MassHealth Flu and Adult Vaccine Program Provider Application Checklist.pdf
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- Solicitation number
- BD-15-1039-EHS01-EHS02-00000004399
- Issued by
- Massachusetts
About this file
This document is a checklist for the MassHealth Flu and Adult Vaccine Program Provider Application. It is issued by the Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid. The program is enrolling and paying local public health departments (LPHDs) for purchasing and administering influenza (flu) and adult vaccines, as well as public school districts (PSDs) for purchasing and administering flu vaccines to MassHealth members. The goal is to provide MassHealth members increased access to these vaccines in public health settings and geographic areas where they have difficulty accessing them. The checklist outlines the required documentation for the application, including a completed provider application, signed provider contract, data collection form, NPI verification, trading partner agreement, disclosures form, W-9, and EFT authorization. LPHDs and PSDs have different form requirements.
The checklist notes that submitting an incomplete application may result in a delay or denial. There are no details provided on pricing, set asides, incumbents, funding sources, or contract term and renewal options.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES
Office of Medicaid | www.mass.gov/masshealth
MassHealth Flu and Adult Vaccine Program Provider Application Checklist NOTE: Local public health departments are eligible for both flu and adult vaccines. Public school districts are only eligible for the flu component.
Please review the application instructions and MassHealth regulations to make sure that you have submitted all documentation needed to complete your application.
Before returning your application, refer to this list of items that you may need to include with your application.
This list is to help ensure that your application is complete. It does not supersede any application requirements in your program regulations. Submitting an incomplete application may result in a delay or denial of your application.
☐ A completed MassHealth Flu and Adult Vaccine Program Provider Application
☐ A signed MassHealth Flu Vaccine Provider Contract (for public school districts) or a signed MassHealth Flu and Adult Vaccine Program Provider Contract (for local public health departments)
☐ A completed Data Collection Form (DCF)
☐ Verification of your national provider identifier (NPI)
☐ A signed Trading Partner Agreement (TPA)
☐ A completed and signed Federally Required Disclosures (FRD) form, with the exception of Section IV.C, Business Transactions.
☐ A Massachusetts Substitute W-9 form, the Request for Taxpayer Identification Number and Certification (Form MA-W-9)
☐ An Authorization for Electronic Funds Transfer of MassHealth Payments form (EFT-1)
Note: Local public health departments must submit the W-9 and EFT-1 forms signed by the municipality’s treasurer. Public school districts must submit the W-9 and EFT-1 forms signed by the appropriate school administrator.
APP-FLU-V-CHK (Rev. 10/13)
File details come from the government source that posted it. Updated .