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IHCP Group and Clinic Provider Application and Maintenance Form, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Dear Prospective Provider:

Thank you for your interest in the Indiana Health Coverage Programs (IHCP). This IHCP provider application is customized to meet the needs of groups and clinics. It is important to complete each field in the application to prevent the form from being returned for correction. Ensure that the appropriate person(s) have signed your forms.

If you are currently enrolled and you need to make multiple changes to your current provider profile, this form can be used for that purpose. If you have a specific change request, refer to the provider maintenance forms. For example, use the IHCP Address Maintenance Form to change an address or the Electronic Funds Transfer (EFT) form to make a change to your direct deposit account with the IHCP.

Group and Clinic Provider Types:

The following providers are eligible to enroll as a group or clinic. Groups and Clinics must have rendering providers (practitioners) linked to their business service locations.

Provider Type and Description

08 Clinic 17 Therapist 27 Dentist

09 Advanced Practice Nurse 18 Optometrist 29 Radiologist

11 Mental Health 20 Audiologist 31 Physician

14 Podiatrist 21 Case Manager

15 Chiropractor

Refer to the Provider Type and Specialty Matrix available on the IHCP Web site at http://www.indianamedicaid.com/ihcp/ProviderServices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf to determine the document requirements for your provider type and specialty. Based on your provider type, the matrix informs you about whether you qualify to be a billing provider. Enter your type and specialty information in Schedule A – Provider Information.

You may submit as many as 15 taxonomies per National Provider Identifier (NPI). If you need more space than what is provided, you may attach a separate sheet listing additional taxonomies and their associated NPI.

Business Structure:

All groups and clinic providers receive a group provider classification. A group or clinic provider is a business entity that submits claims for services provided by rendering practitioners that work in their service locations. Because clinics must link rendering providers to their service locations, clinics are given a group classification. Groups and clinics are responsible for submitting claims to the IHCP by any submission means, including paper, electronic, or the Web interChange for reimbursement. The group provider may be an organization or corporation.

Schedules, Provider Agreement, and Addenda:

Complete the following sections. The IHCP Group and Clinic Provider Application and Maintenance Packet is divided into the following sections:

• Schedule A – Provider Information - This section collects information related to the prospective provider including name, address information, provider type, and provider specialty. Complete all fields.

• Schedule B – Organization Structure - This section collects information about the provider’s business. In addition, Providers may also indicate participation in additional programs. The following programs are listed in Schedule B:

| Overview

IHCP Group and Clinic Provider Application and Maintenance Form www.indianamedicaid.com


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• HealthWatch is a preventative health care program offered to Medicaid-eligible members younger than 21 years of age. Physicians or nurse practitioners who are enrolled as Medicaid providers are qualified to perform HealthWatch screenings. Reimbursement for HealthWatch services is higher than equivalent services billed using standard CPT codes. HealthWatch screenings must be completed in accordance with recommendations set forth in the HealthWatch Provider Manual Periodicity Schedule. Check the box labeled yes to receive the HealthWatch Provider Manual.

• The 590 Program is a State medical assistance program providing reimbursement for medically necessary covered medical services provided off site to individuals who reside in State institutions. The following provider types cannot be 590 providers: transportation, hospice, home health, DME, and long term care facilities. There are no out-of-state 590 providers.

• The Medical Review Program provides determination of an applicant’s eligibility for Medicaid under the disability category. The provider completes a medical assessment of an applicant and submits the required forms to the Office of Family Resources. The MRT issues a favorable or unfavorable eligibility decision based on medical evidence that supports whether the applicant has a significant impairment. Once the documentation has been filed, the provider may submit claims to EDS for payment of certain examination and reports. Services should not be performed unless the applicant has presented the pre-Medicaid eligibility form. To participate solely in the Medical Review Program, the provider should check the Medical Review Program ONLY. Providers that choose not to participate in the IHCP Programs and have been requested to submit medical records, should check MRT Medical Records.

• Schedules C.1-C.4

• Consent to Release Social Security Numbers. The top of Schedule C.1 contains a section that describes the purpose for release of social security numbers and to whom a Social Security number may be released. Schedules C.1, C.2, and C.3 contain signature fields to acknowledge consent for each individual named in the Schedules. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social security number will result in rejection of this application.

Disclosure Information - Schedule C.1. This section collects information required by federal regulation that details information about those entities or individuals with five percent direct or indirect ownership in the prospective provider’s business and the degree of relationship for each individual.

Ownership and Control, Subcontractor Relationships - Schedule C.2. - List the Name, Title, FEIN, and Business Address of any person or entity that has an ownership or controlling interest in any subcontractor in which the provider entity has direct or indirect ownership of five percent or more.

Managing Individuals - Schedule C.3. List all managing individuals as defined on Schedule C.3.

Relationships and Background Information - Schedule C.4. Documents family relationships involved in the provider entity and provider background information. The disclosure of social security numbers is used only for the purpose of determining whether persons and entities named in the application are federally excluded parties. Refusal to provide a social security number will result in rejection of this application.

• Profile Maintenance Signature Page. This page is completed and signed when an additional service location is enrolled, or the form is used to make several changes to the group or clinic’s provider’s service location profile.

• Provider Agreement – The IHCP Provider Agreement must be completed and signed. The Provider Agreement is the first document in this packet following the IHCP Group and Clinic Provider Application and Maintenance Form.

• Federal W-9 Form – The W-9 form must be completed and signed.

• Attached Addenda: Additional forms are available from the IHCP Web site at www.indianamedicaid.com.

• The Electronic Funds Transfer Addendum is included in this packet. Submission of this form allows providers to obtain payment by direct deposit.

• Submit the Claim Certification Statement for Signature on File Addendum that is included in this packet. Processing this document allows adjudication of paper claims without a hand written signature on each form. (Providers that submit claims on the UB form must complete the above named addendum.)

• The Change of Ownership Addendum is included in this packet. The purchasing provider is responsible for submitting all change of ownership information in addition to a new enrollment application packet. Additionally, a copy of the purchase or sales agreement must be included.


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Mailing Instructions:

Retain a copy of the completed application and maintenance packet for your records. Enclose the signed Provider Agreement and copies of all required documentation as listed on the following checklist, and mail the entire packet to the following address:

EDS – Provider Enrollment P.O. Box 7263 Indianapolis, IN 46207-7263

Application Processing:

After the Provider Enrollment Unit receives, reviews, and processes a provider application and maintenance form, the provider receives notification. If the form is incomplete or the required supporting documentation is not present, the entire packet is returned. An instructional letter stating the reason(s) the request was not completed is included with the packet. If the IHCP denies an application, the provider receives notification explaining the denial reason. Please allow at least 30 business days for mailing and processing before checking the status of the submitted provider forms.

Refer to the IHCP Web site at www.indianamedicaid.com for additional information or contact the Provider Enrollment Helpline at 1-877-707-5750 for assistance in completing an IHCP Provider Application and Maintenance Form.

Application and Maintenance Checklist:

The following checklist is designed to assist providers and the IHCP in completing and verifying that information is included in this packet.

For Provider Use Only

Did you remember to…. For IHCP Use Only

Complete all IHCP Group and Clinic Provider Application and Maintenance Form Schedules (A, B, and C).

Complete and sign the IHCP Provider Agreement for an initial enrollment.

Complete and submit the necessary signatures for profile maintenance. A signed provider agreement is not required for profile maintenance.

Complete and sign the current Federal W-9 form for tax identification purposes.

Include copies of license(s) or permits for your provider specialty or specialties .

Include a copy of your Medicare Assignment Letter, if applicable. (Out-of-state groups and clinics must submit proof of participation in Medicare or their State’s Medicaid Program.)

