for all providers in addition to the specific provider type requirements outlined below:

for all providers in addition to the specific provider type requirements outlined below: 1. National Provider Identifier (NPI), verification from the National Plan and Provider Enumeration System (NPPES), 2. A copy of the interim rate notice or current rate letter from CMS, 3. Copy of the nurse practitioner’s protocol and license to practice. If the nurse practitioner is not enrolled with the Division of Medicaid as a provider, the nurse practitioner must complete a provider application and obtain an individual provider number, and 4. Clinical Laboratory Improvement Amendments (CLIA) Information form and current CLIA certificate, if applicable. C. The Division of Medicaid does not allow co-mingling. D. Physicians and non-physician practitioners cannot operate a private Medicare or Medicaid practice during FQHC hours of operation using the FQHC’s resources. E. The effective date of the Medicaid provider agreement will be the applicable date described in Miss Admin Code Title 23, Part 200, Rule 4.4. F. The Division of Medicaid does not enroll out-of-state providers to provide FQHC services, except as described in Miss. Admin. Code Part 200, Rule 4.2 B. G. FQHC mobile units must be surveyed by the Mississippi Department of Health (MSDH) and receive an approval letter from the Centers for Medicare and Medicaid Services (CMS) prior to providing services. 1. All federal and state requirements for FQHC mobile units must be met. 2. The mobile unit must have a fixed set of locations where the unit is scheduled to be providing services at specified dates and times. a) Locations for FQHC mobile unit services must meet the rural and shortage area requirements at the time of survey. b) The schedule of times and locations must be posted on the mobile unit and publicized by other means so that beneficiaries will know the mobile unit's schedule in advance. 3. NPs must remain within a seventy-five (75) mile distance from the primary physician.