Medicaid provider Enrollment overview

PROVIDER ENROLLMENT


An eligible provider who complies with all licensing laws and regulations applicable to the provider’s practice or business in Michigan, who is not currently excluded from participating in Medicaid by state or federal sanction, and whose services are directly reimbursable per MDHHS policy may enroll as a Medicaid provider. Out-of-state providers must be licensed and/or certified by the appropriate standardsetting authority in the state they are practicing. (Refer to the Beyond-Borderland Area subsection of this chapter for more information.) In addition, some providers must also be certified as meeting Medicare or
other standards as specified by MDHHS.


Providers (except managed care organizations) must have their enrollment approved through the on-line MDHHS CHAMPS Provider Enrollment (PE) subsystem to be reimbursed for covered services rendered to eligible Medicaid beneficiaries. Refer to the Directory Appendix for contact information related to the online application process, including a CHAMPS Preparation Checklist of required information. Providers must have their social security number (SSN), employer identification, or tax identification number (EIN/TIN) registered with the Michigan Department of Technology, Management & Budget Vendor Registration prior to enrolling with MDHHS.


MDHHS is prohibited by federal law from issuing Medicaid payment to any financial institution or entity whose address is outside of the United States.


Providers electing to appoint another person to enter their MDHHS enrollment information in the CHAMPS PE subsystem on their behalf should complete and retain a copy of the MDHHS Electronic Signature Agreement (DCH-1401). (Refer to the Forms Appendix for a copy of the DCH-1401.) Managed Care Organizations must complete their enrollment process through their MDHHS Contract
Manager.


Providers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) must be enrolled as a Medicare provider. Each DMEPOS provider must enter their Medicare Provider Transaction Access Number (PTAN) in the CHAMPS Provider Enrollment subsystem.


A provider’s participation in Medicaid will be effective on the date the provider’s on-line application is submitted, or a provider may request that enrollment be retroactive to a specific date when completing the on-line application. Retroactive enrollment is not considered prior to the effective date of licensure/certification. Enrollment may be retroactive one year from the date the request is received if the provider’s licensure/certification is effective for that entire period. Retroactive enrollment eligibility is not a waiver for claims/services that do not meet established Medicaid billing criteria. All providers are required to revalidate their Medicaid enrollment information a minimum of once every five years, or more often if requested by MDHHS. MDHHS will notify providers when revalidation is required. Providers must notify MDHHS within 35 days of any change to their enrollment information. For information regarding substitute physician or a locum tenens arrangement, refer to the Practitioner Chapter of this manual.



A Medicaid Health Plan (MHP) is responsible for reimbursing a contracted provider or subcontractor for its services according to the conditions stated in the subcontract. The MHP must also reimburse noncontracted providers for properly authorized, medically necessary covered services.

To receive Medicaid reimbursement, a provider must be enrolled in Medicaid and meet all provider requirements at the time the service is rendered. Every entity that provides Medicaid services to recipients or billing services of any kind to Medicaid providers must enroll as a Medicaid provider.

Enrollment Qualifications

Providers must meet all the provider requirements and qualifications and their practices must be fully operational before they can be enrolled as Medicaid providers.

Tax ID Number

The provider applicant must enter his tax identification (ID) number on the Enrollment Application and attach a signed W-9 form, proof of federal tax identification number, or a copy of his Social Security Number.

An individual provider’s tax ID number is either his Social Security Number or federal tax ID if he is incorporated. An individual cannot enroll using the group’s tax ID number as his individual tax number.A group provider or facility’s tax identification number is the federal tax ID number that the Internal Revenue

Service (IRS) assigned to the group, entityor corporation.

IRS requires Medicaid to generate IRS 1099 forms for all providers to whomreimbursement is issued. (Tax-exempt providers do not receive 1099 forms,e.g. Medical Foster Care.) The provider’s tax ID number must be correct onthe Medicaid computer system for the IRS 1099 form to be correctlygenerated.

