ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) Rural Health Clinic

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1 LOUISIANA Department of HEALTH and HOSPITALS ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) Rural Health Clinic (Enrollment packet is subject to change without notice) (PT79 or 87) Revised 10/06

2 Louisiana Medicaid Unisys Corporation Provider Enrollment Unit PO Box (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 PO Box 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 received 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 for processing once the enrollment has been completed. 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 informed of your Medicaid provider number that must be used for billing. Unisys Provider Relations will forward a provider manual to you. If Manual is not received within two (2) weeks of notification, please contact 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 Rural Health Clinic 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 Rural Health Clinic provider: Completed Document Name 1. Completed Louisiana Medicaid PE-50 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. Completed Medicaid Direct Deposit (EFT) Authorization Agreement* 6. Copy of Voided Check for account to which you wish to have your funds electronically deposited. Deposit slips are not accepted 7. Completed Form PE-50 or group linkage form for each individual linking to the group. (Make additional copies as needed) PE-50 is required if individual is not currently enrolled in Medicaid program along with a current license. * Linkage form is required if individual has active Medicaid provider number. FORMS MAY BE DUPLICATED AS NEEDED. 8. Copy of Medicare certification letter from CMS (formerly HCFA) verifying the provider is a Rural Health Clinic 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 PO Box 80159

4 Medicaid Provider # (if known) Louisiana s Medicaid Program Provider Enrollment Form (Review Instructions Before Completing) New Change (Group Linkages information is submitted on Form LNK-01) Provider Name (DBA name if applicable) Area Code & Telephone # ( ) Social Security # - - A Individual / Entity Information & Physical Location Provider Street Address (or TAD Address for LTC only) Physical Location (if different) LTC Facilities ONLY Provider City Provider State Provider Zip Code Parish Parish Code State Status Location Type License # In (0) Out (1) Urban (1) Rural (2) Medicare Provider # UPIN Specialty Type Board Certification # Date of Birth (required) Provider Pay To Name (MUST match IRS document EXACTLY) Attn or Other B Pay-To Information Provider Pay To Address Provider Pay To City Provider Pay To State IRS Reporting # Provider Year-End Date Provider Pay To Zip Code C Part 1 Ownership Practice Type (All Providers) Individual (01) Partnership (02) Corporation (03) Hospital Based Physician (04) Health Maintenance Organization (05) Group Practice (Private) (06) Teaching Provider (Physician / Dentist) (07) Public Clinic or Group (08) All Providers Except NEMT / Hospitals / LTC Private (1) Public (4) (In-State Only) OPH (6) (In-State Only) School Board (8) (In-State Only) State (9) (In-State Only) C Part 2 NEMT/Hospitals/LTC NEMT/Hospitals/LTC Only Profit (2) Nonprofit (3) Public (4) (In-State Only) Charity (7) (In-State Only) Hospitals & LTC Facilities # Certified Beds Name of Facility Administrator D EFT ELECTRONIC FUNDS TRANSFER (EFT) IS MANDATORY - COPY OF VOIDED CHECK MUST BE ATTACHED DEPOSIT SLIPS ARE NOT ACCEPTABLE -- REVIEW EFT DIRECT DEPOSIT AUTHORIZATION AGREEMENT IN PACKET Contact Person Contact Phone # Account Name ( ) Financial Institution 9-Digit Routing (ABA) Number Account Number to which funds are to be deposited Financial Institution Name Account Type: (Check One) Checking Savings E Effective Date Information MD DO CNP CNS F Provider Acceptance of Medicaid Requirements & Conditions I, the undersigned, certify to the following: 1. I have read the contents of this application, and the information contained herein is true, correct and complete; 2. I agree to abide by the Medicaid laws, regulations and program instructions that apply to me. I understand that the payment of a claim by Medicaid is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions; and 3. I have reviewed the Medicaid Direct Deposit (EFT) Authorization Agreement and the Medicaid Provider Requirements and Conditions located in this packet and agree to their conditions. Print Provider s Name Provider s Signature Date ALL PROVIDERS MUST COMPLETE ENTIRE FORM INCOMPLETE FORMS WILL BE RETURNED FOR CORRECTION

5 Louisiana s Medicaid Program 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 payment 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

6 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 PO Box For I nt er nal Use Only