NEW MEXICO MEDICAID HOME AND COMMUNITY BASED SERVICES WAIVER PROGRAMS PROVIDER ENROLLMENT DEVELOPMENTALLY DISABLED (DD)-- MEDICALLY FRAGILE (MF)-- ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) 3:56:32 PM - 1 -
All providers must submit required documentation for Affiliated Computer Systems (ACS) to: ACS New Mexico Medicaid Project Attn: Provider Enrollment Unit 1720 A Randolph Road SE Albuquerque, NM 87106 Phone 1-800-299-7304 or 505-246-0710 The required documentation for the programs must be submitted to one of the following. Developmentally Disabled (DD) & Medically Fragile (MF) Waiver Providers New Mexico Department of Health Developmental Disabilities Supports Division Provider Enrollment Unit Attn: Gayla Delgado 2500 Cerrillos Rd. Santa Fe, NM 87505 Phone 1-877-696-1472 or 505-476-2404 - Fax 505-476-7750 Waiver Providers New Mexico Department of Health Acquired Immunodeficiency Syndrome Home and Community-Based Services Waiver Provider Enrollment Unit Attn: Genevieve Rel Public Health Division (IDB) 1190 St. Francis Dr., Suite S 1208 P.O. Box 26110 Santa Fe, New México 87502 Phone 505-576-3618 - Fax 505-476-3637 3:56:32 PM - 2 -
Table of Contents Case Management Agency Providers Page 4 Homemaker/Personal Care Services Page 6 Nursing Providers Page 10 3:56:32 PM - 3 -
Case Management Service Agencies Required Documentation for ACS: Current Professional License/Certification: Bachelor s degree in Social Work, Human Services, Counseling, Psychology, Sociology, Rehabilitation Counseling or related field. MAD 335 Provider Participation Application Service Summary Form W-9 Form Articles of Incorporation or Organization and board members (if applicable) IRS 501 c3 letter if non-profit Proof of Professional Liability Insurance (1 million minimum) Proof of Surety Bond or Fidelity Bond (group) Current NM Business License Letter of Federal Certification or EIN Proof of registration with the NM Department of Taxation and Revenue (CRS#) For Renewing Providers You must also provide your Medicaid number 3:56:32 PM - 4 -
Case Management Service Agencies Required Documentation for AIDS Waiver Program: MAD 335 Provider Participation Application Provider Information Sheet (Demographic and Contact Information) Contract/Provider Agreement Statement of Assurances Service Summary Form Annual Independent financial Audit List of all licensed professionals to include license number, licensing board and effective dates of license. 3:56:32 PM - 5 -
Required Documentation for ACS: Homemaker/Personal Care Services Current Professional License/Certification: Home Health Agency License issued by Department of Health Required Documentation: MAD 335 Provider Participation Application Service Summary Form W-9 Articles of Incorporation or Organization and board members (if applicable) IRS 501 c3 letter if non-profit Proof of Professional Liability Insurance (1 million minimum) Proof of Surety Bond (individual) or of Fidelity Bond (group) Current NM Business License Letter of Federal Certification or EIN Proof of registration with the NM Department of Taxation and Revenue (CRS#) Certificate of Insurance Fire Insurance NPI Number For Renewing Providers You must also provide your Medicaid number 3:56:32 PM - 6 -
Homemaker/Personal Care Services Required Documentation for AIDS Waiver Program: Copy of the MAD 335 Provider Participation Application Provider Information Sheet (Demographic and Contact Information) Contract/Provider Agreement Annual Independent Financial Audit Service Summary Form Statement of Assurances 3:56:32 PM - 7 -
Nursing Providers Required Documentation for ACS: Current Professional License/Certification: Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensed, by the State of NM Required Documentation: MAD 335 Provider Application W-9 Proof of Surety Bond (individual) or of Fidelity Bond (group) Annual Independent Audit (see agreement) Proof of Professional Liability Insurance (1 million minimum) Proof of Surety Bond (individual) or of Fidelity Bond (group) Proof of registration with the NM Department of Taxation and Revenue (CRS#) Certificate of Insurance Fire Insurance Articles of Incorporation or Organization and board members (if applicable) Current NM Business License Letter of Federal Certification or EIN NPI Number (If medical services are provided) For Renewing Providers You must also provide your Medicaid number 3:56:32 PM - 8 -
Nursing Providers Required Documentation for AIDS Waiver Program: MAD 335 Provider Participation Application Provider Information Sheet (Demographic and Contact Information) Contract/Provider Agreement Statement of Assurances Service Summary Form Annual Independent financial Audit List of all licensed professionals to include license number, licensing board and effective dates of license. 3:56:32 PM - 9 -
Table of Contents Case Management Agency Providers Page 2 Homemaker/Personal Care Services Page 4 Nursing Providers Page 8 3:56:32 PM - 10 -