Guide to Provider Forms ACTION Add a Provider to the group YOU WILL NEED TO COMPLETE THE SECTIONS IDENTIFIED BELOW ON THE PROVIDER INFORMATION UPDATE FORM (PIF) AND ANY ADDITIONAL DOCUMENTS LISTED. ALL DOCUMENTS MUST BE COMPLETED AND RETURNED PIF Complete Section A, Section N* and Section O * Section N can be copied when adding multiple providers Attachment A (Primary Care Providers) Attachment B (Non-Primary Care Providers, Specialists, Dental and Ancillary Providers) Attachment D (All Providers) CAQH (if applicable) Terming a provider PIF Complete Section A and Section J Term letter on your organization s letterhead Closing a service location(s) Change Phone/Fax Change the Pay-To/ Billing Address PIF Complete Section A and Section H PIF Complete Section A, Section F and Section O PIF Complete Section A and Section I W-9 Sample Claim Form (de-identified) Change or add a service location PIF Complete Section A, Section G and Section O Attachment A (Primary Care Providers) Attachment B (Non-Primary Care Providers, Specialists, Dental and Ancillary Providers) Attachment D (All Providers) MHO-2452 2537248OH0615
Add a new group to the same Tax Identification Number (TIN) PIF Complete Section A W-9 Attachment A (Primary Care Providers) Attachment B (Non-Primary Care Providers, Specialists, Dental and Ancillary Providers) Attachment D (All Providers) Sample Claim Form (de-identified) Change Group Name Only PIF Complete Section A and Section D Attachment A (Primary Care Providers) with new group name Attachment B (Non-Primary Care Providers, Specialists, Dental and Ancillary Providers) with new group name Sample Claim Form (de-identified) W-9 Change TIN only PIF Complete Section A and Section B W-9 Sample Claim Form (de-indentified) Individual Name Change PIF Complete Section A and Section E Attachment A (Primary Care Providers) Attachment B (Non-Primary Care Providers, Specialists, Dental and Ancillary Providers) Attachment D (All Providers) Provider Directory Update Panel Update Hospital Affiliations Update Group/Provider NPI change FORMS: Provider Information Update Form (PIF) PIF Complete Section A and Section L PIF Complete Section A and Section K PIF Complete Section A and Section M PIF Complete Section A and Section C FORM USAGE: This form is used to communicate changes, deletions and additions regarding participating providers to Molina Healthcare.
Attachment A Attachment B Attachment D This form is used for Primary Care Providers (PCPs) who want membership assigned to them. (IM, PED, GP, FP, FM, OB/GYN) This form is used for Specialists, including RNs, PAs, NPs, Dental and Ancillary Providers. This form is used to determine the types of services the provider offers. W-9 This document is issued by the U.S. Internal Revenue Service (IRS). Molina Healthcare uses it to update the TIN owner name, doing business as name, and Tax ID when received with a PIF. Credentialing - Individual Providers If you have a CAQH number If you do not have a CAQH number Credentialing - Facilities and Other Providers Including Hospitals, Ambulatory Surgical Centers, Home Health Agencies, Durable Medical Equipment (DME) Suppliers, SNFs, Urgent Care Centers, and Retail Clinics YOU WILL NEED TO Complete CAQH Provider Data Form. You also need to update and give Molina Healthcare permission to review. Visit the website at http://www.caqh.org. Go to http://www.caqh.org to request a CAQH number and fill out the information. You will need to give permission to Molina Healthcare to review. YOU WILL NEED TO Print, complete, fax, email or mail the Ohio Department of Insurance Standardized Credentialing Form Part B (Molina Healthcare refers to this as HDO ). This form can also be found at Quicklinks located at http://www.insurance.ohio.gov. Molina Healthcare of Ohio Attention: PIM P.O. Box 349020 Columbus, OH 43234-9904 Fax: (866) 713-1893 Email: MHOProviderUpdates@MolinaHealthcare.com CONTACT INFORMATION If you have additional questions please contact Molina Healthcare s Provider Services department at (855) 322-4079 between the hours of 8 a.m. to 5 p.m. EST, Monday through Friday.
Provider Information Update Form (PIF) Today s Date / / This form and the associated documentation are required to notify Molina Healthcare of Ohio of any changes to your group/practice information and/or to begin the credentialing process. This form is also available at www.molinahealthcare.com. Type of Group: Ancilliary Specialist PCP Hospital Urgent Care FQHC/RHC QFFP/Title X Dental SECTION A Current Group/Practice Information (All fields in this section are required) Group/Practice Name: Group/Practice Tax ID: Group/Practice Medicaid #: Group/Practice NPI #: Email address: Contact Number: Contact Name: Tax Exempt Yes NO Group/Practice Add, Name Change, Tax ID Number Change and NPI Change If changing both the Group/Practice Name and the Tax ID Number, a new contract is required. Please contact Molina Healthcare Provider Services at (855) 322-4079. A representative will be available to assist you Monday through Friday, 8 a.m. - 5 p.m EST. SECTION B Tax ID Number Change Effective Date / / Previous Tax ID Number New Tax ID Number SECTION C Group/Provider NPI Change Group Individual Group/Provider Name: Previous NPI: New NPI:
SECTION D Group/Practice Add or Change Effective Date / / Previous Group/Practice name: Medicaid #: New Group/Practice name: Medicaid #: SECTION E Individual Name Change OTHER CHANGES Previous Name: SECTION F Change Phone/Fax New Name: Effective Date / / Previous Phone Number: Previous Fax Number: Address: SECTION G Add a Service Location Change a Service Location New Phone Number: New Fax Number: City, State, Zip: Effective Date: / / Previous Address New Address Address 1: Address 1: Address 2: Address 2: City, State, Zip: Phone Number: Fax Number: Email: City, State, Zip: Phone Number: Fax Number: Email:
SECTION H Closing a Service Location Effective Date: / / Address 1: Address 2: City, State, Zip: Reason: (Required) Authorizing Signature Printed: Authorizing Signature: Phone Number: Fax Number: Email Address: Date: / / SECTION I Billing Address Change Effective Date / / Previous Billing Information Billing Contact: New Billing Information Billing Contact: Address 1: Address 1: Address 2: Address 2: City, State, Zip: Phone Number: Fax Number: City, State, Zip: Phone Number: Fax Number: Is this a Notice Address Change? No Yes The notice Address is the particular party s address for delivery or mailing of notice purposes.
