Texas Medicaid Provider Enrollment Application Form. This is a Texas form and can be use in Medicaid Statewide.
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Texas Medicaid Provider Enrollment Application Rev. XXI American LegalNet, Inc. www.FormsWorkFlow.com Privacy Statement With a few exceptions, Texas privacy laws and the Public Information Act entitle you to ask about the information collected on this form, to receive and review this information, and to request corrections of inaccurate information. The Health and Human Services Commission’s (HHSC) procedures for requesting corrections are in Title 1 of the Texas Administrative Code, sections 351.17 through 351.23. For questions concerning this notice or to request information or corrections, please contact Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126. Page i 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Introductions and Provider Agreement Dear Health-care Professional: Thank you for your interest in becoming a Texas Medicaid provider. Participation by providers in Texas Medicaid is vital to the successful delivery of Medicaid services, and we welcome your application for enrollment. As a potential new provider to Texas Medicaid, you must follow certain claims filing procedures while completing the enrollment process. This is particularly important if you render Medicaid services to clients before you are enrolled. To access the Texas Medicaid Provider Procedures Manual and Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, visit www.tmhp.com and select “Find Publications/File Library” under the “I would like to…” menu on the right-hand side of the page. Select “Provider Manuals” from the menu to view the provider manuals. There is no guarantee your application will be approved for processing or you will be assigned a Medicaid Texas Provider Identifier (TPI) number. If you make the decision to provide services to a Medicaid client prior to approval of the application, you do so with the understanding that, if the application is denied, claims will not be payable by Texas Medicaid, and the law also prohibits you from billing the Medicaid client for services rendered. Page ii 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Important Information—Please Read TMHP must receive all claims for Medicaid services within the filing deadline. When medical services are rendered to a Medicaid client in Texas, TMHP must receive claims within 95 days of the DOS on the claim. • Claims submitted by newly enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS. • TMHP must receive claims on behalf of an individual who has applied for Medicaid coverage but has not been assigned a Medicaid number on the DOS within 95 days from the date the eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service or from the discharge date for inpatient claims. ◦◦ If a client becomes retroactively eligible or loses Medicaid eligibility and is later determined to be eligible, the 95-day filing deadline begins on the date that the eligibility start date was added to TMHP files (the add date). However, the 365-day federal filing deadline must still be met. • When a service is a benefit of Medicare and Medicaid, and the client is covered by both programs, the claim must be filed with Medicare first. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition. • When a client is eligible for Medicare Part B only, the inpatient hospital claim for services covered as Medicaid only is sent directly to TMHP and subject to the 95-day filing deadline (from date of discharge). • TMHP must receive claims from out-of-state providers within 365 days from the DOS. The DOS is the date the service is provided or performed. The Texas Medicaid Provider Procedures Manual contains important information about provider responsibilities, filing deadlines and procedures, and much more. It is also available for you to download at www.tmhp.com or you may call 1-800-925-9126 to request a printed copy. For information about Medicaid TPI requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126. TMHP customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. central standard time. Thank you for your applying to become a Texas Medicaid Program provider. Page iii 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Table of Contents Texas Medicaid Identification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Required Forms for Medicaid Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Useful Information—Please Read . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Texas Medicaid Provider Enrollment Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 HHSC Medicaid Provider Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Provider Information Form (PIF-1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Principal Information Form (PIF-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 Disclosure of Ownership and Control Interest Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 IRS W–9 Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 Corporate Board of Directors Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Medicaid Audit Information Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Texas Women’s Health Program Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1 Electronic Funds Transfer (EFT) Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 Texas Vaccines for Children Program (TVFC): Provider Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1 Enrollment Requirement by Provider Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1 Final Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1 Page 1 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Identification Form Please check only the appropriate boxes to ensure proper enrollment. For assistance in choosing the appropriate provider type, please refer to Enrollment Requirements by Provider Type. Legend: ● ✪ ▲ ★ Approval Letter/Contract required Eligible for Medicare waiver request (you must check the Medicare waiver request box below) License/certification required Medicare number required ✚ ♦ t Must designate if public provider Palmetto number required Women’s Health Program (WHP) (certification required for reimbursement) Traditional Services FF ★ ✚ ▲ Ambulance/Air Ambulance FF ▲ HCSSA FF ★ ✚ ▲ Ambulatory Surgical Center (ASC) FF ▲ Hearing Aid FF ★ ▲ Home Health FF ▲ Birthing Center FF ✚ ▲ ★ Hospital — In-State FF ★ Catheterization Lab FF ★ ▲ Certified Nurse Midwife (CNM) FF ✚ Hospital Ambulatory Surgical Center (HASC) FF ★ ▲ Certified Registered Nurse Anesthetist (CRNA) FF ▲ Chemical Dependency Treatment Facility FF ★ ✪ ▲ Audiologist FF ★ ▲ Chiropractor FF ★ Community Mental Health Center FF ★ Comprehensive Health Center (CHC) FF ★ Comprehensive Outpatient Rehabilitation Facility (CORF) FF ● Consumer Directed Services Agency (CDSA) FF ★ ✪ ▲ Doctor of Dentistry as a Limited Physician FF ♦ Durable Medical Equipment (DME) FF Durable Medical Equipment/ Home Health FF ✚ ▲ ★ Hospital — Military FF ✚ ▲ ★ Hospital — Out-of-State FF ♦ Hyperalimentation FF ★ ✚ Independent Diagnostic Testing Facility (IDTF) FF ★ ✚ Independent Lab (No Physician Involvement) FF ★ ✚ Independent Lab (Physician Involvement) FF ▲ Licensed Marriage and Family Therapist (LMFT) FF ▲ Licensed Professional Counselor (LPC) FF ✚ t Maternity Service Clinic (MSC) Physiological Lab FF ★ ▲ Podiatrist FF ★ Portable X-Ray FF ★ ✪ ▲ Prosthetist FF ★ ✪ ▲ Prosthetist - Orthotist (choose if licensed as both) FF ★ ▲ Psychologist FF ▲ Qualified Rehabilitation Professional (QRP) FF ★ Radiation Treatment Center FF ★ Radiological Lab