Complete the Change of Ownership Addendum, if applicable.

Complete all of the Rendering Provider forms and signatures.

Include all other elected addenda.

Recertification:

Individuals who practice outside of Indiana must recertify to extend their eligibility. This process occurs at the time of licensure renewal. To recertify, submit the IHCP Provider Recertification Form available at www.indianamedicaid.com.

IHCP Group and Clinic Provider Application and Maintenance Form, Schedule A EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Provider Information 1. Request Type:

New Enrollment Additional Service Location Update 2. IHCP Provider Number and Alpha Suffix: (If currently enrolled)

3. National Provider Identifier

4. ZIP + 4: (Nine digits required)

-

5. Taxonomies:

6. Document Submission Date:

7. Requested Enrollment Effective Date:

8. Change of Ownership?

Yes No (If Yes, complete the enclosed Change of Ownership Addendum)

Billing Provider Office Location Name and Address The billing provider office location name and address is for the site where members obtain services and is either owned or rented by the billing provider. This location maintains supporting documentation related to the claim. The billing provider office location name must be the Doing Business As (DBA) name registered with the Secretary of State, except for informal associations (Sole Proprietorship and General Partnerships). Providers, who provide services at a “place of service site,” such as a hospital or nursing facility, should enter their home/business office as their billing provider office location address and not the place of service address. The address must be a physical location. A post office box is not a valid billing provider office location address. 9. DBA Name:

10. Indiana County:

11. Telephone:

12. Street Address:

13. City:

14. State:


-

16. Is claim documentation kept at this location?

Yes No 17. Are services provided in Indiana?

Yes No

Legal Name and Home Office Address The home office is considered to be the legal entity maintaining ownership of the above billing provider office location. The legal name must be the current name on tax, corporation, and other legal documents, and currently registered with the Secretary of State, or filed with the State as the Assumed Business Name. The legal name and business name, as well as the address, must match what is listed on the W-9. 18. Legal Name:

19. Street Address:

20. City:

21. State:


-

23. Telephone:

24. Tax ID Number:

| Schedule A


IHCP Group and Clinic Provider Application and Maintenance Form, Schedule A EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Mailing Name and Address The mailing address is the location where the IHCP sends provider bulletins, newsletters, manuals, and general correspondence. A post office box is acceptable for a mailing address. 25. Name:

26. Telephone:

27. Street Address:

28. City:

29. State:


-

Pay To Name and Address The pay to address is the location where the IHCP sends checks, remittance advices, and general claims payment information. If this is a billing agent’s address, please provide the name, address, and phone number of the billing agent. The name listed below as the Payee Name will appear as the payee on all checks. A post office box is acceptable for this address. Billing agents must furnish proof of authorization to be the billing agent for provider. 31. Payee Name:

32. Billing Agent Name:

33. Telephone:

34. Street Address:

35. City:

36. State:


-

Contact Name The contact person is the person who answers questions about the information provided in this form. 38. Contact Name:

39. Telephone:

40. Contact E-mail:

41. Would you like a link to the Web interChange application sent to your E-mail address? Yes No

42. Are you willing to receive IHCP bulletins and newsletters via E-mail or the Web? Yes No

Provider Specialty Information Refer to the Provider Type and Specialty Matrix on the IHCP Web site to determine the appropriate provider type, specialty codes, and enrollment requirements for this application. Only one provider type code is permitted per application. Submit a separate application for each additional provider type. 43. Provider Type (two digit code):

44. Primary Specialty (three digit code):

45. Additional Specialties:

46. Taxonomies (Enter only those taxonomies that apply to this service location):

CLIA Certification

Document your Clinical Laboratory Improvement Amendment (CLIA) Certificate information in this section. CLIA numbers are assigned to one specific service location unless CMS exemption status is met. 47. CLIA Number:

48. Certification Type:

49. Effective Date:

50. Expiration Date:

Note: A copy of the certificate must be attached to the application. Failure to attach a copy of the certificate will result in denied claims for laboratory services.

IHCP Group and Clinic Provider Application and Maintenance Form, Schedule B EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Organizational Structure 1. Provider Entity Legally Organized and Structured As (Check only one):

For Profit Corporation Partnership Sole Proprietorship Not For Profit Corporation Government Owned Limited Liability Partnership

Limited Liability Company Other, please specify

2. Registered with Secretary of State*:

Yes No * If yes, submit a copy of the state registration papers (405 IAC 1-19.1b). If no, and your business name is different from your name, please submit a copy of the Assumed Business Name form on file with the State.

3. Date Business Started:

4a. Entity Incorporated:

Yes No 4b. If answered Yes in 4a, Incorporation Date:

5. Chain Affiliated **

Yes No ** If yes, the information about the company or organization must be included in the disclosure information.

6. Operated by Management Company or Leased (Whole or Part) by Another Organization*** :

Yes No ***If yes, the information about the company or organization must be included in the disclosure information.

Previous IHCP Enrollment Information 7a. Are you currently, or have you ever been enrolled as an IHCP provider?

Yes No 7b. IHCP Provider Number(s):

7c. National Provider Identifier:

7d. ZIP + 4: (Nine digits required)

-

7e. Taxonomies:

Other IHCP Program Participation

Providers may elect to participate in additional programs. The application overview provides detailed information about each of the programs listed in this section. 8. Participate in the HealthWatch Program:

Yes No 9a. Participate in the 590 Program:

Yes No 9b. Participate in the PASRR Program:

Yes No

10a. Participate in the Medical Review Program:

Yes No

10b. MRT Participation:

Medical Record Copying only

Medicare Participation Please provide the appropriate Medicare identification numbers. Out-of-state providers must submit proof of participation in Medicare and their state’s Medicaid program. See the Type and Specialty Matrix for specific document requirements. 11. Medicare Number:

12. Issuing State:

13. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Number:

14. Address for Location Where the Medicare Number is Assigned:

Note: A copy of the Medicare number assignment letter (or a Medicare Remittance Notice with correct Medicare number) is recommended to ensure accuracy of Medicare number assignment.

Patient Population Information 15. Percentage of your patient population with the following payment sources:

(15a, b, c, and d must add up to 100%)

15a. Medicaid:

15b. Self-Pay:

15c. Medicare:

15d. TPL:


| Schedule B

IHCP Group and Clinic Provider Application and Maintenance Form, Schedule C EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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C.1 – Disclosure Information – Ownership and Control, Provider Entity Instructions: Please complete all four sections of Schedule C – Ownership and Control, Provider Entity; Ownership and Control, Subcontractor Relationships; Managing Individuals; and Relationships and Background Information. Non-profit providers must list the business entity that owns their tax identification number.

Disclosure of Social Security Numbers: Disclosure of social security numbers is used for the purpose of determining whether persons and entities named in an application are federally excluded parties and to verify licensure. The IHCP Provider Application and Profile Maintenance Form's C Schedules are used to collect information required by State and federal regulations. The regulations detail information about those entities or individuals with five percent direct or indirect ownership in the prospective provider’s business and the degree of relationship for each individual. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social security number will result in rejection of this application.

*Consent To Release Social Security Numbers: All persons whose names are written in boxes marked 1a of Schedules C1, C2, and C3 are asked to place their signature in box 1b. A signature in box 1b shall indicate that the signatory agrees to the following statement regarding the disclosure of his or her social security number:

My signature in box 1b in Schedule C1, C2, or C3 indicates that I give my express consent to the Office of Medicaid Policy and Planning and its contractors to disclose my social security number for the sole purpose of verifying my eligibility to participate in the Medicaid program with the Office of the Inspector General, the Centers for Medicare and Medicaid Services, licensing bodies, and other appropriate state and federal agencies.

