Failure to maintain adequate accounting records will result in recovery of all funds paid in excess of the established fee schedules. All providers are further required to maintain adequate fiscal and Medical records for a period of five years, to fully disclose services rendered to Title XIX Medicaid recipients.
Hearing Instrument Specialist Must submit a copy of the current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. If only licensed as a Hearing Instrument Specialist use 34 provider type. Home Health Agency Must submit a copy of the home health license and a copy of the home health agency Medicare approval letter showing the provider name and Medicare number.
Must enroll with the name and address as Medicare certified and licensed. Aids Waiver Services:. Physical Disability Waiver Services:. This form is available at the MMAC website under A Shortcut to List of Forms and is used for new enrollees as well as current providers who elect to provide this service. Hospice Must submit a copy of the current hospice license, a copy of the Hospice Medicare approval letter showing the provider name and Medicare number, and a copy of the hospice rate letter.
Nursing Facility Contract:. If providing services to nursing home residents you must complete a A Hospice Nursing Facility Addendum Contract showing all contracted nursing homes. This form is used for new enrollees as well as to update the provider records with new contracted nursing homes or nursing homes who are no longer contracted. Hospitals Psychiatric hospitals may only enroll for services provided to patients under 21 and over 65, this does not affect the acute hospitals who have psych units.
Must submit a copy of the hospital license and Medicare certification letter. Bordering State: Must be currently licensed in their state and Medicare certified as a hospital. Must submit a copy of the current hospital license and Medicare certification letter and a copy of the license and Medicare certification covering the date of service provided. Must have treated an eligible Missouri Medicaid recipient before enrollment will be granted. Out of State-Non Bordering: Missouri Medicaid will consider enrollment of an out-of-state provider if at least one of the following conditions is met:.
Health Plan concerning services provided, Missouri Medicaid is not responsible for. It is not necessary that you enroll with Missouri Medicaid unless you. The hospital must maintain and submit a current permanent hospital license and Medicare certification and must submit a copy of their license and Medicare certification covering the date of service. If not required to be licensed, the facility must provide current accreditation approval.
Must be licensed and Medicare certified before enrollment forms will be sent. Laboratory - Independent The physicians working in the lab do not enroll. All applicants must submit a copy of the current CLIA Certificate as an Independent Lab and a copy of the Medicare approval letter showing the provider name and Medicare number.
Each Independent Lab must enroll and bill individually. Nurse - Advanced Practice Nurse Out of state non-bordering nurses and graduates cannot enroll. Each advanced practice nurse must enroll individually. Nurse practitioners and clinical nurse specialists must be currently licensed as registered professional nurses and recognized as an advanced practice nurse within a specific clinical specialty area and role by the Missouri State Board of Nursing pursuant to 4 CSR Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe.
The Collaborative Practice Agreement must meet the requirements of statutes Missouri applicant:. Must submit a copy of current permanent RN license and current Document of Recognition for specialty of practice.
Submit a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare. Bordering State Applicant - Certifying body documentation to be submitted:. Advanced Practice Nurse Specialty Area Certifications : adult nurse practitioner and family nurse practitioner.
American Nurses Credentialing Center ANCC , Maryland Avenue Southwest, Suite West, Washington DC , Advanced Practice Nurse Specialty Area Certifications : adult nurse practitioner, family nurse practitioner, gerontological nurse practitioner, pediatric nurse practitioner, clinical nurse specialist in adult psychiatric and mental health nursing or child and adolescent psychiatric and mental health nursing, clinical nurse specialist in gerontological nursing, clinical specialist in community health nursing, and clinical specialist in medical-surgical nursing.
Nurse Mid-Wife Each nurse mid-wife must enroll and bill individually. Must be currently licensed as a RN and have a current Document of Recognition for the specialty of practice if practicing in Missouri. If enrolled with Medicare, submit a copy of Medicare letter showing the individual provider name and Medicare number. Nursing Facility Any changes to a nursing facility must be approved by DHSS prior to enrollment sending forms. Bordering state nursing homes will not be enrolled unless the recipient has been prior authorized by DHSS to be placed in an out of state facility.