FF ★ ✚ ▲ Renal Dialysis Facility FF ▲ Respiratory Care Practitioner FF ★ ✚ t Rural Health Clinic – Hospital, Freestanding FF ★ ✪ t Multi-Specialty Group FF ★ ▲ Skilled Nursing Facility Nurse Practitioner/Clinical Nurse Specialist (NP/CNS) FF ★ ▲ Social Worker (LCSW) FF ★ ▲ Occupational Therapist (OT) FF ✚ SHARS — School, Co-op, or School District FF SHARS — Non-School FF ✚ t Family Planning Agency FF ★ Optician Federally Qualified Health Center (FQHC) FF ★ ✪ ▲ Optometrist (OD) FF ★ ✪ ▲ Orthotist FF ● Service Responsibility Option (SRO) FF ★ Outpatient Rehabilitation Facility (ORF) FF Specialized/Custom Wheeled Mobility - CCP FF Specialized/Custom Wheeled Mobility - Home Health FF ✚ ● TB Clinic FF ♦ Vision Medical Supplier (VMS) FF ★ t Federally Qualified Satellite (FQS) Freestanding Psychiatric Facility FF ▲ Personal Assistant Services FF ✚ ▲ ★ Pharmacy Group FF ★ Freestanding Rehabilitation Facility FF ★ FF ★ ▲ Pharmacist FF ✚ ▲ Genetics FF ★ ✪ ▲ t Physician Assistant FF ★ FF ★ ✪ ▲ FF ★ t FF t Federally Qualified Look-alike (FQL) FF ★ ✪ ▲ t Physician (MD, DO) OB/GYN and Pediatricians not required to have a Medicare Number FF ★ ▲ Physical Therapist (PT) Medicare Waiver Request Instructions: Choose one of the boxes below if requesting a Medicare waiver. FF I certify my practice is limited to individuals birth through 20 years of age. I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. A signed Explanation / Justification letter on company letterhead must be submitted to TMHP with submission of this application’s signature page for consideration of the Medicare Waiver Request. FF I certify that the service(s) I render is/are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled. A signed Explanation / Justification letter on company letterhead must be submitted to TMHP with submission of this application’s signature page for consideration of the Medicare Waiver Request. Page 2.1 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Identification Form Legend: ● ✪ ▲ ★ Approval Letter/Contract required Eligible for Medicare waiver request (you must check the Medicare waiver request box below) License/certification required Medicare number required ✚ ♦ t Must designate if public provider Palmetto number required Women’s Health Program (WHP) (certification required for reimbursement) Case Management Services FF ✚ ● Early Childhood Intervention (ECI) FF ▲ ● Case Management for Children and Pregnant Women (CPW) FF ✚ ● MH Case Management/MR Case Management FF ● Blind Children’s Vocational Discovery & Development Program FF ● Women, Infants & Children (WIC) — Immunization Only FF ● MH Rehab Comprehensive Care Services (CCP) FF ▲ Dietician FF ▲ Physical Therapist (PT-CCP) FF ▲ Licensed Vocational Nurse (LVN) FF ▲ Registered Nurse (RN) FF Milk Donor FF ▲ Social Worker (LCSW-ACP) FF ▲ Occupational Therapist (OT-CCP) FF ▲ Speech Therapist (SLP) FF ● Pharmacy (please refer to the definition of Pharmacy in the Enrollment Requirements by Provider Type section) Texas Health Steps (THSteps) Services (EPSDT) FF I do not wish to participate as a provider for THSteps preventive medical checkups. Texas Vaccines for Children Program (TVFC) Texas Medicaid does not reimburse for vaccines available from Texas Vaccines for Children (TVFC) program. Yes No Do you currently receive free vaccines from TVFC? (if No, answer the next question) Yes No Does your clinic/practice provide routinely recommended vaccines to children birth through 18 years of age? (If Yes, complete the Texas Vaccines for Children Program Enrollment form at the back of this application) All correspondence related to this application (i.e., enrollment denials, deficiency letters) will also be mailed to the physical address listed on your application unless otherwise requested. Submit a cover letter listing the contact address and phone number to have deficiency letters mailed elsewhere. Page 2.2 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Required Forms for Medicaid Enrollment To avoid any delay of the enrollment process, use this sheet as a checklist. For assistance with completing these forms, call the TMHP Contact Center at 1-800-925-9126 and select option 2. All Providers The following forms must be completed and returned for processing: FF Texas Medicaid Provider Enrollment Application FF Texas Medicaid Identification Form FF HHSC Medicaid Provider Agreement (original signatures required) FF Provider Information Form (PIF-1) FF Principal Information Form (PIF-2) FF Disclosure of Ownership and Control Interest Statement Form (performing providers exempt) FF IRS W-9 Form (performing providers exempt) The following requested attachments must accompany the enrollment when applicable: FF If enrolled with Medicare, you must attach a copy of your Medicare Remittance Advice Notices (MRAN) that is not older than four weeks from the application submitted date FF Copy of Certification of Mammography Systems (for all providers rendering mammography services) FF Medicare Approval letter – if applicable FF CLIA Certificate – if applicable (required for Independent Labs) FF Medicaid Audit Information (facilities only) FF Cover letter with contact information including phone number and address if deficiency letters should be mailed somewhere other than the physical address on the application FF Medicaid Women’s Health Program (WHP) Certification If Incorporated The following forms must be completed and returned for processing: FF Corporate Board of Directors Resolution Form – MUST BE NOTARIZED. FF *For corporations formed prior to January 1, 2006: Articles or Certificate of Incorporation/Certificate of Authority/Certificate of Fact (required for in-state corporations; certificate can be obtained from the Office of Secretary of State) FF *For corporations formed on or after January 1, 2006: Certificates of Formation or Certificate of Filing FF *Certificate of Good Standing *Out-of-state providers not providing services in the state of Texas are exempt Certificate of Good Standing This certificate must be obtained from the Texas State Comptroller’s Office. Obtain a certificate by contacting the following: State Comptroller’s Office: Tax Assistance Section Sales and Use Taxes: 1-800-252-5555 Franchise Tax: 1-800-252-1381 Austin Number: 1-800-252-1386 This request is free and may be made by telephone. The certificate is mailed to the requester. Callers must have the taxpayer’s name, federal tax ID number, and the charter number available at the time of the request. Providers who answer ”yes” to the question “Do you have a 501©(3) Internal Revenue Exemption” must submit a copy of their IRS Exemption Letter with submission of this application’s signature page. Providers who have a 501(c)(3) Internal Revenue Exemption are not required to submit a copy of the Letter of Good Standing from the State Comptroller’s Office. NOTE: Retain a copy of all documents for your records. Page 3 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Useful Information—Please Read Filing Deadline Information When a service is a benefit of Medicare and Medicaid, and the client is covered by both programs, the claim must be filed with Medicare first. TMHP only processes one client per Medicare RA. For multiple clients, submit one copy per client. TMHP must receive Medicaid claims within 95 days from the date of Medicare disposition. Providers submit the Medicare Remittance Advice Notice (MRAN) with the client’s Medicaid number to TMHP. When a client is eligible for Medicare Part B only, the inpatient hospital claim for services covered as Medicaid only is sent directly to TMHP and subject