enrollment/revalidation process.
*** For information related to the pay-to provider:
*** NPI
*** Tax ID on file with Molina which is provided on your case number letter —Federal Employer Identification Number (FEIN) (this may be the Social Security Number (SSN)
*** Name, title, and email address of the office contact person
*** Phone numbers—primary (required), secondary, emergency, mobile, and fax
*** A copy of the provider’s W-9 form
*** For information related to the owners and/or board members:
*** The name, FEIN or SSN, tenure dates, and address information for all owners and/or board members
*** Information regarding sanctions, exclusions, or convictions of owners and/or board members
*** Information regarding owners’ and/or board members’ participation in other organizations that bill Medicaid for services
*** The relationships among owners and/or board members Information regarding the provider, owners, and employees with respect to certain legal situations
Note: If there are no owners or board members holding at least 5% interest or control in the facility, agency or organization, the provider is required to attest to this statement via the portal or in writing if completing a paper application. The ownership information must still be completed on the managing employee of the facility, agency or organization.
*** For service locations:
*** The physical and mailing addresses of the provider’s service location(s)
*** The current Medicaid IDs assigned to the provider’s service location(s)
*** A list of any languages spoken by the provider and his or her staff, in addition to English
*** General information about each service location, such as accessibility, office hours, whether the service location is accepting new patients, and the age range and gender restriction for patients
*** The provider type/specialty pairs that represent the provider’s practice, as well as all licensing and certification documents for those provider type/specialty pairs
*** Information about participation in WV Medicaid programs, including specifics for the Physician Assured Access System program, if applicable.