I further consent that the Office of Medicaid Policy and Planning and its contractors may disclose my social security number to such appropriate organizations or agencies after this application has been approved so that the Office may review my ability to continue to participate in the Medicaid program.

Disclosure of Ownership and Control, Provider Entity – List the Name, Title, Federal Employer Identification Number (FEIN), and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in your provider entity. This includes any person or entity that has a direct or indirect ownership interest equal to five percent or more of the value of the provider entity; or owns an interest of five percent or more in any mortgage, deed of trust, note or other obligation secured by the provider entity if that interest equals five percent of the value of the property of assets of the provider entity. Copy this page to list additional names. If a corporation is publicly held and no person owns five percent or more of the corporation, or if the corporation is not-for-profit entity, then proceed to schedule C-3 and list the Board of Directors with the information requested.

1a. Legal Name: (Please Print)

1b. Signature:*

2. Title:

3. FEIN:

4. Social Security Number:

5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State :


-

| Schedule C



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C.1 – Disclosure Information – Ownership and Control, Provider Entity (Continued) 1a. Legal Name: (Please Print)

1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


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C.2 – Disclosure Information – Ownership and Control, Subcontractor Relationships Disclosure of Ownership and Control, Subcontractor Relationships – List below the Name, Title, FEIN, and Business Address of any PERSON OR ENTITY that has an ownership or controlling interest in any subcontractor in which the provider entity has direct or indirect ownership of five percent or more. Copy this page to list additional names. 1a. Legal Name: (Please Print)

1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


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C.3 – Disclosure Information – Managing Individuals

Managing Individuals – List below the Name, Title, FEIN, and Business Address of ALL agents, officers, directors, and managing employees who have expressed or implied authority to obligate or act on behalf of the provider entity. Any individual who has operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of the provider entity should be included. This may include such individuals as a general manager, business manager, administrator, or director. Copy this page to list additional names. Not-for-profit providers must also list their managing individuals.


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


1b. Signature:*

2. Title:

3. FEIN:


5. Street Address:

6. City:

7. State:


-


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C.4 – Disclosure Information – Relationships and Background Information 1. Indicate if any of the individuals listed in Schedule C.1, C.2, or C.3 are related through blood or marriage, as spouse, parent, child, or sibling. List the names and degree of relationship. Copy this page if additional space is required. Non-profit providers must also complete schedule C.4. Use N/A as appropriate.

1a. Name of Person 1:

Name of Person 2:

Relationship:

1b. Name of Person 1:

Name of Person 2:

Relationship:

1c. Name of Person 1:

Name of Person 2:

Relationship:

2. Indicate if any persons or entities listed in Schedule C.1, C.2, C.3, or any secured creditor(s) of the provider entity, have ever been sanctioned either through criminal conviction, or exclusion from participation in any program under Medicare, Medicaid, or Title XX services since the inception of the programs.

2a. Name:

LPI or NPI:

Date of Sanction:

Type of Sanction:

Date Sanction Ended:

2b. Name:

LPI or NPI:

Date of Sanction:

Type of Sanction:


2c. Name:

LPI or NPI:

Date of Sanction:

Type of Sanction:


3. Indicate if any persons or entities listed in Schedule C.1, C.2, C.3, or any secured creditor(s) of the provider entity, have ever been placed on prepayment review.

3a. Name:

LPI or NPI:

3b. Name:

LPI or NPI:

3c. Name:

LPI or NPI:

3d. Name:

LPI or NPI:

4. Indicate if any persons or entities listed in Schedule C.1, C.2, or C.3 have an ownership or controlling interest in any other current or prospective provider.

4a. Name:

LPI or NPI:

4b. Name:

LPI or NPI:

4c. Name:

LPI or NPI:

5. Indicate any former agent, officer, director, partner, or managing employee from the lists in this schedule, who has transferred ownership to a family member related through blood or marriage, either as spouse, parent, child, or sibling, in anticipation of or following a conviction or imposition of an exclusion.

5a. Name of Person 1:

Name of Person 2:

Relationship:

5b. Name of Person 1:

Name of Person 2:

Relationship:

IHCP Group and Clinic Provider Application and Maintenance Form, Signature Page EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Signature Authorization for Profile Maintenance

ENROLLMENT AND PROFILE MAINTENANCE: An official with the School Corporation must complete and sign Items 1-6 to authorize the request to make changes to a currently enrolled service location profile.

The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth herein. The undersigned acknowledges that the commission of any Medicaid or CHIP related offense, as set out in 42 USC 1320a-7b may be punishable by a fine of up to $25,000 or imprisonment of up to five years or both.

The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. The form will be returned if the appropriate signatures are not submitted. 1. Provider’s Business Name (please print):

2. Tax ID:

3. Authorized Official’s Name (please print):

4. Title:

5. Authorized Official’s Signature:

6. Date:

To the Signatory: Please complete the IHCP Delegated Administrator Addendum if you are not an authorized official with your group. Provider profile maintenance can be processed only if the appropriate signature is present.

IHCP Group and Clinic Provider Maintenance Signature Page www.indianamedicaid.com

| Signature Page


IHCP Provider Agreement, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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IHCP Provider Agreement Overview

New Enrollee or New Provider Type:

If the application you completed is a first-time enrollment in the Indiana Health Coverage Programs (IHCP), you are required to complete and sign a Provider Agreement to fulfill your enrollment requirements. Providers whose eligibility has lapsed for one year or greater are required to re-enroll to restore their eligibility. A full enrollment packet must be submitted for processing. An owner or official with your business must sign the IHCP Provider Agreement. An original signature is required. A new IHCP number is assigned to each Provider Type enrolled in the IHCP.

Additional Service Location:

If the application you completed was used to enroll an additional service location to your existing business, you are not required to sign an IHCP Provider Agreement.

Provider Agreement Summary:

The Agreement details the requirements for participation in the IHCP. Included are provider responsibilities regarding updating provider information, protecting patient health information, requirements for claims processing, overpayments, and record retention. In addition, the Agreement details obligations regarding the appeals process, civil rights regulation compliance, utilization, control, and disclosure rules. The entire Agreement must be read, signed, and returned with the application. A signed copy must be retained by the provider.

| Overview

IHCP Provider Agreement www.indianamedicaid.com

IHCP Provider Agreement EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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This agreement must be completed, signed, and returned to EDS for processing.

By execution of this Agreement, the undersigned entity (“Provider”) requests enrollment as a provider in the Indiana Health Coverage Programs. As an enrolled provider in the Indiana Health Coverage Programs, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members. As a condition of enrollment, this agreement cannot be altered and the Provider agrees to all of the following:

1. To comply, on a continuing basis, with all enrollment requirements established under rules adopted by the state of Indiana Family and Social Services Administration (“IFSSA”).

2. To comply with all federal and state statutes and regulations pertaining to the Indiana Health Coverage Programs, as they may be amended from time to time.

3. To meet, on a continuing basis, the state and federal licensure, certification or other regulatory requirements for Provider’s specialty including all provisions of the state of Indiana Medical Assistance law, state of Indiana Children’s Health Insurance Program law, or any rule or regulation promulgated pursuant thereto.

4. To notify IFSSA or its agent within ten (10) days of any change in the status of Provider’s license, certification, or permit to provide its services to the public in the state of Indiana.

5. To provide covered services and/or supplies for which federal financial participation is available for Indiana Health Coverage Program members pursuant to all applicable federal and state statutes and regulations.