to the 95-day filing deadline (from date of discharge). All claims for services rendered to Medicaid clients who do not have Medicare benefits are subject to a filing deadline from date of service of: • 95 days of the date of service on the claim, or within 95 days from the date a new provider identifier is issued for instate providers and providers located within 50 miles of the Texas state border • 365 days for OUT-OF-STATE providers or from the discharge date for inpatient claims The Texas Administrative Code (TAC), Code of Federal Regulations, and Texas Health and Human Services Commission (HHSC) established these deadlines. Therefore, providers must submit all claims for services that have been provided to Medicaid clients to the following address within the 95-day filing deadline. Texas Medicaid & Healthcare Partnership PO Box 200555 Austin, TX 78720-0555 Providers with a pending application should submit any claims that are nearing the 365-day deadline from the date of service. Claims will be rejected by TMHP until a provider identifier is issued Providers can use the TMHP rejection report as proof of meeting the 365-day deadline and submit an appeal. Procedures for appealing denied or rejected claims are included on the Remittance and Status (R&S) report that is available for download at www.tmhp.com and in the claims filing section of the Texas Medicaid Provider Procedures Manual. Limited (“Lock–In”) Information Clients are placed in the Limited Program if, on review by HHSC and the Office of Inspector General (OIG), their use of Medicaid services shows duplicative, excessive, contraindicated, or conflicting health care and/or drugs; or if the review indicates abuse, misuse, or fraudulent actions related to Medicaid benefits and services. Clients qualifying for limited primary care provider status are required to choose a primary care provider. The provider can be a doctor, clinic, or nurse practitioner in the Medicaid program. If a limited candidate does not choose an appropriate care provider, one is chosen for the client by HHSC/OIG after obtaining an agreement from the provider. The provider is responsible for determining appropriate medical services and the frequency of such services. A referral by the primary care provider is required if the client is treated by other providers. Change of Ownership (CHOW) Under procedures set forth by the Centers for Medicare and Medicaid Services (CMS) and HHSC, a change of ownership of a facility does not terminate Medicare eligibility. Therefore, Medicaid participation may be continued provided that the new owners comply with the following requirements: 1. Obtain recertification as a Title XVIII (Medicare) facility under the new ownership. 2. Complete new Medicaid provider enrollment packet. 3. Provide TMHP with copy of the Contract of Sale (specifically, a signed agreement that includes the identification of previous and current owners). 4. Give a listing of ALL provider identifiers affected by the change of ownership. Written Communication Telephone Communication Enrollment Applications: Texas Medicaid & Healthcare Partnership Attn: Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Claims: Texas Medicaid & Healthcare Partnership PO Box 200555 Austin, TX 78720-0555 CCP Provider Customer Service . . . . . . . . . . . 1-800-846-7470 TMHP Contact Center . . . . . . . . . . . . . . . . . . 1-800-925-9126 TMHP EDI Help Desk . . . . . . . . . . . . . . . . . . . 1-888-863-3638 Page 4.1 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Useful Information—Please Read Q. How long does it take to process an enrollment application? A. After receipt of all information necessary to process the application, the entire application process can take up to 45 days. This may be extended in special circumstances. NOTE: Because family planning agencies may require a site visit, the application process for this provider type could take several weeks to complete. Q. Are original signatures required? A. Yes. Applications must contain original, not copied signatures. Computerized or stamped signatures are not permitted. Forms that are submitted without a hand-written signature will be rejected. Q. Are temporary licenses accepted? A. Temporary licenses are only accepted for physicians. Providers are also required to submit to TMHP, within 10 days of occurrence, notice that the provider’s license or certification has been partially or completely suspended, revoked, or retired. Not abiding by this license and certification update requirement may impact a provider’s qualification to continued participation in Texas Medicaid. Q. Should I send my application via express or certified mail? A. Because of the tremendous amount of incoming mail, sending applications through FedEx or UPS helps to ensure receipt of the information, to locate information through tracking numbers, and guarantee quicker delivery. Do not send certified mail to the post office box as TMHP is unable to track these packages. Send any certified mail to the physical address: TMHP-Provider Enrollment, 12357B Riata Trace Parkway, Austin, TX 78727 Q. How will I be notified of my new Texas Provider Identifier (TPI)? A. Notification letters are printed the business day after an application is processed. Notifications are mailed to the physical address listed on the application. The new provider will also receive a welcome letter informing them where to access provider manuals and other necessary documents. Q. Does TMHP supply claim forms? A. TMHP does not supply CMS-1500, Dental ADA, and UB-04 claim forms. These forms can be purchased at any medical office supply store or you can file electronically using TexMedConnect at no charge to you. Q. Should I hold claims until I receive a TPI? A. No, refer to Read Filing Deadline Information in the Useful Information section for claims filing information. Q. As a Medicaid provider, how long am I required to retain records pertaining to services rendered? A. Records must be retained for a minimum of five years from the date of service or until all audit questions, appeal hearings, investigations, or court cases are resolved. This requirement is extended to six years for freestanding rural health clinics (RHCs), and to 10 years for hospital-based RHCs. The records retention requirements do not affect any time limit to pursue administrative, civil, or criminal claims. Q. How do my address, phone number, and other information get updated when changes occur? A. Texas State Health-Care Program providers can access the TMHP Online Provider Lookup on www.tmhp.com to view their own information to keep their practice and contact information up to date, in accordance with the provider enrollment agreement. Providers can make changes to the following fields: • Address, telephone numbers, and office hours • Languages spoken • Additional sites where services are provided • Accepting new patients • Additional services offered • Client age or gender limitations • Counties served • Medicaid waiver programs Providers must notify TMHP of any changes by submitting the Provider Information Change (PIC) Form located in the forms section of the Texas Medicaid Provider Procedures Manual. Page 4.2 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Provider Enrollment Application • All information must be completed and contain a valid signature to be processed. If a question or answer does not apply, enter “N/A”. • Original signatures only; copies or stamped signatures not accepted. • Use blue or black ink. REQUESTING ENROLLMENT AS: (Refer to Enrollment Requirements by Provider Type) Individual