Occupational Therapy These services are for patients under 21 only. Each occupational therapist must enroll and bill separately. Must be current and permanently licensed as an occupational therapist and submit a copy of the current license.
Optometrist Each optometrist must enroll and bill separately. Must be current and permanently licensed and submit a copy of the current license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare.
Optician Must submit a copy of Medicare letter showing the provider name and Medicare number if enrolled with Medicare. Optometry Clinic Must submit a copy of the clinic Medicare letter showing the clinic provider name, clinic Medicare number, and individual members of the clinic and their Medicare numbers.
Personal Care Must enroll with Medicaid using the same provider information as used with QA. This form is used for new enrollees as well as providers who decide to provide this service after they are enrolled. Pharmacy Each licensed pharmacy must enroll and bill separately.
Must submit a copy of the current Pharmacy Permit if pharmacy is located in Missouri. If pharmacy is located in a bordering state and the scripts will be mailed to a recipient in Missouri, a copy of the current Non-Resident Pharmacy Permit for Missouri and a copy of the current pharmacy permit for their state must be submitted. A physician will not be issued a Pharmacy Dispensing provider number unless they are more than 15 miles from a Pharmacy.
Long Term Care. Physical Therapy Each physical therapist must enroll and bill individually. Must submit a copy of current permanent license. Must submit a copy of current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare with the completed enrollment application. Must maintain and submit a current permanent license and a copy of Medicare letter showing the individual provider name and Medicare number if enrolled with Medicare.
Each physician must enroll and bill separately. Planned Parenthood Clinic Must submit a copy of the clinic Medicare letter showing the clinic provider name, clinic Medicare number, and individual members of the clinic and their Medicare numbers if enrolled with Medicare. Podiatrist Each podiatrist must enroll and bill individually.
Podiatry Clinic Each podiatrist must also enroll individually. Private Duty Nursing Care Physical Disability Waiver Services. Psychologist, Professional Counselor, Social Worker Professional Counselor and Social Worker services are for patients under 21 only.
Psychologist: must submit a copy of the current permanent license and a copy of their Medicare. Professional Counselor or Social Worker: must submit a copy of the current permanent or provisional license.
If professional counselor or social worker is provisionally licensed payment cannot be made to the applicant, must have a license at each location of practice, and must send permanent license when it is issued.
All providers whether permanent or provisionally licensed must enroll at each location of practice and must enroll and bill individually.
Provisional licensed professional counselors and social workers are not permitted to have payment made to their individual name and are not permitted to have an independent practice. If you have questions regarding either of these issues contact your license board.
Public Health Dept. Must enroll one physician or each advanced practice nurse employed. Must submit a copy of the current permanent license and a copy of the Medicare approval letter showing the provider name and Medicare number.
Applicant must accept assignment and must have seen a QMB eligible recipient before enrollment will be granted. Rehabilitation Center - Outpatient Submit a copy of the Medicare Rehabilitation approval letter showing the provider name and Medicare number. Each RHC that is Medicare certified must enroll and bill separately. Individual providers at a RHC may also maintain a clinic if applicable and individual provider numbers at the rural health location. However, per the Health Care Financing Administration HCFA the following specific documentation must be maintained by the provider and made available to the state Medicaid agency, upon request, which includes:.
Documentation of the costs associated with services provided through the private practice;. Contract between the provider and the RHC defining which services provided off-site will be. The list of on-site services and the contract for off-site services must be submitted with the RHC. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report. Must submit a copy of current permanent Speech Language Pathologist license. If enrolling with a school you may submit a copy of the current permanent Teacher Certificate showing speech, provisional license or certificate is not acceptable.
Teaching Institution Department hospital based If each department has a clinic Medicare number then each department must enroll and all practitioners in each department must enroll individually. If one Part B clinic Medicare number is issued for the entire hospital then only one A All Department number is issued. When only one All Department number is used only 3 physicians need to enroll, however, all psychiatrists and other provider types must still enroll individually.