6. To safeguard information about Indiana Health Coverage Program members including at a minimum:

a. members’ name, address, and social and economic circumstances;

b. medical services provided to members;

c. members’ medical data, including diagnosis and past history of disease or disability;

d. any information received for verifying members’ income eligibility and amount of medical assistance payments;

e. any information received in connection with the identification of legally liable third party resources.

7. To release information about Indiana Health Coverage Program members only to the IFSSA or its agent and only when in connection with:

a. providing services for members; and

b. conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the provision of Indiana Health Coverage Program covered services.

8. To maintain a written contract with all subcontractors, which fulfills the requirements that are appropriate to the service or activity delegated under the subcontract. No subcontract, however, terminates the legal responsibility of the contractor to the agency to assure that all activities under the contract are carried out.

9. Provider also agrees to notify the IHCP in writing of the name, address, and phone number of any entity acting on Provider’s behalf for electronic submission of Provider’s claims. Provider understands that the State requires 30-days prior written notice of any changes concerning Provider’s use of entities acting on Provider’s behalf for electronic submission of Provider’s claims and that such notice shall be provided to the IHCP.

10. To submit claims for services rendered by the Provider or employees of the Provider and not to submit claims for services rendered by contractors unless the provider is a healthcare facility (such as hospital, ICF-MR, or nursing home), or a government agency with a contract that meets the requirements described in item 8 of this Agreement. Healthcare facilities and government agencies may, under circumstances permitted in federal law, subcontract with other entities or individuals to provide Indiana Health Coverage Program covered services rendered pursuant to this Agreement.

11. To comply, if a hospital, nursing facility, provider of home health care and personal care services, hospice, or HMO; with advance directive requirements as required by 42 Code of Federal Regulations, parts 489, subpart I, and 417.436.

12. To abide by the Indiana Health Coverage Programs Provider Manual, as amended from time to time, as well as all provider bulletins and notices. Any amendments to the provider manual, as well as provider bulletins and

| Provider Agreement

IHCP Provider Agreement www.indianamedicaid.com


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notices, communicated to Provider shall be binding upon receipt. Receipt of amendments, bulletins and notices by Provider shall be presumed when mailed to the billing Provider’s current “mail to” address on file with IFSSA or its fiscal agent.

13. To submit timely billing on Indiana Health Coverage Program approved claim forms, as outlined in the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages, in an amount no greater than Provider’s usual and customary charge to the general public for the same service.

14. To be responsible and accountable for the completion, accuracy, and validity of all claims filed under the provider number issued, including claims filed by the Provider, the Provider’s employees, or the Provider’s agents. Provider understands that the submission of false claims, statements, and documents or the concealment of material fact may be prosecuted under the applicable federal and/or state law.

15. To submit claim(s) for Indiana Health Coverage Program reimbursement only after first exhausting all other sources of reimbursement as required by the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages.

16. To submit claim(s) for Indiana Health Coverage Program reimbursement utilizing the appropriate claim forms and codes as specified in the provider manual, bulletins and notices.

17. To submit claims that can be documented by Provider as being strictly for:

a. medically necessary medical assistance services;

b. medical assistance services actually provided to the person in whose name the claim is being made; and

c. compensation that Provider is legally entitled to receive.

18. To accept payment as payment in full the amounts determined by IFSSA or its fiscal agent, in accordance with federal and state statutes and regulations as the appropriate payment for Indiana Health Coverage Program covered services provided to Indiana Health Coverage Program members (recipients). Provider agrees not to bill members, or any member of a recipient’s family, for any additional charge for Indiana Health Coverage Program covered services, excluding any co-payment permitted by law.

19. To refund within fifteen (15) days of receipt, to IFSSA or its fiscal agent any duplicate or erroneous payment received.

20. To make repayments to IFSSA or its fiscal agent, or arrange to have future payments from the Indiana Health Coverage Program withheld, within sixty (60) days of receipt of notice from IFSSA or its fiscal agent that an investigation or audit has determined that an overpayment to Provider has been made, unless an appeal of the determination is pending.

21. To pay interest on overpayments in accordance with IC 12-15-13-3, IC 12-15-21-3, and IC 12-15-23-3.

22. To make full reimbursement to IFSSA or its fiscal agent of any federal disallowance incurred by IFSSA when such disallowance relates to payments previously made to Provider under the Indiana Health Coverage Programs.

23. To fully cooperate with federal and state officials and their agents as they conduct periodic inspections, reviews and audits.

24. To make available upon demand by federal and state officials and their agents all records and information necessary to assure the appropriateness of Indiana Health Coverage Program payments made to Provider, to assure the proper administration of the Indiana Health Coverage Program and to assure Provider’s compliance with all applicable statutes and regulations. Such records and information are specified in 405 IAC 1-5 and in the Indiana Health Coverage Programs Provider Manual, and shall include, without being limited to, the following:

a. medical records as specified by Section 1902(a)(27) of Title XIX of the Social Security Act, and any amendments thereto;

b. records of all treatments, drugs and services for which vendor payments have been made, or are to be made under the Title XIX or Title XXI Program, including the authority for and the date of administration of such treatment, drugs or services;

c. any records determined by IFSSA or its representative to be necessary to fully disclose and document the extent of services provided to individuals receiving assistance under the provisions of the Indiana Health Coverage Program;

d. documentation in each patient’s record that will enable the IFSSA or its agent to verify that each charge is due and proper;

e. financial records maintained in the standard, specified form;

f. all other records as may be found necessary by the IFSSA or its agent in determining compliance with any federal or state law, rule, or regulation promulgated by the United States Department of Health and Human Services or by the IFSSA; and

g. any other information regarding payments claimed by the provider for furnishing services to the plan.


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25. To cease any conduct that IFSSA or its representative deems to be abusive of the Indiana Health Coverage Program.

26. To promptly correct deficiencies in Provider’s operations upon request by IFSSA or its fiscal agent.

27. To make a good faith effort to provide and maintain a drug-free workplace. Provider will give written notice to the State within ten (10) days after receiving actual notice that the provider or an employee of the provider has been convicted of a criminal drug violation occurring in the provider’s workplace.

28. To file all appeal requests within the time limits listed below. Appeal requests must state facts demonstrating that:

a. the petitioner is a person to whom the order is specifically directed;

b. the petitioner is aggrieved and, or adversely affected by the order;

c. the petitioner is entitled to review under the law.

29. Provider must file a statement of issues within the time limits listed below, setting out in detail:

a. the specific findings, actions, or determinations of IFSSA from which Provider is appealing;

b. with respect to each finding, action or determination, all statutes or rules supporting Provider’s contentions of error.

30. Time limits for filing an appeal and the statement of issues are as follows:

a. A provider must file an appeal of any of the following actions within sixty days of receipt of IFSSA’s determination:

1) A notice of program reimbursement or equivalent determination regarding reimbursement or a year end cost settlement.

2) A notice of overpayment.

3) The statement if issues must be filed with the request for appeal.

b. All appeals of actions not described in (a) must be filed within 15 days of receipt of IFSSA’s determination. The statement of issues must be filed within 45 days of receipt of IFSSA’s determination.

31. To cooperate with IFSSA or its agent in the application of utilization controls as provided in federal and state statutes and regulations as they may be amended from time to time.

32. To comply with the advance directives requirements as specified in 42 C.F.R. part 489, subpart I, and 42 C.F.R. 417.436(d), as applicable.

33. To comply with civil rights requirements as mandated by federal and state statutes and regulation by ensuring that no person shall, on the basis of race, color, national origin, ancestry, disability, age, sex or religion, be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination in the provision of a Indiana Health Coverage Program covered service.