Facility Group Performing Provider (List group information in Section A) Section A — Provider of Service Information Existing Texas Provider Identifiers (TPIs): (List all TPIs associated with the individual/group enrolling) List NPI and Primary Taxonomy Code: (NPI not required for Consumer Directed Services Agency [CDSA], Milk Donor Bank, Personal Assistance Services, and Service Responsibility Option [SRO]) Group/Company or Last Name First (list performing provider information in Section C) Initial Title/Degree: Do you want to be a limited provider? (see Useful Information) Yes No Provider business e-mail: (if applicable) Provider website address: (if applicable) Telephone number: Social Security Number: (for individual enrollment only) Professional License Number: Copy of license/temporary license required. (see Identification Form for those requiring licenses) Initial issue date: Expiration date: Pharmacist Immunization Certification or CCNA Certification: MM/DD/YYYY Issue date: Expiration date: Medicare Intermediary: Medicare number: Medicare certification date: Legal name according to the IRS: Date of birth: Federal Tax ID number: Primary specialty: Sub-specialty: MM/DD/YYYY (see Identification Form for requirements) Physical address: (where health care is rendered) Street MM/DD/YYYY MM/DD/YYYY (if applicable) (if applicable) MM/DD/YYYY (must match the legal name field on the W-9 & Disclosure of Ownership) Number MM/DD/YYYY Suite City State ZIP Page 5.1 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Provider Enrollment Application Accounting/billing address: (if applicable) Number Street Suite Physical address FAX number: Accepting new clients: Yes No City State ZIP Accounting/billing address FAX number: (optional) Gender served: Male Client age restrictions: Female All Counties served: Indicate your reason for applying to join the Texas State Health-Care Programs: (Select one) FF Access to an online application FF Learned about Texas State Health-Care Programs at a provider workshop FF Adding a new location FF Recruited by Texas State Health-Care Programs staff FF Adding performing provider to an existing group FF Recruited by TMHP Provider Relations representative FF Electronic claims processing FF Re-enrolling a provider under an existing provider identifier FF Improved administrative processes FF Reimbursement increases FF Incentive programs FF Timely reimbursement FF Learned about Texas State Health-Care Programs at a conference Is this a freestanding facility? No Yes No Yes No Are you an audiologist? Yes No Yes No Yes No Do you provide hearing services for children? Yes Will you be dispensing hearing aids? Womens’ Health Program: No Will you be conducting evaluations? If enrolling as a special education co-op, attach a list of all school districts in the coop that will be providing SHARS services. Provide the following information for each school district: • Complete address • School District Number • T.E.A. number Yes Are you a fitter/dispenser? School Health and Related Services (SHARS) Providers Only: Is this a hospital-based facility? Are you a physician? Hearing aid providers only: No Is this an ESRD facility? If Yes, what is your composite rate? Facilities only: Yes Yes No Are you enrolling as a school district? Yes No Are you enrolling as a non-school SHARS provider? If Yes, attach school affiliation letter. Yes No Will you perform Women’s Health Program Services? If Yes, attach the Medicaid Women’s Health Program (WHP) Certification. Yes No If Yes, give school six-digit T.E.A. number: Page 5.2 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Provider Enrollment Application Yes Are you a hospital facility? No If Yes, indicate the type of hospital facility. Children’s Teaching Facility Long Term Private Outpatient Short Term Private Full Care Psychiatric Rehabilitation Hospital providers only: State-owned Non-profit Date of Construction? If you are a hospital facility, what is your average daily room rate for private and semi-private? Private Semi-Private Definition — Public entities are those that are owned or operated by a city, state, county, or other government agency or instrumentality, according to the Code of Federal Regulations, including any agency that can do intergovernmental transfers to the State. Public agencies include those that can certify and provide state matching funds. Public/Private entities: (required of all providers) Private Are you a private or public entity? If you are a public entity, are you required to certify expended funds? Yes Public No Name and address of a person certifying expended funds: Section B — Owners, Partners, Officers, Directors, and Principals Identify sole proprietor or owners, partners, officers, directors, and principals [as defined in Principal Information Form (PIF-2)] of the applicant by providing, social security number, date of birth, driver’s license # and state, and list the percentage of ownership, if applicable. Total ownership should equal 100%. As it relates to owners, include all individuals with 5% or more ownership in the company, whether this ownership is direct or indirect. 1 Name: Social Security Number: 2 Name: Social Security Number: 3 Name: Social Security Number: 4 Name: Social Security Number: Title: Date of birth: MM/DD/YYYY Title: Date of birth: MM/DD/YYYY Title: Date of birth: MM/DD/YYYY Title: Date of birth: MM/DD/YYYY Percentage Owned: Drivers license number/State issuer: Percentage Owned: Drivers license number/State issuer: Percentage Owned: Drivers license number/State issuer: Percentage Owned: Drivers license number/State issuer: Page 5.3 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Provider Enrollment Application Section C — Group Practice Required if enrolling as a GROUP PRACTICE Group 9-digit Texas Medicaid TPI : OR Group Medicare number: (if applicable) Indicate the type of group enrollment you are requesting by checking one of the following: FF Adding additional performing provider(s) to an existing group (Indicate Group TPI above) FF Enrolling a new group with performing provider(s) 1. Name: TPI number(s): (only applicable for existing performing providers) 2. (only applicable for existing performing providers) Name: TPI number(s): (only applicable for existing performing providers) 4. Name: TPI number(s): (only applicable for existing performing providers) 5. (only applicable for existing performing providers) Professional license initial issue date: Pharmacist certification issue date: Medicare number: Social Security Number: Title/Degree: Professional license initial issue date: Pharmacist certification issue date: Medicare number: Social Security Number: Title/Degree: Professional license initial issue date: Pharmacist certification issue date: Medicare number: MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY Date of birth: MM/DD/YYYY Social Security Number: Professional license number: Name: TPI number(s): Professional license number: Title/Degree: Date of birth: MM/DD/YYYY Professional license number: Social Security Number: Date of birth: MM/DD/YYYY Professional license number: Name: TPI number(s): 3. Date of birth: MM/DD/YYYY Title/Degree: Professional license initial issue date: Medicare number: MM/DD/YYYY Pharmacist certification issue date: MM/DD/YYYY Date of birth: MM/DD/YYYY Social Security Number: Professional license number: Title/Degree: Professional license initial issue date: Medicare number: MM/DD/YYYY Pharmacist certification issue date: MM/DD/YYYY Page 5.4 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Texas Medicaid Provider Enrollment Application Section