PROVIDER INFORMATION UPDATE FORM CURRENT CONTRACT INFORMATION - ALL FIELDS IN THIS SECTION ARE REQUIRED 1. Type of Group: Ancillary Specialist PCP Hospital Urgent Care FQHC/RHC QFPP/ X Contracted Entity/Name: Contact Person: Phone: Fax: Email: WHAT IS CHANGING? - SELECT ALL APPOPRIATE BOXES: 2. Billing Address Telephone/Fax New Provider Joining group* Practice Address* Provider leaving group Existing Provider adding new practice address* Closing Practice Address/Office Other, describe: *Must also complete and submit: Attachment A for Primary Care Providers (Pediatricians, General Practice, Family Medicine, or Internal Medicine) Attachment B for non-primary care providers Attachment D for all provider types W9 & De-identified sample 1500 EFF DATE OF CHANGE: BILLING/TIN - NEW/CORRECT INFORMATION - PROVIDE COMPLETE INFORMATION - NEW OR CORRECTION 3. BILLING INFORMATION (NAME): ADDRESS: CITY: STATE: ZIP: PHONE: FAX: TAX ID W9 REQUIRED: - NEW TIN. BILLING NPI: *Must also submit W9 and de-identified, sample claim (1500) with request and provide practice information (below) for new practice PRACTICE LOCATION - NEW/CORRECT INFORMATION - PROVIDE COMPLETE INFORMATION NEW OR CORRECTION 4. PRACTICE NAME:_ ADDRESS: CITY: STATE: ZIP: PHONE: FAX: NPI: *Must also submit W9 and de-identified, sample claim (1500) with request and billing/remit/pay to information for new practice (above)
INCORRECT/OLD INFORMATION - PROVIDE COMPLETE INFORMATION If correcting/changing information above, please provide the incorrect/old information to help us identify what needs to be corrected in our system. Practice Address Billing Address Telephone/Fax Closing Practice: Eff. : 5. PRACTICE / BILLING NAME: NPI: ADDRESS: CITY: STATE: ZIP: PHONE: FAX: - TIN BRIEFLY DESCRIBE ERROR/CHANGE: NAME CHANGE (CONTRACTED ENTITY OR PRACTICE NAME) - PROVIDE COMPLETE INFORMATION 6. CONTRACTED ENTITY NAME PRACTICE LOCATION NAME W9 REQUIRED. EFF DATE OF CHANGE: OLD NAME: NEW NAME: ADDING A NEW PROVIDER - PROVIDE COMPLETE INFORMATION 7. Adding Provider must also complete sections 1, 2, 3, 4, and an Attachment A for Primary Care Providers, or an Attachment B for non-primary care providers, and an Attachment D for all provider types. For each provider added, please also provide the following information: Last Name: First Name: MI or Name: Suffix,: NPI: Medicare ID #: Medicaid ID #: CAQH #: EFF DATE OF CHANGE: TERMING PROVIDER - PROVIDE COMPLETE INFORMATION 8. Terming/Removing Provider EFF DATE OF CHANGE: Last Name: First Name: MI or Name: Suffix,: NPI: Reason for termination: If terming provider is PCP, who will assume patient panel: OTHER: Please complete form(s) and email along with all necessary required information to: MHOProviderUpdates@MolinaHealthcare.com www.molinahealthcare.com Molina Healthcare of Ohio P.O. Box 349020 Columbus, OH 43234-9020 Fax: (614) 781-1537 ATTN: PIM
Attachment A PRIMARY CARE PROVIDER ATTESTATION [Primary Care Providers Only] Capacity represents the maximum number of the MCP s Medicaid-only members the primary care provider (PCP) agrees to serve. PCPs individually or as part of a group, must serve a minimum of 50 of the MCP s Medicaid members at each practice site in order to be listed in the MCP s provider directory. List all PCP names that have been contracted with to provide services to Medicaid Members. Practice Site Provider Name Maximum Capacity # 1) Name: (Maximum #) Address: (Maximum #) City: (Maximum #) State & Zip: (Maximum #) County: (Maximum #) Total: 2) Name: (Maximum #) Address: (Maximum #) City: (Maximum #) State & Zip: (Maximum #) County: (Maximum #) Total: If the practice has more than two locations or more than five PCPs at a location, provide the information requested above in an attached document titled Attachment A. If multiple pages are used, the pages must be numbered sequentially on every page (e.g., 1 of 3, 2 of 3, and 3 of 3) and the last page must be signed by the provider and the MCP. Molina Healthcare of Ohio, Inc. (Contracted Name) Amy Clubbs President
Attachment B [NON-Primary Care Providers Only] List all non-pcp names that have been contracted with to provide services to Medicaid Members. Practice Site Provider Name Specialty 1) Name: Address: City: State & Zip: County: 2) Name: Address: City: State & Zip: County: 3) Name: Address: City: State & Zip: County: If the practice has more than three locations or more than (5) providers at a location, please provide the requested information in a document titled Attachment B. If multiple pages are used, the pages must be numbered sequentially on every page (e.g., 1 of 3, 2 of 3, and 3 of 3) and the last page must be signed by the provider and the MCP. Molina Healthcare of Ohio, Inc. Amy Clubbs President (Contracted Name)
Attachment D Provider agrees to provide services as enumerated below (specify below): Ambulance transportation Ambulette transportation Ambulatory Surgery Center Advanced practice nurse services (specify: ) Chiropractic services Dental services Durable medical equipment (DME) Emergency Services Family planning services and supplies Federally Qualified Health Center services Home health services/private Duty Nursing Hospice care Medical Imaging Inpatient hospital services Laboratory services Mental health and/or substance abuse services Nursing facility services Obstetrical and/or gynecological services Ophthalmology services Outpatient hospital services Physical and occupational therapy Podiatry services Pharmacy Physician services Primary care provider services Renal dialysis Rural Health Clinic services Specialty physician services, Specify (e.g., cardiology, allergy, etc): Speech and hearing services Vision (optical) services, including eyeglasses Other Community Behavioral Health Services (included only in the ICDS benefit package) Pharmacological Management Behavioral Health Assessment Behavioral Health Counseling and Therapy Crisis Intervention Partial Hospitalization Community Psychiatric Support Treatment Ambulatory Detox Targeted Case Management for AOD Intensive Outpatient
Attachment D Provider agrees to provide services as enumerated below (specify below): Laboratory urinalysis Med Somatic Methadone Administration Home and Community Based Services (included only in the ICDS benefit package) Out of Home Respite Services Adult Day Health Services Home Medical Equipment & Supplemental Adaptive & Assistive Devices Waiver Transportation Chore Services Social Work Counseling Emergency Response Services Home Modification Maintenance and Repair Personal Care Services Homemaker Services Waiver Nursing Services Home Delivered Meals Alternative Meals Service Pest Control Assisted Living Services Home Care Attendant Choices Home Care Attendant Enhanced Community Living Services Nutritional Consultation Independent Living Assistance Community Transportation Molina Healthcare of Ohio, Inc. Amy Clubbs President (Contracted Name)