34. The Provider and its agents shall abide by all ethical requirements that apply to persons who have a business relationship with the State, as set forth in Indiana Code § 4-2-6 et seq., Indiana Code § 4-2-7, et seq., the regulations promulgated thereunder, and Executive Order 04-08, dated April 27, 2004. If the Provider is not familiar with these ethical requirements, the Provider should refer any questions to the Indiana State Ethics Commission, or visit the Indiana State Ethics Commission Web site at <<<http://www.in.gov/ethics/>>>. If the Provider or its agents violate any applicable ethical standards, the State may, in its sole discretion, terminate this Agreement immediately upon notice to the Provider. In addition, the Provider may be subject to penalties under Indiana Code § 4-2-6, 4-2-7, 35-44-1-3, and under any other applicable laws.

35. To disclose information on ownership and control, information related to business transactions, information on change of ownership, and information on persons convicted of crimes in accordance with 42 Code of Federal Regulations, part 455, subpart B, and 405 IAC 1-19. Long term care providers must comply with additional requirements found in 405 IAC 1-20. Pursuant to 42 Code of Federal Regulations, part 455.104(c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law.

36. To submit within 35 days of the date of request by the federal or state agency full and complete information about ownership of subcontractors with whom the provider has had more than $25,000 in a twelve month hearing period, and any significant business transactions between the provider and any (1) wholly owned supplier or (2) subcontractor during five-year period ending with the date of request.

37. Long term care providers must comply with additional requirements found in 405 IAC 1-20. Pursuant to 42 Code of Federal Regulations, part 455.104(c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law.

38. To furnish to IFSSA or its agent, as a prerequisite to the effectiveness of this Agreement, the information and documents set out in Schedules A through I to this Agreement, which are incorporated here by reference, and to update this information as it may be necessary.


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39. That subject to item 32, this Agreement shall be effective as of the date set out in the provider enrollment notification letter.

40. That this Agreement may be terminated as follows:

a. By IFSSA or its fiscal agent for Provider’s breach of any provision of this Agreement as determined by IFSSA; or

b. By IFSSA or its fiscal agent, or by Provider, upon 60 days written notice.

41. That this Agreement has not been altered, and upon execution, supersedes and replaces any provider agreement previously executed by the Provider.

42. For long term care providers involved in a change of ownership, this agreement acts as an amendment to the transferor’s agreement with IHCP to bind the transferee to the terms of the previous agreement; and any existing plan of correction and pending audit findings in accordance with 405 IAC 1-20.

43. For new owners of nursing facilities or intermediate care facilities for the mentally retarded, to accept the assignment of the provider agreement executed by the previous owner(s) as required by 42 CFR 442.14.

44. For any entity that receives or makes annual payments totaling at least $5,000,000 annually as described in 42 U.S.C. 1396a(a)(68), to establish written policies that provide detailed information about federal and state False Claims Acts, whistleblower protections, and entity policies and procedures for preventing and detecting fraud and abuse. In any inspection, review, or audit of the entity by OMPP or its contractors, the entity shall provide copies of the entity’s written policies regarding fraud, waste, and abuse upon request. Entity shall submit to OMPP a corrective action plan within 60 days if the entity is found not to be in compliance with any part of the requirements stated in this paragraph.

45. To verify and maintain proof of verification that no employee or contractor is an excluded individual or entity with the Health and Human Services (HHS) Office of the Inspector General (OIG). Providers shall review the HHS-OIG List of Excluded Individuals/Entities (LEIE) database for excluded parties. This LEIE database is accessible to the general public at http://www.oig.hhs.gov/fraud/exclusions.asp.

THE UNDERSIGNED, BEING THE PROVIDER OR HAVING THE SPECIFIC AUTHORITY TO BIND THE PROVIDER TO THE TERMS OF THIS AGREEMENT, AND HAVING READ THIS AGREEMENT AND UNDERSTANDING IT IN ITS ENTIRETY, DOES HEREBY AGREE TO ABIDE BY AND COMPLY WITH ALL THE STIPULATIONS, CONDITIONS, AND TERMS SET FORTH HEREIN. THE UNDERSIGNED ACKNOWLEDGES THAT THE COMMISSION OF ANY INDIANA HEALTH COVERAGE PROGRAM RELATED OFFENSE AS SET OUT IN 42 USC 1320a-7b MAY BE PUNISHABLE BY A FINE OF UP TO $25,000 OR IMPRISONMENT OF UP TO FIVE YEARS OR BOTH.

Provider Agreement-Authorized Signature – All Schedules and Applicable Addendums The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. In addition, all rendering providers must sign this section. Provider’s Business Name (Please Print):

Tax ID:

Authorized Official’s or Rendering Provider's Name (Please Print):

Title:

Authorized Official’s or Rendering Provider's Signature:

Date:

Federal W-9 Form Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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W-9 Form Overview A W-9 must be completed and submitted with each new enrollment and addition of new service locations.

| Overview

Federal W-9 Form Overview www.indianamedicaid.com

Federal W-9 Form EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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IHCP Electronic Funds Transfer Addendum, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Electronic Funds Transfer Overview

The IHCP will establish a direct deposit account with your bank for claims payment. After you have established electronic funds transfer (EFT), the IHCP will electronically transfer payments into the account you specify on the following EFT Addendum. Please read the instructions on the EFT Addendum carefully and ensure that the appropriate signature and attachment are included.

All claims processed by Friday at 4:30 p.m. will appear on the weekly remittance advice produced on the following Tuesday. EFT payment occurs each Wednesday.

It takes approximately 18 days for the bank to process and completely establish your EFT account. If you bill claims prior to your EFT activation, paper checks are mailed to the Pay To address documented on Schedule A of the enrollment application. When your EFT account becomes active, direct deposits begin.

Thank you for considering EFT as a payment option.

| Overview

IHCP Electronic Funds Transfer Addendum Overview www.indianamedicaid.com

IHCP Electronic Funds Transfer Addendum EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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General Information Complete all fields on form, and follow attachment instructions below. Confirm bank’s ABA transit routing number. Account Belongs to Billing Agency: Yes No

Provider Name:

Provider LPI Number:

Service Location (alpha suffix):

Provider Tax ID:

National Provider Identifier:

Provider Location ZIP + 4:

-

Name on Bank Account:

Bank Name:

Tax ID of Account Holder:

ABA Transit Routing Number:

Bank Account Number:

Bank Address:

City:

State:

ZIP + 4:

-

Bank Telephone Number:

Type of Account

Savings Checking

Type of Authorization:

Start Cancel Change

Due to Change of Ownership

Yes No

ATTACHMENT: Please include one of the following documents with this form for verification of account owner and account numbers: voided check or a signed letter from your bank that lists the account holder’s name, tax identification number, and the appropriate account and routing numbers.