Medicare Certification

The following providers must be Medicare certified to enroll as Medicaid providers and to remain enrolled:

• Ambulatory Surgical Centers

• Freestanding Dialysis Centers

• Hospices

• Hospitals

• Rural Health Clinics

• Portable X-ray Providers

• Skilled Nursing Facilities

CLIA Certification 

Providers with laboratories must be certified under the Clinical Laboratory Improvement Act (CLIA) for the tests that they perform to enroll as Medicaid providers and to remain enrolled.

Required Enrollment Forms and Documentation

To enroll in Medicaid, non-institutional provider applicants must submit the following forms and documentation.

• Medicaid Provider Enrollment Application;

• Non-Institutional Medicaid Provider Agreement;

• Fingerprint Card or FDLE Criminal History Check and Fingerprinting Exemption Request;

• Surety Bond Form or Certification of Ownership Form for Physician Groups, if applicable;

• Authorization Agreement for Electronic Funds Transfer or Exemption Request;

• Copies of required licenses, certifications, and other required documentation; and

• Any other information that is requested in the enrollment package.

The provider must keep a copy of the application form and attachments for his own records. Legible photocopies of the application forms or printed forms from the Internet with original signatures are acceptable.

How to Obtain Enrollment Forms

Enrollment forms can be obtained from the Medicaid fiscal agent by writing or calling:

ACS – Florida Medicaid

Provider Enrollment

P. O. Box 7070

Tallahassee, Florida 32314-7070

PH – 800-377-8216

Where to Submit the Enrollment Package

The Provider Enrollment application contains the addresses for specific provider types to submit the completed enrollment package and required documentation.

Effective Date of Enrollment

The effective date of enrollment is the date the provider application is approved.

PROVIDER OWNERSHIP AND CONTROL DISCLOSURES


Provider enrollment information, including home address, date of birth, and Social Security Number, is required from providers and other disclosed individuals (e.g., owners, managing employees, agents, etc.).




A. REQUIRED DISCLOSURE INFORMATION


Providers (including fiscal agents and managed care entities) are required to disclose the following information on ownership and control during enrollment, revalidation, and within 35 days after any change in ownership:


** The name and address of any person (individual or corporation) with ownership or control interest. The address for corporate entities must include, as applicable, primary business address, every business location, and P.O. Box address.


** Date of birth and Social Security Number (in the case of an individual).


** Other Tax Identification Number, in the case of a corporation, with an ownership or control interest or of any subcontractor in which the disclosing entity has a five percent or more interest.


** Whether the person (individual or corporation) with an ownership or control interest is related to another person with ownership or control interest as a spouse, parent, child or sibling; or whether the person (individual or corporation) with an ownership or control interest of any subcontractor in which the disclosing entity has a five percent or more interest is related to another person with ownership or control interest as a spouse, parent, child or sibling.


** The name of any other fiscal agent or managed care entity in which an owner has an ownership or control interest in an entity that is reimbursable by Medicaid and/or Medicare.


** The name, address, date of birth and Social Security Number of any managing employees.




B. CRIMINAL OFFENSE NOTIFICATION


Providers must notify the state licensing agency and MDHHS Provider Enrollment of any person(s) with an ownership or controlling interest in a facility that has been convicted of a criminal offense related to their involvement in any programs under Medicare, Medicaid, or Social Services Block Grants since the inception of these programs.


ENROLLMENT APPLICATION FEES


Enrollment application fees are required from all institutional providers, as defined by the Centers for Medicare & Medicaid Services (CMS). Individual physicians and non-physician practitioners are not considered institutional providers and, as such, are not subject to an application fee. Providers who are enrolled in or have paid the application fee to Medicare or another state’s Medicaid or Children’s Health Insurance Program (CHIP) are not required to pay an application fee to the Michigan Medicaid Program. 


The fee is required for each enrolled provider type at the time of initial enrollment and re-enrollment.




The fee is not required for revalidation or interim updates to provider enrollment information. The application fee amount is established by CMS and updated annually.

Medical billing concept Enrollment process