7/31/2015 J Bews C Taylor 3.0 Published version 8/3/2015 TQD. 9/1/2015 J Bews C Taylor 4.0 Published version 9/1/2015 TQD

Transcription

1 Revision History Version Modification Description Date SME 1.0 Initial Document 4/24/2015 V Gatfield 1.1 Added Table of Contents and Revision History 4/27/2015 H McCain 2.0 Published version after DHW sent via ST00423A 5/4/2015 TQD 2.1 Updated Diabetes Educator requirements 7/31/2015 J Bews C Taylor 3.0 Published version 8/3/2015 TQD 3.1 Updated requirements for Ambulance. 9/1/2015 J Bews C Taylor 4.0 Published version 9/1/2015 TQD 4.1 Updated per CR /29/2016 J Bews K Duke 5.0 Published version 3/1/2016 TQD Removed "address must match physical address" from license requirement for Hospital (General Acute Care, LTC, Military, Psychiatric, Psychiatric Unit, 6/2/2016 J Bews K Duke Rehabilitation, Rehabilitation Unit, Medicare Defined 5.1 Swing Bed) and Suppliers (Home Delivered Meals) 6.0 Published version 6/2/2016 TQD 6.1 Updated dental vendor to MCNA. 2/1/2017 F Clarke 7.0 Published version 2/1/2017 TQD

2 Table of Contents Enrollment Type: Individual Allopathic and Osteopathic Physician Behavioral Health and Social Service Providers Chiropratic Providers Dental Provider Dietary and Nutritional Service Provider Eye and Vision Services Provider Nursing Service Providers Physician Assistants & Advanced Practice Nursing Providers Podiatric Medicine & Surgery Service Providers Respiratory, Developmental, Rehab & Restorative Service Speech, Language and Hearing Service Providers Technologists, Technicians & Other Tech Service Providers Enrollment Type: Group Group of Providers Enrollment Type: FAO (Facility/Agency/Organization) Ambulatory Health Care Facilities Adult Residential Care Agency - Institutional Agency - Professional Hospital Laboratory Long Term Care Facility Non-Emergent Transportation Providers Nursing and Custodial Care Facilities Suppliers Transportation Services Other Service Providers