On behalf of the provider entity named above, I agree to keep, and disclose upon request to authorized agencies, records that fully disclose the extent of claim payments received from and services rendered to members of the Indiana Health Coverage Programs (IHCP). I accept, as payment in full, the amount paid by the IHCP for claims submitted with the exception of authorized cost sharing by members. I understand payment of IHCP claims is from state and federal funds and that any false claims, statements, documents or concealment of a material fact may be prosecuted under state or federal law. I ensure that this EFT request complies with the regulation set forth in 42 CFR 447.10, which prohibits State payments for any IHCP service to be made to anyone other than a Provider, a non-cash member, or to one of the listed exceptions. I understand that an IHCP payment may be sent via EFT to an account held by the following only: (1) to the Provider; (2) a non-cash member; (3) a government agency on reassignment by the Provider (IRS); (4) a third party by court order on reassignment by the Provider (child support); (5) a business agent (billing service, account firm) if three specific criteria are met (see page 2*); (6) the employer of the Practitioner (if a contract so requires); (7) a health care facility, or a health care delivery system (if a contract so requires) if the organization itself submits the claim directly to the IHCP. I authorize the electronic transfer of IHCP payments (including 590, Medicaid, and Package C) made to the above provider number. I understand that I am responsible for the validity of the above information. I agree to notify EDS within ten days of any change in any of the information included on this form. This section must be completed by an authorized officer or owner of the billing provider. Name (Printed):

Title:

Signature:

Date:

It will take approximately four weeks for this information to be processed by EDS and validated by your bank. Please send this form to EDS, Provider Enrollment, P.O. Box 7263, Indianapolis, IN 46207-7263.

| Addendum

IHCP Electronic Funds Transfer Addendum www.indianamedicaid.com

IHCP Electronic Funds Transfer Addendum EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Billing Agent Information The following section must be completed if a billing agent is receiving payment on behalf of the provider. *The exception for a business agent is limited to agents who furnish statements and receive payments in the name of the provider, and the service provided by the agent is: (1) related to the cost of processing the bill; (2) not related to a percentage or other basis to the amount billed or collected; and (3) not dependent upon the collection of payment. Further, a payment for a provider may not be made to or through an individual or organization (collection agency or service bureau), or by power of attorney thereof, that advances money for accounts receivable that a provider has assigned, sold, or transferred to the organization for a fee or deduction of accounts receivable. If the EFT for the provider named on this document will be sent to a bank account belonging to a billing agent and not the bank account of the provider, you must complete the section below. Billing Agent Name:

Telephone Number:

Billing Agent’s Tax ID:

Billing Agent Address:

City:

State:

ZIP + 4:

-

Authorized Billing Agent Contact Name:

Title:

Authorized Billing Agent Signature:

Date:

IHCP Claim Certification Statement for Signature on File, Addendum EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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IHCP Claim Certification Statement for Signature On File Overview

UB BILLERS ARE REQUIRED TO SUBMIT the IHCP Claims Certification Statement for Signature on File

Dear Provider:

If you are not a UB billing provider, you are not required to complete the IHCP Claim Certification Statement for Signature on File. Additionally, rendering providers are not required to complete the form.

After your request is processed in IndianaAIM, the system will bypass the signature on file edit when paper claims are adjudicated. Providers that submit claims electronically may complete the form to cover those instances where submission of a paper claim is necessary. An owner or official with the business must sign the form. An original signature is required.

IHCP Claim Certification Statement for Signature on File (Please read carefully)

This is to certify that any and all information contained on any Indiana Health Coverage Programs (IHCP) billings submitted on my behalf by electronic, telephonic, mechanical, and/or standard paper means of submission shall be true, accurate, and complete. I accept total responsibility for the accuracy of all information obtained on such billings, regardless of the method of compilation, assimilation, or transmission of the information (either by myself, my staff, and/or a third party acting on my behalf, such as a service bureau). I fully recognize that any billing intermediary or service bureau that submits billings to the Indiana Family and Social Services Administration (IFSSA) or its Fiscal Agent Contractor is acting as my representative and not that of the IFSSA or its Fiscal Agent Contractor. I further acknowledge that any third party that submits billings on my behalf shall be deemed to be my agent for the purposes of submission of IHCP claims. I understand that the standard paper claim form may include a signature line. I understand that all of the stipulations, conditions, and terms of the provider agreement apply in the event that I fail, for any reason, to sign the paper claim and the claim is approved for payment. I agree that payment of a paper claim that did not contain my signature, in no way absolves me of the terms stated in the provider agreement that I have signed. THE UNDERSIGNED, BEING THE PROVIDER OR HAVING THE SPECIFIC AUTHORITY TO BIND THE PROVIDER TO THE TERMS OF THIS CERTIFICATION STATEMENT, AND HAVING READ THIS CERTIFICATION STATEMENT AND UNDERSTANDING IT IN ITS ENTIRETY, DOES HEREBY AGREE TO ABIDE BY AND COMPLY WITH ALL STIPULATIONS, CONDITIONS, AND TERMS SET FORTH THEREIN.

Authorized Signature Section 1. IHCP Billing Provider Number:

2. Service Location(s):

3. National Provider Identifier:

4. ZIP + 4: (Nine digits required) - 5. Taxonomy:

6. Billing Provider Business Name (Printed):

7. Billing Provider or Authorized Official’s Signature:

8. Title:

9. Date:

Note: A retroactive program eligibility effective date must be supported by claim activity. The signature above certifies claim activity for the entire program eligibility effective period.

Contact Information The contact person is the person who answers questions about the information provided in this form. 10. Contact Name: 11. Telephone:

12. Contact E-mail:

13. Would you like a Web interChange application sent to your Mail To address? Yes No

14. Are you willing to receive IHCP updates via E-mail or the Web? Yes No

| Addendum

IHCP Claim Certification Statement for Signature on File www.indianamedicaid.com

IHCP Change of Ownership Addendum, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Complete this addendum if a change of ownership has occurred or is expected.

Purchasing Provider Document Requirements:

The purchaser must submit the following documents to the Indiana Health Coverage Programs (IHCP) for each service location being purchased: Provider Application, Provider Agreement, W-9, IHCP Change of Ownership Addendum, purchase agreement, bill of sale, or other documentation to verify the change of ownership.

Addendum Detail:

Providers use the IHCP Change of Ownership Addendum to let the IHCP know about a change of ownership when it occurs or is anticipated.

Purchaser Information helps the IHCP identify the person or entity that is purchasing a currently enrolled provider business. If the purchaser is not currently enrolled they complete all fields except the provider IHCP provider number field.

Seller Information helps the IHCP identify the business and specific service locations being purchased.

Note: Change of ownership can result in the assignment of a new provider number. Long-term care facilities (provider type 03, provider specialty 030, 031, 032, and 033) retain their provider number and service location when a change of ownership occurs. When a nursing facility or ICF/MR changes ownership, the new owner shall accept the provider agreement of the previous owner as required by 42 CFR 442.14.

A change of ownership occurs, but is not limited to, any of the following circumstances: For a sole proprietorship – if a provider of services is an entity owned by a single individual, a transfer of title and property to the enterprise to another person or firm, whether or not including a transfer of title to the real estate or if the former sole proprietorship becomes one of the members of a business entity succeeding him or her as the new owner.

For a partnership – a new partnership, or the removal, addition, or substitution of an individual partner in an existing partnership, in the absence of an express statement to the contrary in the partnership agreement that dissolves the old partnership and creates a new partnership.

For a corporation – a new corporation, the merger of the applicant or provider corporation into another corporation, or the consolidation of two or more corporations, or any change resulting in the creation of a new corporation. In an incorporated provider entity, the corporation is the owner. The governing body of the corporation is the group having direct legal responsibility under state law for operation of the corporation’s entity, whether that body is: a board of trustees; a board of directors; the entire membership of the corporation; or known by some other name.

Change of Ownership Checklist:

The following checklist is designed to assist providers and the IHCP in completing and verifying that information is included on the attached form.

For Provider Use Only Did you remember to… For IHCP Use

Only

Complete a Provider Application (One application per each service location)

Complete and submit a signed Provider Agreement (Original signature required)

Include appropriate licensure, certificates, approval letters, insurance information for your provider type and specialty

Enclose a copy of the purchase agreement

| Overview

IHCP Change of Ownership Addendum Overview www.indianamedicaid.com

IHCP Change of Ownership, Addendum EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Change of Ownership Information 1. Has a Change of Ownership Occurred?