D — Required Information for Specific Provider Types All Licensed Providers Ambulance Services Providers Birthing Center Providers Certified Registered Nurse Anesthetist Providers Chemical Dependency Treatment Facility Providers CLIA Providers ECI Providers FQHC/FQS/FQHL Mammography Services Providers MH/MR Providers If enrolled with Medicare, you must attach a copy of a current Medicare Remittance Advice Notice (MRAN). You must attach a copy of your permit/license. You must attach a copy of your certification permit. You must attach a copy of your CRNA certification or re–certification card. You must attach a copy of your license. You must attach a copy of your CLIA license with approved specialty services as appropriate. You must attach a copy of your approval letter from the Interagency Council on Early Childhood Intervention. You must attach a copy of your grant award. You must attach a copy of your mammography systems certification from the Bureau of Radiation Control (BRC) and enter your certification number below. Certification Number: ________________________________________________ You must attach a copy of your approval letter from the State of Texas. Case Management for Children and Pregnant Women Providers You must attach a copy of your approval letter from the Department of State Health Services (DSHS) if you are enrolling as a new group or individual. Non-School SHARS Providers You must attach a copy of your affiliation letter from the school district. Requirements of a valid affiliation letter are found in the Texas Medicaid Provider Procedures Manual, School Health and Related Services (SHARS) section. You must submit proof of meeting one of the following criteria prior to being able to enroll with Texas Medicaid: • Services are more readily available in the state where the client is temporarily located • The customary or general practice for clients in a particular locality is to use medical resources in the other state (this is limited to providers located in a state bordering Texas). Out of State Providers The following are subject to a 90 day enrollment: • A medical emergency documented by the attending physician or other provider • The client’s health is in danger if he or she is required to travel to Texas • All services provided to adopted children receiving adoption subsidies (these children are covered for all services, not just emergency). • Other out-of-state medical care may be considered when prior authorized. • Medicare primary, Medicaid secondary for coinsurance and/or deductible payments only Refer to the Texas Medicaid Provider Procedures Manual at www.tmhp.com for further information. Page 5.5 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com HHSC Medicaid Provider Agreement Name of provider enrolling: Medicaid TPI: (if applicable) Physical address: Number Street Accounting/billing address: (if applicable) Number Street Medicare provider ID number: (if applicable) Suite City State ZIP Suite City State ZIP As a condition for participation as a provider under the Texas Medical Assistance Program (Medicaid), the provider (Provider) agrees to comply with all terms and conditions of this Agreement. I. ALL PROVIDERS 1.1 Agreement and documents constituting Agreement. A CD of the current Texas Medicaid Provider Procedures Manual (Provider Manual) has been or will be furnished to the Provider. The Provider Manual, all revisions made to the Provider Manual through the bimonthly update entitled Texas Medicaid Bulletin, and written notices are incorporated into this Agreement by reference. The Provider Manual, bulletins and notices may be accessed via the internet at www.tmhp.com. Providers may obtain a copy of the manual by calling 1-800-925-9126. Provider has a duty to become educated and knowledgeable with the contents and procedures contained in the Provider Manual. Provider agrees to comply with all of the requirements of the Provider Manual, as well as all state and federal laws governing or regulating Medicaid, and provider further acknowledges and agrees that the provider is responsible for ensuring that all employees and agents of the provider also comply. Provider is specifically responsible for ensuring that the provider and all employees and agents of the Provider comply with the requirements of Title 1, Part 15, Chapter 371 of the Texas Administrative Code, related to waste, abuse and fraud, and provider acknowledges and agrees that the provider and its principals will be held responsible for violations of this agreement through any acts or omissions of the provider, its employees, and its agents. For purposes of this agreement, a principal of the provider includes all owners with a direct or indirect ownership or control interest of 5 percent or more, all corporate officers and directors, all limited and non-limited partners, and all shareholders of a legal entity, including a professional corporation, professional association, or limited liability company. Principals of the provider further include managing employee(s) or agents who exercise operational or managerial control or who directly or indirectly manage the conduct of day-to-day operations. 1.2 State and Federal regulatory requirements. 1.2.1 By signing this agreement, Provider certifies that the provider and it’s principals have not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any program under Title XVIII (Medicare), Title XIX (Medicaid), or under the provisions of Executive Order 12549, relating to federal contracting. Provider further certifies that the provider and its principals have also not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any other state or federal health-care program. Provider must notify the Health and Human Services Commission (HHSC) or its agent within 10 business days of the time it receives notice that any action is being taken against Provider or any person defined under the provisions of Section 1128(A) or (B) of the Social Security Act (42 USC §1320a-7), which could result in exclusion from the Medicaid program. Provider agrees to fully comply at all times with the requirements of 45 CFR Part 76, relating to eligibility for federal contracts and grants. 1.2.2 Provider agrees to disclose information on ownership and control, information related to business transactions, and information on persons convicted of crimes in accordance with 42 CFR Part 455, Subpart B, and provide such information on request to the Texas Health and Human Services Commission (HHSC), Department of State Health Services (DSHS), Texas Attorney General’s Medicaid Fraud Control Unit, and the United States Department of Health and Human Services. Provider agrees to keep its application for participation in the Medicaid program current at all times by informing HHSC or its agent in writing of any changes to the information contained in its application, including, but not limited to, changes in ownership or control, federal tax identification number, phone number, or provider business addresses, at least 10 business days before making such changes. Provider also agrees to notify HHSC or its agent within 10 business days of any restriction placed on or suspension of the Provider’s license or certificate to provide medical services, and Provider must provide to HHSC complete information related to any such suspension or restriction. Provider agrees to disclose all convictions of Provider or Provider’s principals within 10 business days of the date of conviction. For purposes of this disclosure, Provider must use the definition of “Convicted” contained in 42 CFR 1001.2, which includes all