45 C.F.R. § 162. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. C. Sole Proprietor: A Sole Proprietor is a form of business in which one (1) person owns all of the assets of the business and is solely liable for all debts on an individual basis. As a result of the National Provider Identifier (NPI) requirements, a Sole Proprietor must apply for their NPI as individuals. Medicaid will no longer issue a group number to an individual effective with the adoption of this rule revision. The subpart concept does not apply to a sole proprietorship, even one (1) with multiple locations, because the sole proprietorship is not an organization as defined in the final NPI Rule. An individual Medicaid provider number and the appropriate NPI issued by the Centers for Medicare & Medicaid Services (CMS) are entered into the Medicaid system with the individual’s social security number (SSN); and if applicable, the Federal Employer Identification Number (FEIN) assigned to it. If this number is used as a Medicaid provider billing number, income or earnings information are reported to the IRS for this SSN or FEIN, as applicable. Deferred compensation is only available via a sole proprietor’s SSN. D. Group/Organization: A Group/Organization provider is not an individual/sole proprietor. This may include hospitals, long-term care facilities, laboratories, home health agencies, ambulance companies, and group practices; suppliers of durable medical equipment or pharmacies. Any subpart of the group/organization must apply for a different Medicaid provider number as determined by the provider type per Medicaid rule. A group provider requesting individual providers/servicing providers to be affiliated to their billing provider number must be approved Medicaid providers. For monies to be reported to the IRS on its Tax Identification, the group provider should be the biller, unless otherwise restricted by the Division of Medicaid. Group providers that have various servicing locations should apply to Medicaid to become a provider according to their enumeration application with CMS. The provider should also apply to Medicaid to become a provider according to the conduct of their own standard transactions and as required by the Division of Medicaid‘s program rules. E. Effective Date: The earliest date a provider may begin billing for services. F. Officer: Any person whose position is listed as being that of an officer in the provider’s “articles of incorporation” or “corporate bylaws” or anyone who is appointed by the board of directors as an officer in accordance with the provider’s corporate bylaws. G. Director: A member of the provider’s “board of directors.” It does not necessarily include a person who may have the word “director” in his/her job title. Moreover, where a provider has a governing body that does not use the term “board of directors,” the members of that governing body will still be considered “director”. Thus, if the provider has a governing body titled “board of trustees,” as opposed to “board of directors,” the individual trustees are considered “directors” for Medicaid enrollment purposes. H. Managing/Directing Employee: A managing/directing employee may be a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of the entity, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the entity. I. Authorized Official: An appointed official to whom the organization has granted the legal authority to enroll it in the Medicaid program, to make changes or updates to the organization’s status in the Medicaid program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicaid program. Examples include: chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner. J. Delegated Official: An individual who is delegated by an authorized official with the authority to report changes and updates to the entity’s enrollment record. A delegated official must be an individual with an “ownership or control interest,” or be a W-2 managing employee of the entity. Documentation in the application or as an attachment must be included with the application. A change of a delegated official will only be made to the file with the appropriate documentation signed by a documented authorized official. K. Majority Interest: Ownership interest greater than fifty percent (50%) of the voting interest in a business enterprise.