3 These requirements are for all Pay-To providers: Pay-To EIN or SSN Provider or Organization Name General Provider Agreement W9 Information Ownership & Conviction Information Provider Contact Information Address Information Office Hours Gender and Age Restriction Information Handicap Accessible Information Accepting New Patients Provider Agreement Enrollment Type: INDIVIDUAL Provider Type Provider Specialty (Bold = specialty, bullets = sub-specialty) Requirements Allergy & Immunology Allergy; Clinical & Laboratory Immunology Anesthesiology Addiction Medicine; Critical Care Medicine; Hospice & Palliative Medicine; Pain Medicine; Pediatric Anesthesiology Colon & Rectal Surgery Dermatology Clinical & Laboratory Dermatological Immunology; Dermatopathology; MOHS - Micrographic Surgery; Pediatric Dermatology; Procedural Dermatology Emergency Medicine Emergency Medical Services; Hospice & Palliative Medicine; Medical Toxicology; Pediatric Emergency Medicine; Sports Medicine; Undersea & Hyperbaric Machine Family Medicine Addiction Medicine; Adolescent Medicine; Adult Medicine; Bariatric Medicine; Geriatric Medicine; Hospice & Palliative Medicine; Sports Medicine General Practice Internal Medicine Addiction Medicine; Adolescent Medicine; Allergy & Immunology; Bariatric Medicine; Cardiovascular Disease; Clinical & Laboratory Immunology; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes & Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hematology & Oncology; Hepatology; Hospice & Palliative Medicine; Infectious Disease; Interventional Cardiology; Magnetic Resonance Imaging (MRI); Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine; Transplant Hepatology Neurological Surgery Neuromusculoskeletal Neuromusculoskeletal Medicine & OMM; Sports Medicine Nuclear Medicine In Vivo & In Vitro; Nuclear Cardiology; Nuclear Imaging Therapy Obstetrics & Gynecology Bariatric Medicine, Critical Care Medicine, Gynecologic Oncology, Gynecology, Hospice & Palliative Medicine, Maternal & Fetal Obstetrics; Obstetrics; Reproductive Endocrinology Ophthalmology Oral & Maxillofacial Surgery Allopathic and Osteopathic Physician Orthopaedic Surgery Adult Reconstructive Orthopaedic Surgery; Foot & Ankle; Hand; Orthopaedic Trauma; Pediatric; Spine; Sports Otolaryngology Facial Plastic Surgery; Plastic Surgery within the Head & Neck Otolaryngology (ENT) Otolaryngic Allergy; Otolaryngology/Facial Plastic Surgery; Otology & Neurotology; Pediatric; Sleep Medicine Pathology Anatomic & Clinical; Anatomic Pathology; Chemical; Clinical & Laboratory; Clinical Pathology; Cytopathologist; Dermatopathology; Forensic Pathology; Hematology; Immunopathology; Medical Microbiology; Molecular Genetic; Neuropathology; Pediatric Pediatrics Adolescent Medicine; Allergy & Immunology; Clinical & Laboratory Immunology; Critical Care Medicine; Developmental- Behavioral Pediatrics; Gastroenterology; Hospice & Palliative Medicine; Infectious Diseases; Medical Toxicology; Neonatal/Perinatal Medicine; Neurodevelopmental Disabilities; Pediatric Cardiology; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Hematology-Oncology; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology; Sleep Medicine; Sports Medicine; Transplant Hepatology Physical Medicine & Rehabilitation Hospice & Palliative Medicine; Neuromuscular Medicine; Pain Medicine; Pediatric Rehabilitation Medicine; Spinal Cord Injury Medicine; Sports

4 Behavioral Health and Social Service Providers Social Worker Chiropractic Providers Dental Provider Dental providers can only enroll with Idaho Medicaid for Interpretive services (T1013 and T1013CG). All other dental claim payments are made through MCNA. Dietary and Nutritional Service Provider Plastic Surgery Hand; Head & Neck Preventive Medicine Occupational Medicine; Public Health & General Preventative Medicine Preventive Medicine/Occupational Environmental Medicine Psychiatry & Neurology Addiction Psychiatry; Bariatric Medicine; Child & Adolescent Psychiatry; Clinical Neurophysiology; Diagnostic Neuroimaging; Forensic Psychiatry; Geriatric Psychiatry; Neurology; Neurology with Special Qualifications in Child Neurology; Neuromuscular Medicine; Psychiatry; Vascular Neurology Radiology Body Imaging; Diagnostic Neuroimaging; Diagnostic Radiology; Diagnostic Ultrasound; Hospice & Palliative Medicine; Neuroradiology; Nuclear; Pediatric Radiology; Radiation Oncology; Radiological Physics; Therapeutic Radiology; Vascular & Interventional Radiology Surgery Critical Care; Hand; Hospice & Palliative Medicine; Pediatric; Surgical Oncology; Trauma; Plastic & Reconstructive Surgery; Surgery-Vascular Surgery Thoracic Surgery Cardiothoracic Vascular Surgery Transplant Surgery Urology Pediatric Urology DD Child Independent Crisis Intervention - Professional DD Child Independent Therapeutic Consultation Social Worker - Clinical Chiropractor Internist; Neurology; Nutrition; Occupational Medicine; Orthopedic; Pediatric; Radiology; Rehabilitation; Sports Medicine; Thermography Dentist Endodontics; General Practice; Oral & Maxillofacial (Pathology, Radiology, Surgeons); Orthodontics & Dentofacial Orthopedics; Pediatric; Periodontics; Prosthodontics Denturist Dietician Registered Nutrition, Metabolic; Nutrition, Renal; Nutrition, Pediatric Criminal History Check required Certificate required Eye and Vision Services Provider Nursing Service Providers PHA-Weight Management-Dietician Optician Optometrist Corneal & Contact Management; Low Vision Rehabilitation; Occupational Vision; Pediatrics; Sports Vision; Vision Therapy Diabetes Educator Registered Nurse Independent (PDN) Additional question when completing enrollment: Are you certified to treat eye diseases? If the answer is Yes, a certification must be submitted. Certification - Must be certified as a diabetes educator by the American Association of Diabetes Educators (AADE) or NCDBE (National Certification Board for Diabetes Educators). Certification must match the providers name.