convictions, deferred adjudications, and all types of pretrial diversion programs. Send the information to Office of Inspector General, P.O. Box 85211 – Mail Code 1361, Austin, Texas 78708. Fully explain the details, including the offense, the date, the state and county where the conviction occurred, and the cause number(s). Page 6.1 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com 1.2.3 This Agreement is subject to all state and federal laws and regulations relating to fraud, abuse and waste in health care and the Medicaid program. As required by 42 CFR § 431.107, Provider agrees to create and maintain all records necessary to fully disclose the extent and medical necessity of services provided by the Provider to individuals in the Medicaid program and any information relating to payments claimed by the Provider for furnishing Medicaid services. On request, Provider also agrees to provide these records immediately and unconditionally to HHSC, HHSC’s agent, the Texas Attorney General’s Medicaid Fraud Control Unit, DARS, DADS, DFPS, DSHS and the United States Department of Health and Human Services. The records must be retained in the form in which they are regularly kept by the Provider for a minimum of five years from the date of service (six years for freestanding rural health clinics and ten years for hospital based rural health clinics); or, until all audit or audit exceptions are resolved; whichever period is longest. Provider must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning, or prosecuting suspected fraud and abuse. Provider must also allow these agencies and their agents unconditional and unrestricted access to its records and premises as required by Title 1 TAC, §371.1643. Provider understands and agrees that payment for goods and services under this agreement is conditioned on the existence of all records required to be maintained under the Medicaid program, including all records necessary to fully disclose the extent and medical necessity of services provided, and the correctness of the claim amount paid. If provider fails to create, maintain, or produce such records in full accordance with this Agreement, provider acknowledges, agrees, and understands that the public monies paid the provider for the services are subject to 100% recoupment, and that the provider is ineligible for payment for the services either under this agreement or under any legal theory of equity. 1.2.4 The Texas Attorney General’s Medicaid Fraud Control Unit, Texas Health and Human Services Commission’s Office of Inspector General (OIG), and internal and external auditors for the state and federal government may conduct interviews of Provider employees, agents, subcontractors and their employees, witnesses, and clients without the Provider’s representative or Provider’s legal counsel present. Provider’s employees, agents, subcontractors and their employees, witnesses, and clients must not be coerced by Provider or Provider’s representative to accept representation from or by the Provider, and Provider agrees that no retaliation will occur to a person who denies the Provider’s offer of representation. Nothing in this agreement limits a person’s right to counsel of his or her choice. Requests for interviews are to be complied with in the form and the manner requested. Provider will ensure by contract or other means that its agents, employees and subcontractors cooperate fully in any investigation conducted by the Texas Attorney General’s Medicaid Fraud Control Unit or the Texas Health and Human Services Commission’s Office of Inspector General or its designee. Subcontractors include those persons and entities that provide medical or dental goods or services for which the Provider bills the Medicaid program, and those who provide billing, administrative, or management services in connection with Medicaid-covered services. 1.2.5 Nondiscrimination. Provider must not exclude or deny aid, care, service, or other benefits available under Medicaid or in any other way discriminate against a person because of that person’s race, color, national origin, gender, age, disability, political or religious affiliation or belief. Provider must provide services to Medicaid clients in the same manner, by the same methods, and at the same level and quality as provided to the general public. Provider agrees to grant Medicaid recipients all discounts and promotional offers provided to the general public. Provider agrees and understands that free services to the general public must not be billed to the Medicaid program for Medicaid recipients and discounted services to the general public must not be billed to Medicaid for a Medicaid recipient as a full price, but rather the Provider agrees to bill only the discounted amount that would be billed to the general public. 1.2.6 AIDS and HIV. Provider must comply with the provisions of Texas Health and Safety Code Chapter 85, and HHSC’s rules relating to workplace and confidentiality guidelines regarding HIV and AIDS. 1.2.7 Child Support. (1) The Texas Family Code §231.006 requires HHSC to withhold contract payments from any entity or individual who is at least 30 days delinquent in court-ordered child support obligations. It is the Provider’s responsibility to determine and verify that no owner, partner, or shareholder who has at least 25 percent ownership interest is delinquent in any child support obligation. (2) Under Section 231.006 of the Family Code, the vendor or applicant certifies that the individual or business entity named in the applicable contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this Agreement may be terminated and payment may be withheld if this certification is inaccurate. A child support obligor who is more than 30 days delinquent in paying child support or a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25 percent is not eligible to receive the specified grant, loan, or payment. (3) If HHSC is informed and verifies that a child support obligor who is more than 30 days delinquent is a partner, shareholder, or owner with at least a 25 percent ownership interest, it will withhold any payments due under this Agreement until it has received satisfactory evidence that the obligation has been satisfied. 1.2.8 Cost Report, Audit and Inspection. Provider agrees to comply with all state and federal laws relating to the preparation and filing of cost reports, audit requirements, and inspection and monitoring of facilities, quality, utilization, and records. 1.3 Claims and encounter data. 1.3.1 Provider agrees to submit claims for payment in accordance with billing guidelines and procedures promulgated by HHSC, or other appropriate payer, including electronic claims. Provider certifies that information submitted regarding claims or encounter data will be true, accurate, and complete, and that the Provider’s records and documents are both accessible and validate the services and the need for services billed and represented as provided. Further, Provider understands that any falsification or concealment of a material fact may be prosecuted under state and federal laws. 1.3.2 Provider must submit encounter data required by HHSC or any managed care organization to document services provided, even if the Provider is paid under a capitated fee arrangement by a Health Maintenance Organization or Insurance Payment Assistance. Page 6.2 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com 1.3.3 All claims or encounters submitted by Provider must be for services actually rendered by Provider. Physician providers must submit claims for services rendered by another in accordance with HHSC rules regarding providers practicing under physician supervision. Claims must be submitted in the manner and in the form set forth in the Provider Manual, and within the time limits established by HHSC for submission of claims. Claims for payment or encounter data submitted by the provider to an HMO or IPA are governed by the Provider’s contract with the HMO or IPA. Provider understands and agrees that HHSC is not liable or responsible for payment for any Medicaid-covered services provided under the HMO or IPA Provider contract, or any agreement other than this Medicaid Provider Agreement. 