Yes No Anticipated

1a. Actual Date of Change:

1b. Date of Expected Change:

Purchaser Information 2. Legal Business Name:

3. Tax ID:

4. IHCP Provider Number: (if currently enrolled)



-

7. Taxonomies:

Seller Information 8. Legal Business Name:

9. Service Location DBA Name Being Purchased:

10. Service Location Address:

11. City:

12: State:


-

14. Tax ID:

15. IHCP Provider Number:

16. Familial Relationship to Previous Owner:



-

19. Taxonomies:

The purchaser must submit the following documents: Provider Application, Provider Agreement, W-9, IHCP Change of Ownership Addendum, purchase agreement, bill of sale, or other documentation to verify the change of ownership.

Long Term Care Information

Complete this addendum, or send a notification letter within 45 days of the contemplated transfer date. Include a Certificate and Transmittal (C&T) indicating a change of ownership. A pay hold will be initiated on the expected date of transfer to ensure appropriate payee information for claim payments.

View the Long Term Care Providers’ Change of Ownership Types at 405 IAC 1-20-3.

Record Retention

The following Indiana Administrative Code outlines the requirements for record retention:

405 IAC 1-20-5 Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3 Affected: IC 12-13-7-3; IC 12-15405 IAC 1-20-5) A transferee shall take possession of the Medicaid records of the transferor and safeguard them for no less than three years from the date of the last claim reimbursed by the office or until any pending administrative or judicial appeal is closed, whichever is longer. (Office of the Secretary of Family and Social Services; 405 IAC 1-20-5)

Sanction Information Note: If a provider is sanctioned by the Indiana State Department of Health (ISDH), the effective date of the change of ownership is determined by the date indicated on the ISDH Certificate and Transmittal form and amended by the ISDH, if necessary, to correspond with the transferor or transferee agreement of sale or transfer.

| Addendum

IHCP Change of Ownership www.indianamedicaid.com

IHCP Rendering Provider Application and Maintenance Form, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Dear Prospective Provider:

Thank you for your interest in the Indiana Health Coverage Programs (IHCP). This IHCP provider application and maintenance form is customized to meet your individual provider needs. It is important to complete each field in the form to prevent the document from being returned to you for correction. Groups and clinics are responsible for completing the following forms and obtaining appropriate signatures.

Rendering Provider Types:

The following provider types can be enrolled as rendering providers linked to groups or clinics.

Provider Type Provider Type Provider Type

09 Advanced Practice Nurse 17 Therapist 21 Case Manager

11 Mental Health Provider (specialty 114) 18 Optometrist 27 Dentist

14 Podiatrist 19 Optician (with Optometry groups only) 31 Physician

15 Chiropractor 20 Audiologist 32 Waiver

Refer to the Provider Type and Specialty Matrix available on the IHCP Web site at http://www.indianamedicaid.com/ihcp/ProviderServices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf to determine the document requirements for your provider type and specialty. Based on your provider type, the matrix informs you about whether you qualify to be a billing provider. Enter your type and specialty information in Schedule A – Provider Information.

You may submit as many as 15 taxonomies per National Provider Identifier (NPI). If you need more space than what is provided, you may attach a separate sheet listing additional taxonomies and their associated NPI.

Schedule A

Request Type: (Field 1)

Action Requested Instructions

Enrollment (Initial enrollment) Group completes Schedules A and B and the Provider Agreement. (The owner or an officer with the group and the rendering provider must sign the form and agreement. Read the instructions included in the signature section of the form. A delegated administrator cannot sign a provider agreement.)

Profile Maintenance (Currently-enrolled rendering providers) Group reports changes on Schedules A and B. (The owner, officer with the group, or delegated administrator and the rendering provider must sign the form.)

Terminate Linkage Group reports terminated linkages by completing Schedules A and B. (The owner, officer with the group, or delegated administrator and the rendering provider must sign the form.)

Group or Clinic Identification (Fields 2-9)

Identify the legal business name of the group or clinic where the rendering provider sees patients. A rendering provider cannot be linked to a group service location that is not currently enrolled. To ensure the group’s service location is enrolled, please document the provider number assigned to the group by the IHCP. Documentation of the Medicare number allows Provider Enrollment to link the group or clinic’s Medicare number to the rendering provider’s Medicare number for crossover claims purposes. The tax identification number is used to validate the selection of the appropriate billing provider in IndianaAIM. Document the mailing address for the group or clinic.

Rendering Provider Information (Fields 10–15)

Complete the following fields to clearly identify the rendering provider. Use the IHCP Provider Type and Specialty Requirements Matrix to determine the rendering provider’s type and specialty codes and document requirements. The matrix is found on the IHCP Web site at www.indianamedicaid.com.

IHCP Rendering Provider Application and Maintenance Form www.indianamedicaid.com

| Overview


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Field Instructions

10 Rendering provider’s legal name

11 Social Security Number (SSN). SSNs are used to verify licensure when necessary and to determine if a provider is named as an excluded party on the Office of the Inspector General’s Web site. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social security number will result in rejection of this application.

12 Currently enrolled rendering provider’s IHCP number (no alpha suffix is needed)

13 Rendering provider’s National Provider Identifier (NPI)

14a Provider type code

14b Primary specialty that applies to the rendering provider type

14c Additional specialties that apply (Refer to the Provider Type and Specialty Matrix located on the IHCP Web site to determine the appropriate type and specialty for the type of services rendered)

15 Rendering provider’s taxonomies, if available. A maximum of three taxonomies are submitted per form. (To add additional taxonomies, complete an additional form)

Group Service Location Linkage Information (Fields 16a–16g)

Fields 16a-16g describe which service locations the rendering provider is linked. The rendering provider’s Medicare numbers are documented for crossover claims purposes.

If the rendering provider no longer performs services at one or more service locations, the form allows the group to report the changes in the termination column.

Because rendering providers can perform services across state lines for those groups that are in multi-states, the license number for each service location is required. If all of the service locations are in the same state, write in the license number one time and write in “same” for the remaining linkage lines.

Additional Programs (Fields 17a–17d)

This section collects information about the provider’s business. In addition, Providers may also indicate participation in additional programs. The following programs are listed:

• HealthWatch is a preventative health care program offered to Medicaid-eligible members younger than 21 years of age. Physicians or nurse practitioners who are enrolled as Medicaid providers are qualified to perform HealthWatch screenings. Reimbursement for HealthWatch services is higher than equivalent services billed using standard CPT codes. HealthWatch screenings must be completed in accordance with recommendations set forth in the HealthWatch Provider Manual Periodicity Schedule. Check the box labeled yes to receive the HealthWatch Provider Manual.

• The 590 Program is a State medical assistance program providing reimbursement for medically necessary covered medical services provided off site to individuals who reside in State institutions. The following provider types cannot be 590 providers: transportation, hospice, home health, DME, and long term care facilities. There are no out-of-state 590 providers.

Field Instructions

16a Enter the alpha suffix for the service location where the rendering provider is linked.

16b Enter the group’s NPI for the first listed service location. If one NPI applies to all of your service locations, indicate so on the remaining lines if other entries are made.

16c Enter the ZIP + 4 that belongs to the location.

16d Enter the linkage start date.

16e For termination of linkage(s), enter the date the rendering provider last provided service at the service location.

16f

Enter the Medicare number for the rendering provider for each service location. (A copy of the Centers for Medicare & Medicaid Services approval letter showing the group or clinic’s Medicare number along with the rendering provider’s number is used to verify the accuracy of the submitted number).

16g Enter the appropriate rendering provider license number for the state where the service location is located (If the license number is the same for all linkages, quote marks may be used after the first entry).