5 Certified Nurse Midwife Certified Registered Nurse Anesthetist Certificate required and must match provider's name. Physician Assistants & Advanced Practice Nursing Providers Podiatric Medicine & Surgery Service Providers Respiratory, Developmental, Rehab & Restorative Service Clinical Nurse Specialist Adult Health; Chronic Care; Emergency; Family Health; Home Health; Long Term Care; Medical - Surgical; Neonatal; Neuroscience; Occupational Health; Oncology; Oncology, Pediatrics; Pediatrics; Perinatal; Perioperative; Rehabilitation; Transplantation; Women's Health Clinical Nurse Specialist - Psych/Mental Health Adult; Child & Adolescent; Child & Family; Chronically Ill; Community; Geropsychiatric Nurse Practitioner Acute Care; Adult Health; Community Health; Critical Care Medicine; Family; Gerontology; Neonatal; Neonatal, Critical Care; Obstetrics & Gynecology; Occupational Health; Pediatrics; Pediatrics, Critical Care; Perinatal; Primary Care; Women s Health Nurse Practitioner - Psych/Mental Health Physician Assistant Medical; Surgical Podiatrist Foot & Ankle Surgery; Foot surgery; General Practice; Primary Podiatric Medicine; Public Medicine; Radiology; Sports Medicine) Occupational Therapist Physical Therapist Cardiopulmonary; Electrophysiology, Clinical; Ergonomics; Geriatrics; Hand; Human Factors; Neurology; Orthopedic; Sports Occupational Therapist - Pediatrics Physical Therapist - Pediatrics Certificate required and must match provider's name. Certificate required and must match provider's name. Medicare certificate required and must match the provider's name. Speech, Language and Hearing Service Providers Audiologist Assistive Technology Practitioner; Assistive Technology Supplier; Hearing Aid Fitter Hearing Aid Vendor Speech-Language Pathologist

6 Radiologic Technologist Quality Management; Bone Densitometry; Cardiac-Interventional Technology; Cardiovascular Interventional Technology; Computed Tomography; Radiation Therapy; Sonography; Vascular-Interventional Technology; Vascular Sonography; Magnetic Resonance Imaging; Nuclear Medicine Technology; Radiography Technologists, Technicians & Other Tech Service Providers Spec/Tech Cardiovascular; Cardiovascular-Invasive Specialist; Cardiovascular-Sonography; Cardiovascular-Vascular Specialist; EEG Technician, Other - EEG Radiologic Technologist - Mammography Certificate required Enrollment Type: GROUP Provider Type Provider Specialty (Bold = specialty, bullets = sub-specialty) Requirements Single Specialty License required of staff Group of Providers Certificate required of Staff Multi-Specialty Group Roster with signatures required Enrollment Type: FAO (Facility/Agency/Organization) Provider Type Provider Specialty (Bold = specialty, bullets = sub-specialty) Requirements Adult Day Care Signature of Adult Day Care Additional Terms Clinic/Center - Ambulatory Surgical Medicare certificate required and must match the provider's name. Clinic/Center - Federally Qualified Health Center (FQHC) Certificate required Group Roster with signatures required Clinic/Center - Hearing & Speech Certificate required of Staff Ambulatory Health Care Facilities Clinic/Center - Indian Health Services Group Roster with signatures required Clinic/Center - Physical Therapy Facility License required of staff Medicare certificate required and must match the provider's name.

7 Medicare certificate required and must match the provider's name. Clinic/Center - Radiology, Mobile Professional Liability Insurance required Clinic/Center - Rural Health Clinics Medicare certificate required and must match the provider's name. Group Roster with signatures required Diagnostic Service License required of staff PWC Clinic Certified Family Home (CFH) Certificate required Additional Terms - If Adult Day Care will be provided, the applicant must complete and sign the Adult Day Care Additional Terms Adult Residential Care Residential Assisted Living Facility (RALF) Certificate required Additional Terms - If Adult Day Care will be provided, the applicant must complete and sign the Adult Day Care Additional Terms Home Health Certificate required of Staff Agency - Institutional Hospice Hospital based Home Health? Nursing home based Home Health? Non-hospital or Non-nursing home based Home Health? Hospice associated with a Nursing Home? Hospice associated with a Home Health Agency? Freestanding Hospice? Health District based Hospice? Hospital based Hospice?

8 License required. Idaho Nurse Licenses must be submitted for care staff only. Behavior Consultation/Crisis Management Additional Terms - Behavior Consultation Agreement must be signed & dated by Access Unit and Provider Children s Service Coordination License required. Idaho Nurse Licenses must be submitted for care staff only. Criminal History Check required DD Case Management Chore Services Agency - Professional Supports Brokerage-FEA Developmental Disability Agency Development Disability Agency Support Only Child Services Early Intervention ITP Nursing Agency (PDN) Certificate required and address must match physical address. Criminal History Check required Additional Terms - If Adult Day Care will be provided, the applicant must complete and sign the Adult Day Care Additional Terms Additional question when completing enrollment: Will Adult Day Care be provided at this location? Criminal History Check required License required. Idaho Nurse Licenses must be submitted for care staff only. PCS/Aged & Disabled Services Agency Public Health or Welfare (District Health Departments) School Based Services Additional Terms - Aged & Disabled / PCS Additional Terms must be signed and dated by the Provider

9 License required of staff Certificate required and address must match physical address. Residential Habilitation Agency Additional Terms - If Adult Day Care will be provided, the applicant must complete and sign the Adult Day Care Additional Terms Hospital Respite Care Supported Employment Services General Acute Care Hospital Children; Critical Access; Rural; Women Long Term Care Hospital Military Hospital Military General Acute Care Hospital Psychiatric Hospital Psychiatric Unit Rehabilitation Hospital Children Rehabilitation Unit Dialysis Unit Additional question when completing enrollment: Will Adult Day Care be provided at this location? Criminal History Check required Additional Terms - Supported Employment Agreement must be signed and dated by both the Provider and DHW License required Out-of-State hospital must submit a copy of a Medicare RA indicating paid claim(s) to confirm Medicare certification. Fiscal Year End? Transplant Facility Option? Total number of licensed hospital beds? Are you Medicare Certified as a Transplant Facility? If Yes - Heart, Kidney, Liver, Lung or all If applicable, describe hospital: Not for Profit, For Profit, Freestanding State Owned or Freestanding District or County Owned Fiscal Year End? Transplant Facility Option? Total number of licensed hospital beds? Are you Medicare Certified as a Transplant Facility? If Yes - Heart, Kidney, Liver, Lung or all If applicable, describe hospital: Not for Profit, For Profit, Freestanding State Owned or Freestanding District or County Owned

10 License required Medicare Defined Swing Bed Unit Fiscal Year End? Transplant Facility Option? Total number of licensed hospital beds? Are you Medicare Certified as a Transplant Facility? If Yes - Heart, Kidney, Liver, Lung or all If applicable, describe hospital: Not for Profit, For Profit, Freestanding State Owned or Freestanding District or County Owned Laboratory Laboratory-Clinical Medical Laboratory CLIA Required. CLIA address must match physical address. License required. In State Labs - Register with Idaho and are assigned a State of Idaho Registration Number Out-of-State Labs - resident state's license. Non-Emergent Transportation Providers Skilled Nursing Facility Agency Transportation Commercial Transportation Individual Transportation Provider Independent laboratory? Physician base laboratory? State laboratory? Hospital based nursing home? Non-hospital based nursing home? Valid drivers licenses for staff Auto Insurance required Auto Insurance required. Minimum of $500,000 personal injury per person / $500,000 property damage per occurrence. Criminal History Check required Valid drivers license Auto Insurance required