SECTION J Terming a Provider A termination letter is required on company letterhead including: name of the provider to be termed, group name, effective date of termination, reason for termination and address of practice location(s). If terming provider is a PCP, who will assume patient panel? Provider Name (Last, First, MI) SECTION K Panel Update Effective Date / / Existing Patients Only Close Panel to all Members Open Panel Reason: (Required) SECTION L Provider Directory Update Include in Provider Directory Effective Date / / Exclude from Provider Directory Reason: (Required) SECTION M Hospital Affiliations Update Add Hospital Affiliation(s) Effective Date / / Remove Hospital Affiliation(s) Names of Hospital(s)
SECTION N Provider Joining a Group/Practice Effective Date: / / Provider Name (Last, First, MI): Provider Type (MD, DO, DC DDS, DPN, etc.): Date of Birth: Last Four Digits of Social Security #: Medicaid #: NPI#: Specialty: CAQH Purposes#: Secondary Specialty: Applying as: PCP Specialist Allied Health Professional Board Certified: Yes No Effective Date: / / Expiration Date: / / Certification Board: Group/Practice Name: Primary Group/Practice Address: City, State, Zip: Phone Number: Fax Number: Email Address: If you have any questions, visit our website at www.molinahealthcare.com or call Provider Services at (855) 322-4079. Representatives are available to assist you Monday through Friday from 8 a.m. to 5 p.m. Please mail, fax or email this form and supporting documentation to: Molina Healthcare of Ohio Attn: PCM P.O. Box 349020 Columbus, OH 43234-9904 Fax (866) 713-1893 MHOProviderUpdates@MolinaHealthcare.com
Section O Office Hours From To Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Attachment A Capacity Attestation - Primary Care Provider MCP Name: Molina Healthcare of Ohio, Inc. Signature: Printed Name: Brad Bryant Title: Director, Provider Contracts Date: Subcontractor/Pvdr Name: Signature: Printed Name: Title: Date: Last First MI Deg Spec Group Address City State Zip County Capacity Capacity represents the maximum number of the MCP s Medicaid members the primary care provider (PCP) agrees to serve. Each PCP s name must be listed. 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 MCPs provider directory. 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. (Formerly Attachment B - Capacity Attestation) MHO-1721 v 10/26/2012 2537248OH0615
Attachment B [NON-Primary Care Providers Only] MCP Name: Molina Healthcare of Ohio, Inc. Signature: Printed Name: Brad Bryant Title: Director, Provider Contracts Date: Subcontractor/Pvdr Name: Signature: Printed Name: Title: Date: Last First MI Deg Spec Group Address City State Zip County 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. (Formerly Attachment C - Non-primary care providers) v 10/26/2012 2537248OH0615
Attachment D: Services Provided Provider agrees to provide services as enumerated below (specify below): Ambulance transportation Ambulette transportation Ambulatory Surgery Center Advanced practice nurse services, specify: Mental health and/or substance abuse services Nursing facility services Obstetrical and/or gynecological services Ophthalmology services 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 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): Inpatient hospital services Laboratory services Other Speech and hearing services Vision (optical) services including eyeglasses Community Behavioral Health Services (included only in the MyCare Ohio 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 lntensive Outpatient Laboratory urinalysis Med -Somatic Methadone Administration Home and Community Based Services (included only in the MyCare Ohio benefit package) * indicates service provider types which may be counted in more than one county or region. All others may only count in the county where the provider is physically located. Out of Home Respite Services Adult Day Health Services Waiver Transportation* Chore Services* Waiver Nursing Services Home Delivered Meals* Assisted Living Services Home Care Attendant
Social Work Counseling Choices Home Care Attendant Emergency Response Services* Enhanced Community Living Services Home Modification Maintenance and Repair* Nutritional Consultation Personal Care Services lndependent Living Assistance Homemaker Services Community Transition Services Pest Control* Alternative Meals Service Home Medical Equipment and Supplemental Adaptive and Assistive Device Services* Signatures MCP Name: Molina Healthcare of Ohio, Inc. Signature: Printed Name: Brad Bryant Title: Director, Provider Contracting Date: Provider Name: Signature: Printed Name: Title: Date: