Provider Application - Independent Clinic.pdf

| page 1 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

PROVIDER APPLICATION

INDEPENDENT CLINIC/CENTER

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

APPLICATION TRACKING NUMBER (ATN)

This application will not be processed if any sections are left unanswered.

CONTACT INFORMATION FOR INDIVIDUAL COMPLETING THIS APPLICATION (MassHealth may contact you if there are questions about this application.)

Name Tel.

Email

REASON FOR APPLICATION

New Enrollment

Reactivation – Provider ID Service Location (PID/SL)

Adding New Location (s) – Current PID

Change of Address (Please complete the grid below; the PID/SL for the old location will be terminated for a change of address.)

PID/SL of the Old Location Effective Date DBA (doing business as) Address of the New Location

Is the application being submitted as a result of a merger, acquisition, closure, or change in corporate structure or other ownership structure? Yes No If Yes, please describe.

SECTION 1: ORGANIZATIONAL INFORMATION

Note: The information included in Section 1 MUST apply to all service locations included in Section 2. If the information in Section 1 does not apply, a separate provider application must be completed for that service location.

1.1 ORGANIZATION TYPE

Please indicate your provider type below (select one).

Community Health Center (CHC) (PT–20)* Family Planning Agency (PT–21) Abortion/Sterilization Clinic (PT–22) Renal Dialysis Clinic (PT–25) Mental Health Center (PT–26)

Substance Use Disorder Treatment (PT–28) Independent Diagnostic Testing Facility (IDTF) (PT–45) Certified Independent Laboratory (PT–46) Psychiatric Day Treatment (PT–65) Ambulatory Surgery Center (PT–84)

Freestanding Birth Center (PT-85) Radiation Oncology Treatment Center (PT–87) Indian Health Services (PT–91) Limited Services Clinic (PT–96)

Urgent Care Clinic (UCC) (PT–B8)

*These providers can enroll as PCCs. Providers who are interested in enrolling in the PCC plan must submit a completed Primary Care Clinician (PCC) Plan Provider Application (APP-PCC) along with a Primary Care Clinician (PCC) Plan Signature Page CON-PCC-SP.

| page 2 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

1.2 ORGANIZATION INFORMATION

Legal Name of the Clinic/Center Applicant (as reported to the Internal Revenue Service)

Legal Address (address registered with Internal Revenue Service for the independent clinic/center's federal employer identification number (FEIN))

Number/Street Building, Suite, or PO Box (if applicable)

City State Zip

ATTN/Title

Email Tel. Fax

1.3 TAXPAYER IDENTIFICATION NUMBER OF THE APPLICANT

Federal Employer Identification Number (FEIN)

1.4 MEDICAID INFORMATION FOR OTHER STATES (Attach additional pages, if necessary.)

Does the applicant currently participate, or did the applicant previously participate, in another state’s Medicaid program? Yes No

List Other State Medicaid Number

Effective Date End Date (if applicable)

List Other State Medicaid Number

Effective Date End Date (if applicable)

List Other State Medicaid Number

Effective Date End Date (if applicable)

1.5 MEDICARE INFORMATION

Is the applicant enrolled in Medicare as a provider? Yes No In process

Note: Medicare participation is required for certain provider types, including 25, 26, 45, 46, 84, and 87. MassHealth requires Medicare enrollment for any provider that files claims for services provided to MassHealth members who are also enrolled in Medicare (dual eligible members). Please refer to MassHealth's all-provider regulations and all applicable program-specific regulations. You can access these publications from the MassHealth website at www.mass.gov/masshealth-and-eohhs-regulations.

| page 3 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

1.6 CRIMINAL CONVICTION(S) INFORMATION (Attach additional pages, if necessary.)

Has the applicant ever been convicted of any state or federal crime in Massachusetts or any other state in the U.S., including, but not limited to, any criminal offense relating to the applicant’s involvement in any program established under Title XVIII, XIX, or XXI of the Social Security Act (i.e., Medicare, Medicaid, or CHIP)? Yes No

If Yes, provide the following information for each such conviction. Note: Convictions for criminal offenses other than offenses relating to the applicant’s involvement in any program established under Title XVIII, XIX, or XXI of the Social Security Act may be omitted if such conviction(s) 1) occurred more than 10 years before the date of this application, or 2) were punishable by imprisonment of less than one year, regardless of the date of such conviction.

Type of Crime

Date of Conviction Court/State Case or Record Number

Type of Crime

Date of Conviction Court/State Case or Record Number

Type of Crime

Date of Conviction Court/State Case or Record Number

1.7 SANCTION(S) INFORMATION (Attach additional pages, if necessary.)

Has the applicant or any of its affiliated service locations ever been subject to any disciplinary action, sanction, or other limitation or restriction of any nature imposed with or without consent by any state (including Massachusetts) or federal agency, board, or other regulatory/licensing agency including, but not limited to, revocation, suspension, reprimand, censure, admonishment, fine, probation agreement, practice limitation, practice monitoring, remedial training, or other educational or public service activities? Yes No

If Yes, for each such action provide the following information.

Agency or Board Action Taken Date of Action

Agency or Board Action Taken Date of Action

Agency or Board Action Taken Date of Action

1.8 PENDING PROCEEDINGS (Attach additional pages, if necessary.)

Are there any pending proceedings that could result in either a criminal conviction reportable in Section 1.6 or other sanction reportable in Section 1.7?

Yes No

If Yes, provide the following information for each such proceeding.

Court/State, Agency, or Board

Charge or Allegation Case or Record Number

Court/State, Agency, or Board

Charge or Allegation Case or Record Number

1.9 BILLING ADDRESS (Address of the entity that submits claims)

If same as legal address in Section 1.2, check here. (You do not need to fill out this section.)

Number/Street Building or Suite

City State Zip

ATTN/Title

Email Tel. Fax

| page 4 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

1.10 ELECTRONIC FILE SUBMISSION METHOD

Please indicate which transactions will be submitted electronically and what method will be used to transmit electronic files.

(With limited exceptions, MassHealth does not accept paper claims (see 130 CMR 450.302)). You must submit a Trading Partner Agreement (TPA) if completing this section.

TRANSACTION TYPES: Check the type of transaction that the applicant will be submitting and/or receiving. Also check who will be submitting and/or receiving on behalf of the applicant and how they will be submitting and/or receiving the transactions.

835 Health Care Claims Payment/Advice

837P Professional Health Care Claim

837P COB Professional Health Care Claim for Secondary Insurers

270 Health Care Eligibility Benefit Inquiry

271 Health Care Eligibility Benefit Response

276 Health Care Claims Status Request

277 Health Care Claims Status Response

VOID and/or REPLACE claims

* DDE = Direct Data Entry ** EDI = Electronic Data Interchange

VENDOR INFORMATION: If you checked the "Vendor" box one or more times in the preceding "transaction types" section, you must complete this section.

Check the box that describes the vendor: Billing Intermediary Clearing House Software Vendor In order for the vendor to submit transactions on your behalf, the vendor must also be an approved MassHealth provider with a valid MassHealth provider ID.

Vendor Name

Doing Business As (DBA) Name (if applicable)

MassHealth PIDSL Number (if applicable) Vendor Contact Name

Vendor Tel. Vendor Email

Note: Vendors must apply for a MassHealth relationship entity number before they can submit claims on behalf of the applicant.

For more information, email MassHealth at edi@mahealth.net.

| page 5 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

SECTION 2: SERVICE LOCATION/SATELLITE

Please list each nonenrolled service location where services will be provided to MassHealth members. Failure to do so is a violation of MassHealth regulations 130 CMR 450.222 and 450.223.

Enter the applicant trade name (DBA) and street address, national provider identifier (NPI) number, and all other information requested below, applicable to this service location where services will be provided to MassHealth members;

correspondence will be mailed to this address. PO box addresses are not acceptable.

Enrollment will not be approved if a PO box address is entered in this space.

Please attach each completed copy of this page to the signed application. Each such copy shall become part of the application.

PLEASE MAKE A COPY OF THIS PAGE IF YOU NEED TO LIST MORE LOCATIONS. NUMBER OF

SITE

Is this a non-billing site? Yes. If Yes, provide the PIDSL of the billing site ________________________________ No Please note, if this is a non-billing site, then W-9, EFT and ERA forms are not required.

Clinic/Trade/Doing Business As (DBA) Name

Business Address Number/Street Building or Suite

City State Zip

ATTN/Title

Email Tel. Fax

Clinic National Provider Identifier Number (NPI) Medicare Number (if applicable) Drug Enforcement Agency (DEA) Number Controlled Substance Number

Clinic License Number (The following provider types require a license: B8, 20, 21, 22, 25, 26, 28, 46, 65, 84, 85, and 96. Provider types 45 and 87 may require a license.)

Bureau of Substance Addiction Services (BSAS) Number (BSAS certification is optional for provider type 26 and required for provider type 28 billing for substance use codes)

Clinical Laboratory Improvement Amendments (CLIA) Number.

Provider type 46 (Certified Independent Laboratory) requires a CLIA number. Provider type B8 (Urgent Care Clinic) requires a CLIA number if the Urgent Care Clinic will perform any of the laboratory services listed in Subchapter 6 of the Urgent Care Clinic Manual.

Accreditation Number (PT–84 Ambulatory Surgery Center)

PT-85 ONLY: Freestanding Birth Center (FBC) Accreditation Number from the Commission for the Accreditation of Birth Centers (CABC) (Once the number is available, the applicant must provide it no later than April 21, 2022). In addition, please attach a copy of (1) the FBC's accreditation from the CABC (Once it's available. An applicant must provide this number no later than April 21, 2022), and (2) the FBC's written agreement with the local hospital providing obstetrical and newborn services for the transfer of their patients for emergency treatment beyond that provided by the FBC.

FBC Director Name and Title

FBC Director License Number FBC Director NPI

| page 6 |PE-ICC (Rev. 02/24) PROVIDER APPLICATION: Independent Clinic/Center

SECTION 3: CERTIFICATION

PLEASE READ CAREFULLY AND SIGN.

I certify that I am duly authorized to act on behalf of the applicant including all its affiliated service locations.

I certify under the pains and penalties of perjury that the information on this provider application and any attachments submitted on behalf of the applicant have been reviewed by me, and are true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein, and that the failure to provide true, accurate, and complete information in this provider application may result in the denial of the applicant’s enrollment as a MassHealth provider or the termination of any provider agreement resulting from or related to this provider application. I understand the applicant must notify the MassHealth Provider Enrollment Unit of any change in the information submitted in this provider application, in accordance with and within the time specified in 130 CMR 450.223(B).

I hereby authorize MassHealth and its designees to access, and agree to furnish MassHealth upon request, any information MassHealth deems relevant to the applicant’s eligibility and qualifications to be a participating provider in MassHealth.

I understand and agree that the applicant has the burden to produce adequate information to MassHealth to permit evaluation of the applicant’s eligibility and qualifications to be a participating provider in MassHealth, and for resolving any doubts that MassHealth may have about the applicant’s eligibility and qualifications.

The applicant hereby releases from any liability MassHealth and all representatives of MassHealth for any acts performed in good faith in connection with the evaluation of the applicant’s eligibility and qualifications to be a participating provider in MassHealth.

I understand that I am obligated to cooperate with MassHealth during this application process; any revalidation of enrollment (including, but not limited to, revalidation required by Section 6401 of the Affordable Care Act and occurring at least every five years); or other review process.

Printed Legal Name of Applicant

Printed Legal Name of Individual Signing on Behalf of Applicant Title/Relationship to Applicant

Signature Date

The form can either be signed traditionally and then scanned, or it can be signed electronically using DocuSign or Adobe Sign. For electronic signatures, the signer can upload a picture of their wet signature. The typed text of a signature is not an acceptable form of an electronic signature.

Return your completed application packet to MassHealth.

If you have any questions about the enrollment process, please email PEC@Maximus.com. For general questions, you may contact MassHealth by email at provider@masshealthquestions.com. Please note: These email boxes are only for general questions. They are not secure. Please do not send documents to these email boxes, or include any personal health information (PHI) or personally identifiable information (PII). You may also call (800) 841-2900, TDD/TTY: 711.