New Mexico Medicaid Project 1720-A Randolph Road SE Albuquerque, NM 87106 505-246-9988 505-246-8485 (fax) Dear Medicaid Provider Applicant: Thank you for your interest in becoming a New Mexico Medicaid provider. A provider participation agreement packet is enclosed. Please read the following instructions carefully before completing the agreement(s). The application process takes 6-8 weeks from the date a properly completed provider participation agreement is received. When your agreement is approved, a unique provider identification number will be assigned to you. Do not provide services to New Mexico Medicaid clients until your Medicaid provider number has been assigned and you have received a copy of the New Mexico Medicaid Program Policy Manual and Billing Instructions. In order for us to process your provider participation agreement in a timely manner, please follow these guidelines: ¾ The MAD Form 312, PROVIDER PARTICIPATION AGREEMENT – INDIVIDUAL APPLICANT WITHIN A GROUP should be completed by individual applicants who perform services within a group or organization. Payments will be made only to the group or organization. No payments will be made directly to the individual. ¾ The MAD Form 335, PROVIDER PARTICIPATION AGREEMENT should be completed by groups, organizations, or individual applicants to whom payment will be made. ¾ When applying for a group Medicaid provider number, include an agreement for the group (MAD 335) as well as individual agreements (MAD 312) for each practitioner who will be a member of the group if they do not already have a Medicaid number. For a group that already has an active Medicaid provider number that wishes to enroll an individual within their group, complete an agreement (MAD form 312) for the individual only. For practitioners who already have an assigned Medicaid number and who wish to be affiliated with a newly enrolling group, a signed letter must be submitted by the enrolled provider stating they wish to be affiliated with the group. ¾ Please do not use “highlighter” or “whiteout” on the agreement(s) or on any of the attachments. Agreements that are submitted with “highlighter” or “whiteout” will be returned without any further processing. To correct information on the agreement, make one line across the incorrect information and write in the corrected information. The person making the corrections should initial the changes. ¾ Review the enclosed Type and Specialty List and Documentation Requirements and select the provider type and provider specialty (if applicable) that best describes your practice, license and/or certification. If you are unsure which provider type or specialty to use, please contact the Provider Enrollment Unit at 1-800299-7304 or 505-246-0710, option #3, then #5. ¾ If services have already been provided on an emergency basis, you may enter a requested effective date on the last page (signature page) of the Provider Participation Agreement. The date requested should be no more than 120 days prior to the date the completed agreement is being sent to ACS. There is no guarantee that the requested effective date will be granted, as the Medical Assistance Division will make the final determination. ¾ The enclosed W-9 form must be completed for applicants submitting a MAD 335, Provider Participation Agreement. The purpose of the W-9 is to assure that payments to providers are reported to the IRS with names and numbers that match IRS records. If you are a business, corporation, or sole proprietorship, enter the ID number assigned by the IRS. Please attach a copy of the letter or other proof from the IRS assigning this tax identification number. Revised January 2004 American LegalNet, Inc. www.FormsWorkFlow.com ¾ If you are enrolling as an individual, you must enter your Social Security number and date of birth on the agreement. Even if you are an individual who will be billing under a group number, you must enter your Social Security number and date of birth. You will bill your claims using the group provider number, which will be reported to the IRS with the group name and tax identification number. ¾ Tax exempt providers must submit a copy of their 501(c)3 tax-exempt letter. ¾ Every provider who completes a MAD 335 agreement and who renders services within New Mexico must provide their New Mexico Tax and Revenue identification number (box 19 of the agreement). ¾ The applicant’s Medicare number and/or DEA number must be included on the agreement, if applicable. Also include a copy of the Medicare letter and/or DEA registration certification with the agreement. If the DEA number and/or Medicare number is/are pending at the time of application, please send ACS a copy of the certification when you receive this information. ¾ Applicants completing the MAD 335 form should also complete the enclosed Addendum form that requests information regarding Medicare carrier(s). ¾ New Mexico Medicaid project staff may need to obtain additional information from you in order to process your agreement. Please indicate a contact name and telephone number in the space provided on the last page of the Provider Participation Agreement. ¾ The applying provider must sign and date the agreement. Please sign in blue ink only! Only an original signature with a date is acceptable. We cannot accept signature stamps or copies of signatures. Applications with signatures that cannot easily be determined as original will be returned for correction. This standard is strictly enforced. ¾ Please be sure to include all required documentation as listed on the attached Provider Participation Agreement, MAD 312 and 335 forms and Type and Specialty List and Documentation Requirements. Required documentation may include: i i i i i i i i i i i i i i ¾ Professional licensure Agency licensure or certification Business license DEA registration certificate New Mexico Non-Residential Pharmacy License (for certain out-of-state providers) Proof of malpractice or liability insurance Federal tax identification letter CLIA certificate Physician board specialty certification Medicare certification letter JCAHO accreditation letter FQHC certification and interim rates Medicare letter setting reimbursement rates for Rural Health Clinics (RHCs) Renal dialysis Medicare composite rate letter If you plan to submit claims electronically, please review the HIPAA Claims Submission Instructions information that is attached to this packet. If you have ANY questions at all, please do not hesitate to contact ACS’s Provider Enrollment Unit at 1-800-2997304 or 505-246-0710, option #3, then #5. Sincerely, Provider Enrollment ACS Revised January 2004 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com