1.3.4 Federal and state law prohibits Provider from charging a client or any financially responsible relative or representative of the client for Medicaid-covered services, except where a co-payment is authorized under the Medicaid State Plan (42 CFR §447.20). 1.3.5 As a condition of eligibility for Medicaid benefits, a client assigns to HHSC all rights to recover from any third party or any other source of payment (42 CFR §433.145 and Human Resources Code §32.033). Except as provided by HHSC’s third-party recovery rules (Texas Administrative Code Title 1 Part 15 Chapter 354 Subchapter J), Provider agrees to accept the amounts paid under Medicaid as payment in full for all covered services (42 CFR §447.15). 1.3.6 Provider has an affirmative duty to verify that claims and encounters submitted for payment are true and correct and are received by HHSC or its agent, and to implement an effective method to track submitted claims against payments made by HHSC or its agents. 1.3.7 Provider has an affirmative duty to verify that payments received are for actual services rendered and medically necessary. Provider must refund any overpayments, duplicate payments and erroneous payments that are paid to Provider by Medicaid or a third party as soon as any such payment is discovered or reasonably should have been known. 1.3.8 TMHP EDI and Electronic Claims Submission. Provider may subscribe to the TMHP Electronic Data Interchange (EDI) system, which allows the Provider the ability to electronically submit claims and claims appeals, verify client eligibility, and receive electronic claim status inquiries, remittance and status (R&S) reports, and transfer of funds into a provider account. Provider understands and acknowledges that independent registration is required to receive the electronic funds or electronic R&S report. Provider agrees to comply with the provisions of the Provider Manual and the TMHP EDI licensing agreement regarding the transmission and receipt of electronic claims and eligibility verification data. Provider must verify that all claims submitted to HHSC or its agent are received and accepted. Provider is responsible for tracking claims transmissions against claims payments and detecting and correcting all claims errors. If Provider contracts with third parties to provide claims and/or eligibility verification data from HHSC, the Provider remains responsible for verifying and validating all transactions and claims, and ensuring that the third party adheres to all client data confidentiality requirements. 1.3.9 Reporting Waste, Abuse and Fraud. Provider agrees to inform and train all of Provider’s employees, agents, and independent contractors regarding their obligation to report waste, abuse, and fraud. Individuals with knowledge about suspected waste, abuse, or fraud in any State of Texas health and human services program must report the information to the HHSC Office of Inspector General (OIG). To report waste, abuse or fraud, go to www.hhs.state.tx.us and select “Reporting Waste, Abuse, or Fraud”. Individuals may also call the OIG hotline (1-800-436-6184) to report waste, abuse or fraud if they do not have access to the Internet. II. ADVANCE DIRECTIVES – HOSPITAL AND HOME HEALTH PROVIDERS 2.1 The client must be informed of their right to refuse, withhold, or have medical treatment withdrawn under the following state and federal laws: 2.1.1 the individual’s right to self-determination in making health-care decisions; 2.1.2 the individual’s rights under the Natural Death Act (Health and Safety Code, Chapter 672) to execute an advance written Directive to Physicians, or to make a non-written directive regarding their right to withhold or withdraw life-sustaining procedures in the event of a terminal condition; 2.1.3 the individual’s rights under Health and Safety Code, Chapter 674, relating to written Out-of-Hospital Do-Not-Resuscitate Orders; and, 2.1.4 the individual’s rights to execute a Durable Power of Attorney for Health Care under the Civil Practice and Remedies Code, Chapter 135, regarding their right to appoint an agent to make medical treatment decisions on their behalf in the event of incapacity. 2.2 The Provider must have a policy regarding the implementation of the individual’s rights and compliance with state and federal laws. 2.3 The Provider must document whether or not the individual has executed an advance directive and ensure that the document is in the individual’s medical record. 2.4 The Provider cannot condition giving services or otherwise discriminate against an individual based on whether or not the client has or has not executed an advance directive. 2.5 The Provider must provide written information to all adult clients on the provider’s policies concerning the client’s rights. 2.6 The Provider must provide education for staff and the community regarding advance directives. Page 6.3 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com III. STATE FUND CERTIFICATION REQUIREMENT FOR PUBLIC ENTITY PROVIDERS 3.1 Public providers are those that are owned or operated by a state, county, city, or other local government agency or instrumentality. Public entity providers of the following services are required to certify to HHSC the amount of state matching funds expended for eligible services according to established HHSC procedures: • School health and related services (SHARS) • Case management for blind and visually impaired children (BVIC) • Case management for early childhood intervention (ECI) • Service coordination for mental retardation (MR) • Service coordination for mental health (MH) • Mental health rehabilitation (MHR) • Tuberculosis clinics • State hospitals 3.2 A school district that is the sponsoring entity for a non-school SHARS provider is required to reimburse HHSC, according to established HHSC procedures, the non-federal portion of payments to the nonschool SHARS provider, since nonschool SHARS providers are paid the lesser of the provider’s billed charges and 100% of the published fee for the service (i.e., both federal and state shares). To enroll in Texas Medicaid, a nonschool SHARS provider must submit in its enrollment packet an affiliation letter that meets the requirements in Texas Medicaid Provider Procedures Manual, School Health and Related Services. IV. CLIENT RIGHTS 4.1 Provider must maintain the client’s state and federal right of privacy and confidentiality to the medical and personal information contained in Provider’s records. 4.2 The client must have the right to choose providers unless that right has been restricted by HHSC or by waiver of this requirement from the Centers for Medicare and Medicaid Services (CMS). The client’s acceptance of any service must be voluntary. 