ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) Chiropractor

Transcription

1 LOUISIANA Department of HEALTH and HOSPITALS ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) Chiropractor (Enrollment packet is subject to change without notice) (PT30) Revised 10/06

2 Louisiana Medicaid Unisys Corporation Provider Enrollment Unit (225) To Whom It May Concern: Enclosed is the enrollment packet for the Louisiana Medical Assistance Program (also known as the Louisiana Medicaid program) you requested. It contains a participation agreement, enrollment data and forms with instructions. You should carefully review these materials, including all instructions, before completing the necessary forms. The Medicaid Program requires all providers to be state certified for claims to be processed. After completing the enrollment packet materials, please return all forms to: Unisys Provider Enrollment Unit Please be sure to include any and all Medicare provider numbers you want linked to the Medicaid provider number. If you have applied for a Medicare provider number but have not received the number(s), please submit the number(s) to Provider Enrollment at the above address upon receipt. Claims will not automatically cross electronically from Medicare to Medicaid unless these provider numbers are linked in our system. If you have provided services to a Louisiana Medicaid recipient prior to the date you receive State certification, you must send a letter with your enrollment packet stating the earliest date that services were provided to a Louisiana Medicaid recipient. It will be necessary that all eligibility requirements are met at the time of service for Unisys to authorize retroactive eligibility. Any claims submitted prior to receipt of this letter must be resubmitted and returned with your application for enrollment. The Unisys Provider Enrollment Unit will take necessary steps to certify you as a provider and participant in the Louisiana Medical Assistance Program. Upon certification, you will be notified of your Medicaid provider number that must be used for billing. Also, Unisys Provider Relations will forward a provider manual to you. If manual not received in two (2) weeks of notification, please notify Provider Relations at (800) or (225) If you have any questions concerning the completion of this enrollment packet, please contact the Provider Enrollment Unit at the above address or at (225) Thank you for your cooperation. Sincerely, Provider Enrollment Unit Louisiana Medicaid Project

3 Chiropractor CHECKLIST OF FORMS TO BE SUBMITTED The following checklist shows all documents that must be submitted to the Unisys Provider Enrollment Unit in order to enroll in the Louisiana Medicaid Program as a Chiropractor provider: Completed Document Name 1. Completed Louisiana Medicaid PE-50 Enrollment Form* (Read instructions carefully before completing this form) 2. Completed PE-50 Addendum Provider Agreement* 3. Copy of printed document received from IRS showing Employer Identification Number (EIN) and official name as recorded on IRS records. W-9 forms are not accepted 4. If provider name in Section 1 of the PE-50 is: An entity completed LA Medicaid Entity Ownership Disclosure Information form (5 pages located in the Basic Enrollment Packet). An individual completed LA Medicaid Individual Disclosure Information form (2 pages, located in the Basic Enrollment Packet). 5. Copy of the current Chiropractic license from LSBCE. If requesting retroactive coverage, license must be submitted that covers the retroactive period of coverage.(a temporary permit will allow coverage for only the time specified on the temporary permit.) 6. Completed Medicaid Direct Deposit (EFT) Authorization Agreement* 7. Copy of Voided Check for account to which you wish to have your funds electronically deposited. Deposit slips are not accepted 8. Completed OFS Form 24, if applicable* 9. To submit electronic claims, a Completed EDI contract* and Power of Attorney* (if applicable) must accompany this application. Refer to Basic Enrollment Packet for details. For Group Linkages: 1. Completed Group Linkage form* (Review instructions in their entirety before completing form.) * Forms are included in the Basic Enrollment Packet PLEASE USE THIS CHECKLIST TO ENSURE THAT ALL REQUIRED ITEMS ARE SUBMITTED WITH YOUR APPLICATION FOR ENROLLMENT. FORMS MUST BE SUBMITTED AS ORIGINALS WITH ORIGINAL SIGNATURES (NO STAMPED SIGNATURES OR INITIALS) DO NOT SUBMIT COPIES OF THE ATTACHED FORMS. Please submit all required documentation to: Unisys Provider Enrollment Unit