Teaching Institution not hospital based Must submit a copy of the clinic Medicare letter showing the department provider name, department Medicare number, and individual members of the department and their Medicare numbers.
If the departments are not enrolled with Medicare separately they will not be enrolled with Medicaid separately. All individuals practicing in each department must enroll individually. Each physician working for an Independent X-Ray must enroll individually. All individuals practicing for the Independent X-Ray must enroll individually. Individuals working for a Portable X-Ray are not required to enroll. This site does not support the AOL browsing software. Please install the latest version of either Internet Explorer or Netscape Navigator before using this site.
Instructions for each field of the Medicaid Enrollment Application are listed on the bottom bar of your screen. Use HELP for more detailed instructions on completing the enrollment application. If you have problems faxing or using this site contact the Help Desk at General enrollment questions may be e-mailed to: www. Make sure the forms and attachments are of good quality so when they are faxed they will be legible.
Illegible forms or attachments will automatically be denied. Altered forms will automatically be denied. Forms complete d by typewriter or hand written will automatically be denied. Fields cannot be blacked out, whited out or crossed out, writing information on the forms is not acceptable, however, the provider must sign with.
Applications printed prior to being completed on the Internet will be denied. Partial applications will not be processed. The provider is responsible to retain all of the original enrollment forms. After you verify that all information is correct. If you choose. After saving you must.
After completing each page of the application. If you wish to participate in direct deposit the. If the direct deposit form is not submitted. After the application is finalized you cannot. However, you can hit the to go back if you need to edit information. Only one application per fax transmission will be accepted. If you are sending multiple enrollment applications, each application must be faxed separately.
In order for the applications to be submitted by fax separately you must make sure that each time a fax is completed, the fax machine you are using not only finishes moving the pages through the machine, but has finished the transmission and has disconnected from the fax number dialed, then you can re-dial to submit your next application.
The enrollment fax number is used exclusively for submitting enrollment applications. All other faxes will be disregarded. List the following information for each satellite office the agency may have:.
Service Area Commitment form indicating the services and geographic areas counties the applicant plans to serve. Applicants must assure the Department that sufficient financial resources exist to provide continuous service to clients of the Department.
The use of a Business Plan will help entities manage their business and ensure financial stability. The following policies and procedures must be detailed, step-by-step instructions of how your company will comply with the requirements of the program. The policies and procedures must answer who, what, where, when and how. Nursing Facility Contract:. If providing services to nursing home residents must complete a Hospice Nursing Facility Addendum Contract showing all contracted nursing homes.
This form is used for new applicants as well as to update the provider records with new contracted nursing homes or nursing homes whose contract has ended. Hospitals Psychiatric hospitals may only enroll for services provided to patients under 21 and over 65, this does not affect the acute hospitals who have psych units. Must submit a copy of the hospital license and Medicare number.
Bordering State : Must be currently licensed in their state and Medicare certified as a hospital. Must submit a copy of the current hospital license, Medicare number and a copy of the license covering the date of service provided. Must have treated an eligible Missouri Medicaid recipient before enrollment is granted. Out of State Non-Bordering : Provider Enrollment considers enrollment of an out of state provider if at least one of the following conditions is met:.
The hospital must maintain a current permanent hospital license and must submit a copy of their license and Medicare number covering the date of service. If not required to be licensed, the facility must provide current accreditation approval. Must be licensed and Medicare certified before enrollment forms are sent.
Laboratory - Independent The physicians working in the lab cannot enroll. Each Independent Lab must enroll and bill individually. Out of State Non-Bordering : MO HealthNet considers enrollment of an out of state provider if at least one of the following conditions is met:.
