Requirements for All Providers

Requirements for All Providers A. All providers are required to submit the following information or documentation: 1. Mississippi Medicaid Provider Enrollment Application a) Individuals and Sole Proprietor applications must be signed by the individual provider. b) Business/Entity applications must be signed by the Authorized Official. 2. Medical Assistance Participation Agreement (Provider Agreement) 3. Direct Deposit Authorization/Agreement Form a) Include a copy of a voided check, deposit slip, or letter from the bank noting the account number and transit routing number. b) Starter checks and counter deposit slips are not acceptable. 4. Legal Name and Federal Tax Identification Number a) For organizational providers, the legal business name and Federal Employer Identification Number (FEIN) must match the information on record with the Internal Revenue Service (IRS) and must correspond to the legal name and FEIN provided in the Mississippi Medicaid Provider Enrollment Application. b) For individual providers enrolling as a sole proprietor using a FEIN, the name and FEIN must match IRS records and must align with the information provided in the Mississippi Medicaid Provider Enrollment Application. c) For individual providers, the name and Social Security Number must match IRS records and be consistent with the information submitted in the Mississippi Medicaid Provider Enrollment Application. d) A copy of written confirmation from the IRS must be made available, upon request, within sixty (60) days. 5. Electronic Data Interchange (EDI) Provider Agreement and Enrollment Form is required if the intent is to submit electronically. 6. Civil Rights Compliance Attestation. The following documents are not required at the time of attestation but must be provided upon request within sixty (60) days, including but not limited to: a) A copy of the provider’s Nondiscrimination Policy. b) A copy of the provider’s Limited English Proficiency Policy. c) A copy of the provider’s Sensory and Speech Impairment Policy. d) A copy of the provider’s Notice of Program Accessibility Policy. e) A copy of the Department of Health and Human Services (DHHS) Office of Civil Rights letter of compliance may be submitted in lieu of the listed policies. f) A copy of the provider’s published non-discrimination policy, required only for healthcare facilities. 7. Providers who have changes of information which are not considered a change of ownership (CHOW) must submit the following information, if applicable: a) Tax Identification Number and Legal Name, b) Change of Address form for provider mailing and/or business addresses, e-mail contact information or telephone number changes, c) Electronic Funds Transfer (EFT) form for provider banking information changes, and/or d) Provider Disclosure Form for any other applicable changes. 8. Certain disclosures are required for participation as a provider in the Mississippi Division of Medicaid. a) The Division of Medicaid requires use of the Mississippi Medicaid Provider Disclosure Form, signed by the Authorized Official, in the following instances: 1) Upon the provider’s submission of the provider enrollment application, 2) Upon request of the Division of Medicaid during the re-validation of enrollment process, and 3) Within thirty-five (35) days after any change in ownership of the provider. b) Required disclosures include: 1) The name and address of any individual or corporation with an ownership or control interest in the provider. The address for corporate entities must include an applicable primary business address, every business location, every P.O. Box address, and/or other mailing address. 2) Date of birth and Social Security Number (in the case of an individual). 3) Other tax identification number (in the case of an organization) with an ownership or control interest in the provider or in any subcontractor in which the disclosing entity has a five percent (5%) or more interest. 4) Whether the person (individual or corporation) with an ownership or control interest in the provider is related to another person with ownership or control interest in the provider as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity has a five percent (5%) or more ownership interest is related to another person with ownership or control interest in the provider as a spouse, parent, or sibling. 5) The name of any other provider in which the ownership of the provider has an ownership or control interest. 6) The name address, date of birth, and Social Security Number of any managing employee, authorized official, and delegated official of the provider. 7) Any additional disclosures as required and enumerated by state and/or federal law. 9. Certain disclosures are required upon request by the Division of Medicaid during initial enrollment and/or during the re-validation of enrollment process as follows: a) Any and all affiliations that the provider or any of its owning or managing employees or organizations, consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101, has with a currently or formerly enrolled Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) provider or supplier that has a disclosable event, as defined in § 455.101. b) Any and all affiliations that the provider or any of its owning or managing employees or organizations, consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101, had within the previous five (5) years with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event, as defined in § 455.101. 10. Provide a National Provider Identifier (NPI), received from the National Plan and Provider Enumeration System (NPPES), unless receipt of an NPI is prohibited by NPPES. 11. The following providers are required to attest that a collaborative agreement with a Mississippi Medicaid enrolled physician is on file with the appropriate licensing board: a) Certified Registered Nurse Anesthetist (CRNA), b) Nurse Practitioner (NP), c) Certified Nurse Midwife (CNM), or d) Physician Assistant (PA) 12. The abovementioned provider attestation must be available for review within sixty (60) days, upon request, unless collaboration or supervision is not required in the state in which the provider is practicing. 13. Any changes in the provider’s collaborating physician should be reported to the Division of Medicaid once approved by the appropriate licensing board. B. Failure to comply with the terms of this rule may result in rejection of the Provider Enrollment Application, revocation of provider enrollment, or a suspension in the payment of claims.