11 Intermediate Care Facility, Intellectually Disabled - ICFs/ID Private Nursing and Custodial Care Facilities PCS Family Alternate Care Home PCS Family Alternate Care Home - DD Children Assistive Technology Supplier Contractor Home Modifications Durable Medical Equipment & Medical Supplies Dialysis Equipment & Supplies; Oxygen Equipment & Supplies; Parenteral & Enteral Nutrition Non-Pharmacy Dispensing Site (aka: DME & Suppliers - Supplies only) Emergency Response System Companies Home Delivered Meals Additional question when completing enrollment: Will Adult Day Care be provided at this location? Additional Terms - Aged & Disabled / PCS Additional Terms must be signed and dated by both the Provider and DHW Certificate required. Copy of "Visions Training" Certificate or it's equivalent with no expiration date. - Certificate name must match provider's name - Address must match physical address. May be any sort of liability insurance (General, Professional, or Personal) Additional Terms - Aged & Disabled / PCS Additional Terms must be signed and dated by both the Provider and DHW License required

12 Optometric Supplies Suppliers PHA - Weight Management Pharmacy Clinic; Community/Retail; Institutional; Specialty; Unit Dose Pharmacy DME Pharmacy Mail Order Pharmacy - Home Infusion Therapy Portable X-Ray Supplier Prosthetic/Orthotic Supplier DEA Required Out-of-State Mail Order Pharmacies who ship mail order to Idaho must submit a copy of resident state's license with expiration date and must be licensed with the Idaho Board of Pharmacy. Out-of-State Provider: Resident state's license. Out-of-State Mail Order Pharmacies who ship mail order to Idaho must submit a copy of resident state's license with expiration date and must be licensed with the Idaho Board of Pharmacy. DEA Required Professional Liability Insurance required Certificate required and address must match physical address.

13 License required. Transportation Services Other Service Providers Ambulance Air Transport; Land Transport; Water Transport PHA-Weight Management-Personal Trainer Crossover Only Provider If a provider has already enrolled under another type and specialty they cannot enroll with this specialty. If a provider can enroll as a different type and specialty they cannot enroll as a Crossover Only provider. Licensed Midwife Additional question when completing enrollment: Hospital based transportation by both ground and air? Non-hospital based transportation by both ground and air? Hospital based ambulance transportation by fixed wing and rotary? Non-hospital based ambulance transportation by fixed wing and rotary? Hospital based ambulance transportation by ground only? Non-hospital based ambulance transportation by ground only? Hospital based ambulance transportation by rotary only? Non-hospital based ambulance transportation by rotary only? Hospital based ambulance transportation by fixed wing only? Non-hospital based ambulance transportation by fixed wing only? Medicare certificate required and must match the provider's name. The State of Idaho does not enroll Service Providers. Below is a listing of these provider types and specialties. Adult Companion Home Health Aide Psychologist - Family Clinical Neuropsychologist Marriage & Family Therapist Psychologist - Group Psychotherapy Clinical Neuropsychologist - Clinical Nurse's Aide Psychologist - Health Psychologist Counselor Psychologist Psychologist - Health Service Counselor - Professional Psychologist - Addiction (Substance Use Disorder) Psychologist - Mental Retardation & Developmental Disabilities Counselor-Addiction (Substance Use Disorder) Psychologist - Adult Development & Aging Psychologist - Prescribing (Medical) Counselor-Mental Health Psychologist - Clinical Psychologist - Psychoanalysis Counselor-Pastoral Psychologist - Clinical Child & Adolescent Psychologist - Rehabilitation Day Training/Habilitation Specialist Psychologist - Cognitive & Behavioral Technician - Attendant Care Provider Driver Psychologist - Counseling Technician - Personal Care Attendant