It is your responsibility to verify the recipient eligibility for dates of service provided. Nurse - Advanced Practice Nurse Out of state non-bordering nurses and graduates cannot enroll. Each advanced practice nurse must enroll individually. Nurse practitioners and clinical nurse specialists must be currently licensed as registered professional nurses and recognized as an advanced practice nurse within a specific clinical specialty area and role by the Missouri State Board of Nursing pursuant to 4 CSR Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe.
The Collaborative Practice Agreement must meet the requirements of statutes Missouri Applicant :. Must submit a copy of current permanent RN license and current Document of Recognition for specialty of practice. Supply us with the Medicare number if enrolled with Medicare. Bordering State Applicant - Certifying body documentation to be submitted:. Advanced Practice Nurse Specialty Area Certifications : adult nurse practitioner and family nurse practitioner. American Nurses Credentialing Center ANCC , Maryland Avenue Southwest, Suite West, Washington DC , Advanced Practice Nurse Specialty Area Certifications : adult nurse practitioner, family nurse practitioner, gerontological nurse practitioner, pediatric nurse practitioner, clinical nurse specialist in adult psychiatric and mental health nursing or child and adolescent psychiatric and mental health nursing, clinical nurse specialist in gerontological nursing, clinical specialist in community health nursing, and clinical specialist in medical-surgical nursing.
Nurse Mid-Wife Each nurse mid-wife must enroll individually. Must be currently licensed as a RN and have a current Document of Recognition for the specialty of practice if practicing in Missouri.
If enrolled with Medicare please supply us with the Medicare number. Nursing Facility Any changes to a nursing facility must be approved by DHSS prior to enrollment sending forms.
Bordering state nursing homes are not enrolled unless the recipient has been prior authorized by DHSS to be placed in the bordering state facility. Recipients wishing to be placed in an out of state facility must apply for Medicaid in the state the facility is located. Occupational Therapy These services are for patients under 21 only. Each occupational therapist must enroll individually.
Must be current and permanently licensed as an occupational therapist and submit a copy of the current license. Optometrist Each optometrist must enroll individually. Must be current and permanently licensed and submit a copy of the current license and Medicare number if enrolled with Medicare. Optician Please supply us with the Medicare number if enrolled with Medicare.
Personal Care Must enroll with Medicaid using the same provider information as used with QA. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled. Pharmacy Each licensed pharmacy must enroll and bill separately. Out of state non-bordering pharmacy providers cannot enroll unless they are approved by MHD. Out of state non-bordering pharmacies must either see a participant or supply a medication that is not supplied in Missouri or a bordering state.
Must submit a copy of the current Pharmacy Permit if pharmacy is located in Missouri. If pharmacy is located in a bordering state and the scripts will be mailed to a recipient in Missouri, a copy of the current Missouri Non-Resident Pharmacy Permit and a copy of the current pharmacy permit for the state in which the pharmacy is located must be submitted. A physician is not issued a Pharmacy Dispensing provider number unless they are more than 15 miles from a Pharmacy.
Long Term Care. Physical Therapy Physical Therapy provider types can currently enroll with a provider type 48 and provider specialty type of Physical Therapy services will require a Smart prior authorization PA for participants 21 years of age and older. Must submit a copy of current permanent license and Medicare number if enrolled with Medicare.
Must maintain and submit a current permanent license and Medicare number if enrolled with Medicare. Each physician must enroll and bill separately. If enrolling clinic and physicians at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.
Assistant Physician If you are an individual applicant and the payee indicated in field 11 of the Provider Questionnaire is either to yourself or a group that is not Missouri Medicaid enrolled, you must submit the following documents. If you are an individual applicant and the payee is a group that is enrolled with Missouri Medicaid, you do not need to submit the following documents. Physician Assistants Planned Parenthood Clinic If you are enrolled with Medicare, please supply us with your Medicare number, and individual members of the clinic and their Medicare numbers if enrolled with Medicare.
Each individual practicing at the clinic must also be enrolled. Attach a cover letter stating the individual provider names practicing at the clinic. Podiatrist Must submit a copy of the current permanent license and Medicare number if enrolled with Medicare.