4 Provider Enrollment Form Group Linkage/Unlinkage Form Instructions PURPOSE This form is used by providers to supply identifying data to the Unisys Provider Enrollment Unit to link or unlink individual Medicaid provider numbers to group Medicaid provider numbers on the Medicaid Management Information System (MMIS). This form can be used only if the individual already has a Medicaid provider number. Linkages of individuals requesting new provider numbers require a complete Enrollment Packet. INDIVIDUAL PROVIDER NUMBER The individual provider number is the exclusive Medicaid number assigned to an individual or entity that is to be used to bill Medicaid for services rendered to Medicaid recipients: By an individual or entity; or As an Attending Provider in a group setting. GROUP PROVIDER NUMBER The group provider number is the exclusive Medicaid number assigned to a group that is to be used to bill Medicaid for services rendered to Medicaid recipients. This group number is used to bill all services rendered and an individual provider number is entered onto the claim as the Attending Provider. ADDITIONAL INFORMATION The address for the individual provider number does not have to be the same as the group address in order for the group to receive payments and/or remittance advice for services that are billed under the group s provider number. Those payments will automatically be sent to the Pay To address on the group s provider file. For claims submitted by the group to process correctly, the individual provider number used as the Attending Provider must be linked to the group number. This is accomplished by completing the attached form and returning it to the Unisys Provider Enrollment Unit. This form is also used to notify Unisys Provider Enrollment of an unlinkage meaning that an individual Medicaid provider no longer provides services under the group affiliation. PREPARATION Complete the form in its entirety and mail the original to the Provider Enrollment Unit at the address on the bottom of the form. The completed form may be photocopied for your records. Incomplete forms will be returned to you for completion. The following fields must be completed: Individual Provider Number: enter the seven (7) digit Medicaid provider number for the individual to be linked to the group Individual Provider Name: enter the name for the individual provider number listed as it appears on the MMIS provider file Area Code and Telephone Number: enter the complete telephone number where the individual provider can be reached by the Provider Enrollment Unit should there be any questions Group Provider Name: enter the name of the group to which the individual provider wishes to be linked or unlinked Group Provider Number: enter the seven (7) digit Medicaid provider number of the group indicated in the Group Provider Name Link / Unlink: check the appropriate box to indicate whether you are requesting a linkage or unlinkage Effective Date of Linkage: enter the date you wish to have the linkage of the individual provider number to the group provider number activated Termination Date of Unlinkage: enter the date the individual provider stopped performing services with the group

5 LNK01-INT Revised5/02 Louisiana s Medicaid Program Provider Enrollment Form Group Linkage/Unlinkage Form Please review the instructions on the reverse side before completing the form. Individual Provider Number: Individual Provider Name: Area Code & Telephone Number: ( ) - Group Provider Name: Group Provider Number: LINK UNLINK Effective Date of Linkage: Termination Date of Unlinkage: Group Provider Name: Group Provider Number: LINK UNLINK Effective Date of Linkage: Termination Date of Unlinkage: Print Provider s Name Provider s Signature Date MAIL Completed Forms To: Unisys Provider Enrollment Unit For I nt er nal Use Only

6 OFS Form 24 STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS Dear Provider: It is the policy of the Bureau of Health Services Financing that the Medicaid Program will only pay for the inoffice performance of certain laboratory and diagnostic services which are billed by physicians if the following conditions are met: 1. The physician has completed and has on file with Louisiana State Medicaid Program Provider Enrollment Unit a completed OFS Form The completed OFS Form 24 fully describes the laboratory or diagnostic equipment required to perform these tests. 3. The OFS Form 24 information is updated as needed. Our policy towards laboratory or diagnostic services performed outside of a physician office remains unchanged. Physicians may not be reimbursed for laboratory or diagnostic services ordered for their patients but which are performed outside of their office. Only the performer of a test may seek reimbursement for their services. Any interpretive service by the attending physician is reimbursed through the physician visit payment. The OFS Form 24 requirements only pertain to (1) those participating physicians who own or lease laboratory or diagnostic testing equipment that is located in their office or place of practice and (2) for which use the physician will be submitting a claim to the Medicaid program. Example 1: Example 2: Example 3: Dr. Jones is an individual practitioner who owns or leases a SMA-12, and EKG monitor, and X-Ray equipment. Dr. Jones wishes to perform laboratory and diagnostic services on Medicaid patients in his office and bill the Medicaid Program for these laboratory or diagnostic services. Dr. Jones must complete the OFS Form 24. Drs. Smith, Jones, Doe, and Rae are a group practice. As a group they own or lease laboratory and diagnostic equipment. It is their desire to use this equipment in treating Medicaid recipients, and they will bill the Medicaid Program for these services. If each physician is individually enrolled in the Medicaid Program, each physician in the group must complete the OFS Form 24, even though the descriptive information will be identical. If the physicians are enrolling as a group, only one OFS Form 24 is required as long as all members of the group are indicated. An individual or group practitioner utilizes an external source for laboratory or diagnostic tests. The individual or group practitioner would not complete the OFS Form 24 as they would not bill the Medicaid Program directly. A Louisiana OFS Form 24 is enclosed for completion and submittal where applicable. Return the completed form to: Unisys Provider Enrollment Unit Sincerely, Provider Enrollment Unit

7 OFS Form 24 Name: Provider Number: Diagnostic and/or Laboratory Equipment Address: Pay to Number: Diagnostic and/or Laboratory Equipment Make Model Serial # Capabilities Names of individuals performing diagnostic and/or laboratory tests: Signature* I certify that the above is a true and accurate rendering of diagnostic and/or laboratory equipment in my office. * Acceptable signatures are as follows: physician signature for individuals or authorized physician signature for groups. Original provider signature is required (no stamps or initials). Date COPY PAGE IF ADDITIONAL SPACE IS NEEDED