4.3 The client must have the right to choose any qualified provider of family planning services. V. THIRD PARTY BILLING VENDOR PROVISIONS 6.1 Provider agrees to submit notice of the initiation and termination of a contract with any person or entity for the purpose of billing Provider’s claims, unless the person is submitting claims as an employee of the Provider and the Provider is completing an IRS Form W-2 on that person. This notice must be submitted within 5 working days of the initiation and termination of the contract and submitted in accordance with Medicaid requirements pertaining to Third Party Billing Vendors. Provider understands that any delay in the required submittal time or failure to submit may result in delayed payments to the Provider and recoupment from the Provider for any overpayments resulting from the Providers failure to provide timely notice. Provider must have a written contract with any person or entity for the purpose of billing provider’s claims, unless the person is submitting claims as an employee of the Provider and the Provider is completing an IRS Form W-2 on that person. The contract must be signed and dated by a Principal of the Provider and the Biller. It must also be retained in the Provider’s and Biller’s files according with the Medicaid records retention policy. The contract between the Provider and Biller may contain any provisions they deem necessary, but, at a minimum, must contain the following provisions: • • Biller understands that they may be criminally convicted and subject to recoupment of overpayments and imposed penalties for submittal of false, fraudulent, or abusive billings. • Provider agrees to submit to Biller true and correct claim information that contains only those services, supplies, or equipment Provider has actually provided to recipients. • Provider understands that they may be criminally convicted and subject to recoupment of overpayments and imposed penalties for submittal of false, fraudulent, or abusive billings, directly or indirectly, to the Biller or to Medicaid or it’s contractor. • Provider and Biller agree to establish a reimbursement methodology to Biller that does not contain any type of incentive, directly or indirectly, for inappropriately inflating, in any way, claims billed to the Medicaid program. • Biller agrees to enroll and be approved by the Medicaid program as a Third Party Billing Vendor prior to submitting claims to the Medicaid program on behalf of the Provider. • Biller agrees they will not alter or add procedures, services, codes, or diagnoses to the billing information received from the Provider, when billing the Medicaid program. Biller and Provider agree to notify the Medicaid program within 5 business days of the initiation and termination, by either party, of the contract between the Biller and the Provider. Page 6.4 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com VI. TERM AND TERMINATION This Agreement will be effective from the date finally executed until the termination date, if any, indicated in the enrollment correspondence issued by HHSC or its agent. If the correspondence/notice of enrollment from HHSC or its agent states a termination date, this agreement terminates on that date with or without other advance notice of the termination date. If the correspondence/notice of enrollment from HHSC or its agent does not state a termination date, this agreement is open-ended and remains effective until either a notice of termination is later issued or termination occurs as otherwise provided in this paragraph. Either party may terminate this Agreement voluntarily and without cause, for any reason or for no reason, by providing the other party with 30 days advance written notice of termination. HHSC may immediately terminate this agreement for cause, with or without advance notice, for the reason(s) indicated in a written notice of termination issued by HHSC or its agent. Cause to terminate this agreement may include the following actions or circumstances involving the provider or involving any person or entity with an affiliate relationship to the provider: exclusion from participation in Medicare, Medicaid, or any other publicly funded health-care program; loss or suspension of professional license or certification; any circumstances resulting in ineligibility to participate in Texas Medicaid; any failure to comply with the provisions of this Agreement or any applicable law, rule or policy of the Medicaid program; and any circumstances indicating that the health or safety of clients is or may be at risk. HHSC also may terminate this agreement due to inactivity, with or without notice, if the Provider has not submitted a claim to the Medicaid program for 12 or more months. VII. ACKNOWLEDGEMENTS AND CERTIFICATIONS By signing below, Provider acknowledges and certifies to all of the following: • Provider must notify TMHP if the Provider files or is the subject of a bankruptcy petition. The Provider must provide TMHP and HHSC with notice of the bankruptcy and must copy TMHP and HHSC with all the Provider’s pleading in the case. A failure to notify TMHP and HHSC of a bankruptcy petition is a material breach of the Provider Agreement. • Provider has screened all employees and contractors to determine whether any of them have been excluded before and after enrollment. • Provider has carefully read and understands the requirements of this agreement, and will comply. • Provider has carefully reviewed all of the information submitted in connection with its application to participate in the Medicaid program, including the provider information forms (PIF-1) and principal information form (PIF-2), and provider certifies that this information is current, complete, and correct. • Provider agrees to inform HHSC or its designee, in writing and within 10 business days, of any changes to the information submitted in connection with its application to participate in the Medicaid program, whether such change to the information occurs before or after enrollment. • Provider understands that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and state law. Fraud is a felony, which can result in fines or imprisonment. • Provider understands and agrees that any falsification, omission, or misrepresentation in connection with the application for enrollment or with claims filed may result in all paid services declared as an overpayment and subject to recoupment, and may also result in other administrative sanctions that include payment hold, exclusion, debarment, contract cancellation, and monetary penalties. Name of Applicant _____________________________________________________________________________________ Applicant’s Signature __________________________________________________ Date _____________________________ For applicants that are entities, facilities, groups, or organizations, and an authorized representative is completing this application with authority to sign on the applicant’s behalf, the authorized representative must sign above and print their name and title where indicated below. Representative’s Name _________________________________________________________________________________ Representative’s Position/Title ____________________________________________________________________________ Page 6.5 5/01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Provider Information Form (PIF-1) Provider Information Form (PIF-1) Each Provider must complete this Provider Information Form (PIF-1), before enrollment. A provider is any person or legal entity that meets the definition below. Each Provider must also complete a Principal Information Form (PIF-2), for each person who is a Principal of the Provider (see the PIF-2 form for a complete definition of every person who is considered to be a Principal of the Provider). All questions on this form must be answered by or on behalf of