Each podiatrist must enroll individually. Private Duty Nursing Care Each PDN provider must enroll separately. Physical Disability Waiver Services. This form is used for new enrollees as well as providers who decide to provide this service after they are enrolled.
Psychologist, Professional Counselor, Social Worker Professional Counselor and Social Worker services are for patients under 21 only. Required documentation must be submitted with the original signed participation agreement.
Psychologist : must submit a copy of their current permanent license and their Medicare number, if enrolled with Medicare. School Psychologist : must submit a copy of their Nationally Certified School Psychologist certificate. Must enroll as a performing provider with a MO HealthNet enrolled public or charter school district in the State of Missouri.
Professional Counselor or Social Worker : must submit a copy of their current permanent or provisional license. If the professional counselor or social worker is provisionally licensed, the applicant must have a license at each location of practice, and must send permanent license when it is issued.
All providers, whether permanently or provisionally licensed, must provide all of their practice locations. Provisionally licensed professional counselors and social workers are not permitted to receive payment directly from MO HealthNet and are not permitted to have an independent practice. If you have questions regarding either of these issues contact your license board. Public Health Dept. Clinic Each Public Health Department must enroll individually.
One physician or each advanced practice nurse employed must be enrolled. Each QMB provider who has a Medicare number must enroll individually. Must submit a copy of the current permanent license and Medicare number. Applicants must accept assignment and must have seen a QMB eligible recipient before enrollment is granted. Rehabilitation Center - Outpatient Please supply us with your Medicare number. Each RHC that is Medicare certified must enroll and bill separately.
Please supply us with your Medicare number and the RHC rate letter. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report. School District Must be a Department of Elementary and Secondary Education recognized public or charter school district in the State of Missouri. Must submit a copy of current permanent Speech Language Pathologist license.
If enrolling with a school you may submit a copy of the current permanent Teacher Certificate showing speech. Provisional license or provisional Teacher Certificate is not acceptable. Each therapist must enroll individually.
Teaching Institution Department hospital based Teaching Institution not hospital based Please supply us with your Medicare number, and individual members of the department and their Medicare numbers. If the departments are not enrolled with Medicare separately they are not enrolled with MO HealthNet separately.
All individuals practicing in each department must be enrolled individually. Attach a cover letter stating the individual provider names practicing in each department.
Third Party Assessor - Reassessments Questions can be directed to: mmac. Enrollment requirements for out of state non-bordering applicants : MO HealthNet recipients are required to obtain services from Missouri or bordering state providers. If a MO HealthNet participant leaves the state of Missouri and requires services, one of the following conditions must be met before the services are considered for reimbursement:.
If prior authorization is approved and reimbursement is received for equipment, supplies, or services for a MO HealthNet patient who is not Medicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may be recouped on any amounts paid. If the claim DOES NOT meet one of the specific conditions listed above, the participant is responsible for the services, and enrollment is not granted. This site does not support the AOL browsing software. Please install the latest version of either Internet Explorer or Netscape Navigator before using this site.
Instructions for each field of the MO HealthNet Enrollment Application are listed on the bottom bar of the application screen. Use HELP for more detailed instructions on completing the enrollment application. If you have problems faxing or using this site contact the Help Desk at General enrollment questions should be e-mailed to: MMAC.
Please fax the signature page and required attachments in an upright position to Make sure the forms and attachments are of good quality so when they are faxed they are legible. Illegible forms or attachments are automatically denied. Altered forms are automatically denied. Forms complete d by typewriter or hand written are automatically be denied.
Fields cannot be blacked out, whited out or crossed out, writing information on the forms is not acceptable, however, the provider must sign with their original wet signature. All forms must be completed while on the Internet before they can be submitted and printed. Applications printed prior to being completed on the Internet are denied. Partial applications are not processed. The provider is responsible to retain printed pages of the enrollment application, including the signature page showing the original wet signature.
After all fields are verified and correct, choose: Edit or Continue. Your choices from this screen are to:. Each part must be printed before advancing to the next page.
In order to finish remaining pages later, the full page must be completed. The PIN number at the top of the page must be used to. If changes are necessary, a new application must.
Only one signature page and its required attachments is accepted per fax transmission. If sending multiple signature pages along with required attachments, each signature page along with its required attachments must be faxed separately. In order for the signature page along with required attachments to be submitted by fax separately, make sure that each time a fax is completed, the fax machine being used is not only finished moving the pages through the machine, but has finished the transmission and has disconnected from the fax number dialed.
Then re-dial to submit the next signature page along with required attachments. The enrollment fax database number is used exclusively for submitting enrollment applications.
All other faxes are disregarded. This is the only number that may be used to fax a signature page along with its required attachments. The Provider Enrollment Unit also has an auto-responder that confirms the receipt of the e-mail. E-mails are processed in date order as they are received. Your patience is appreciated. If enrolling as a hospital, optical company, DME company, pharmacy, etc. This number is used by recipients, providers, and MO HealthNet employees, etc.
Box alone is not an acceptable address, as correspondence may be sent by a commercial carrier, such as UPS. If mail is returned to our office the provider number is made inactive. If you participate with Medicare each physical location that is issued a Medicare number must also enroll with a separate MO HealthNet enrollment record.
If using a Social Security Number the name must be the exact same name as used with the Social Security Administration. This information must be entered correctly even if payment is direct deposited. The name completed in this field appears on the paper check if you do not participate in direct deposit , the paper remittance advice, and the tax form at the end of the year. If there is a DBA name please enter it after the appropriate payment name.
If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification Number, contact IRS at Provider Enrollment must be notified in writing of remittance address changes. The name completed in this field appears on the paper check if you do not participate in direct deposit, the paper remittance advice, and the tax form at the end of the year.
If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification number, contact IRS at Individual applicants only.
If the Medicare number covers more than one office location, complete the forms with the physical location address the Medicare number is issued to. If there are separate Medicare numbers for different locations, each location must enroll with MO HealthNet as with Medicare.
Any provider that is issued a license to practice must submit a copy of current, permanent license unless otherwise requested. This number is used for MMAC tracking purposes and must be included on all applications. If box indicating City, Municipal, County, Dist. This information is needed for correct payment of claims. Read the agreement carefully. An authorized representative of the owner may sign for a facility, clinic, or other entity. Billing agents etc. Indicate the title of the person signing and the date signed.
All questions must be answered. Field number 1: If you do not have any other NPI numbers enrolled, put none. All forms must be signed by the same person. All applicants are required to be in compliance with the Office of Civil Rights. Applicants are required to review the civil rights information via the Internet at www.
Click on Providers, under Provider Enrollment select civil rights. The provider name s , NPI number, and signature of the provider must be included on the form. New enrollment records are not issued for, but not limited to these changes:. Once the Provider Update Request form is received, the Provider Enrollment Unit determines what action needs to be taken.
Some changes can be made from the form, other changes require an update application be completed. MO HealthNet providers must enroll at the physical practice location the Medicare number is issued. However, they are still required to submit Medicare documentation so the claims can crossover automatically. Duplicate billing of crossover claims is considered MO HealthNet fraud. If you have a Medicare number with more than one carrier please submit documentation for all carriers, separate MO HealthNet provider records may be necessary in some cases.
If services are provided to MO HealthNet participants at different office locations that have separate Medicare numbers for each location, separate MO HealthNet enrollment records must be created for all providers and the providers must bill under the appropriate Medicare and MO HealthNet record for each location.
If services are provided to MO HealthNet participants at different office locations and all locations are approved by Medicare to use one Medicare number, then all providers must enroll with MO HealthNet in the same manner and bill with one Medicare number and MO HealthNet enrollment record.
Since all offices are permitted to use the same Medicare number in this instance, all providers must enroll at the physical location the Medicare number is issued even if they do not practice at that location. All other provider members must enroll and bill under their individual provider name and record.
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