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• The Medical Review Program provides determination of an applicant’s eligibility for Medicaid under the disability category. The provider completes a medical assessment of an applicant and submits the required forms to the Office of Family Resources. The MRT issues a favorable or unfavorable eligibility decision based on medical evidence that supports whether the applicant has a significant impairment. Once the documentation has been filed, the provider may submit claims to EDS for payment of certain examination and reports. Services should not be performed unless the applicant has presented the pre-Medicaid eligibility form. To participate solely in the Medical Review Program, the provider should check the Medical Review Program ONLY. Providers that choose not to participate in the IHCP Programs and have been requested to submit medical records, should check MRT Medical Records.

• Pre-Admission Screening and Resident Review (PASRR) – All Diagnostic and Evaluation Teams must be contracted and approved by the Division of Disability, Rehabilitative Services (DDARS) and Bureau of Developmental Disability Services (BDDS). Community Mental Health Centers must be contracted and approved by the Division of Mental Health and Addiction (DMHA)

Managed Care Information (Field 18)

Medical providers that believe they qualify to be a primary medical provider may contact one of the managed care organizations associated with the IHCP. Refer to the managed care section on the IHCP Web site or contact Customer Assistance for more information.

Schedule B

Section and Field Numbers Description

Contact Information (Fields 1 – 5) Person responsible for the submitted form

Release of Social Security Number (Field 6)

Rendering providers are asked to sign the Consent to Release Social Security Numbers section of Schedule B. The rendering provider’s signature in Field 6 gives expressed consent to the IHCP and its contractors to release the provider’s Social Security number to state and federal agencies for verification purposes. An original signature is required.

IHCP Rendering Provider Application and Maintenance Form Signature Authorization (Fields 7 – 14)

An authorized official with the group or clinic is responsible for signing the Authorized Signature Page of the form. An original signature is required.

Provider Agreement (Used only at the time of initial enrollment)

The IHCP Provider Agreement must be completed and signed. The agreement follows Schedule B of the IHCP Rendering Provider Application and Maintenance Form.

Mailing Instructions:

Retain a copy of the completed application and maintenance packet for your records. Enclose the signed IHCP Provider Agreement and copies of all required documentation as listed on the provider application checklist, and mail the entire packet to the following address:

EDS – Provider Enrollment P.O. Box 7263 Indianapolis, IN 46207-7263

Application Processing:

When the Provider Enrollment Unit receives, reviews, and processes a provider form, the provider receives notification. If the submitted document is incomplete or the required supporting documentation is not present, the entire packet is returned. An instructional letter stating the reason(s) the request was not completed is included with the packet. If the IHCP denies an application, the provider receives notification explaining the denial reason. Please allow at least 30 business days for mailing and processing before checking the status of the submitted provider document.


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Refer to the IHCP Web site at www.indianamedicaid.com for additional information or contact the Provider Enrollment Helpline at 1-877-707-5750 for assistance in completing your IHCP Rendering Provider Application and Maintenance Form.

Document Checklist:

The following checklist is designed to assist providers in completing the application and maintenance process.

For Provider Use Only

Did you remember to…. For IHCP Use Only

Complete all IHCP Rendering Provider Application and Maintenance Form fields on Schedules A and B

Complete and sign a Provider Agreement when initially enrolling. The agreement must be signed by the rendering provider and an owner or authorized official with the group or clinic.

Complete Schedules A and B for provider maintenance and terminations. An IHCP Provider Agreement is not required to make changes to a currently enrolled provider’s profile.

Include copies of license(s) or permits for your provider specialty or specialties

Include a copy of the Medicare Assignment Letter to support addition of a Medicare Number to the rendering provider’s profile, if applicable

Out-of-state rendering providers must submit proof of participation in Medicare or their state’s Medicaid Program

Recertification:

Check the Provider Type and Specialty Requirements Matrix located on the IHCP Web site to determine if a provider type and specialty must recertify to extend eligibility. This process occurs at the time of licensure, insurance, or certificate renewal depending on the provider type. To extend eligibility, submit the IHCP Provider Recertification Form available at www.indianamedicaid.com. Providers that permit their eligibility to lapse due to failure to recertify must re-enroll and submit a new provider agreement.

IHCP Rendering Provider Application and Maintenance Form, Schedule A EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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1. Request Type:

Enrollment Profile Maintenance Terminate Linkage Group or Clinic Information

2. Group or Clinic LPI:

3. Group or Clinic Medicare Number:

4. Group or Clinic’s Tax ID:

5. Group or Clinic Provider Name:

6. Mailing Address:

7. City:

8. State:


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Note: Only groups and clinics have group members. If the rendering provider below is not actively enrolled, a signed IHCP Provider Agreement must be submitted with the IHCP Rendering Provider Enrollment and Maintenance Form. Rendering Providers must authorize enrollment and linkage information submitted by a group. The signature authorizes billing of claims through any method submitted on behalf of the group provider.

(Authorized Signature on following page for changes to an enrolled rendering provider’s profile)

Rendering Provider Information 10. Rendering Provider’s Name (Please Print):


12. Rendering Provider Number:

13. Rendering Provider’s NPI:

14a. Provider Type:

14b. Primary Specialty Code:

14c. Additional Specialty Codes: (Use appropriate codes)

15. Rendering Provider’s Taxonomies:

(16 a-g) Group Service Location Linkage Information 16a. Group Service Location Alpha Suffix:

16b. Group Service Location NPI:

16c. ZIP + 4: (Nine digits required)

16d. Requested Start Date:

16e. Termination Date:

16f. Rendering Medicare Number for Each Service Location:

16.g Rendering Provider License Number for Each Service Location:

Additional Programs Requested 17a. Healthwatch Program:

Yes No

17b. MRT:

Yes No

17c. PASRR:

Yes No

17d. 590 Program Participation:

Yes No

Manage Care Information 18. Prospective Managed Care PMP:

Yes No If you answer Yes in Field 18, contact the appropriate Managed Care Organization.

Please copy this form for additional Rendering Providers.

| Schedule A


IHCP Rendering Provider Application and Maintenance Form, Schedule B EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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Contact Information The contact person is the person who answers questions about the information provided in this application. 1. Contact Name:

2. Telephone:

3. Contact E-mail:

4. Active Billing Providers: Would you like a Web interChange application sent to your Mail To address? Yes No

5. Active Billing Providers: Are you willing to receive IHCP bulletins and newsletters via E-mail or the Web? Yes No

Social Security Number Release Consent

My signature in box 6a of Schedule B indicates that I give my express consent to the Office of Medicaid Policy and Planning and its contractors to disclose my social security number for the sole purpose of verifying my eligibility to participate in the Medicaid program with the Office of the Inspector General, the Centers for Medicare and Medicaid Services, licensing bodies, and other appropriate state and federal agencies.

I further consent that the Office of Medicaid Policy and Planning and its contractors may disclose my social security number to such appropriate organizations or agencies after this application has been approved so that the Office may review my ability to continue to participate in the Medicaid program.

6a. Rendering Provider’s Signature:

6b. Date:

Signature Authorization

PROFILE MAINTENANCE: An official with the group or clinic and the rendering provider must complete and sign Items 1-8 below to authorize changes to the rendering provider’s profile.

The undersigned, being the provider or having the specific authority to bind the provider to the terms of the provider agreement, does hereby agree to abide by and comply with all the stipulations, conditions, and terms set forth herein. The undersigned acknowledges that the commission of any Medicaid or CHIP-related offense, as set out in 42 USC 1320a-7b may be punishable by a fine of up to $25,000 or imprisonment of up to five years or both.

The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. The rendering provider is also obligated to sign this form. The form will be returned if the appropriate signatures are not submitted. 7. Group or Clinic’s Business Name (please print):

8. Tax ID:

9. Authorized Official’s Name (please print):

10. Title:

11. Authorized Official’s Signature:

12. Date:

13. Rendering Provider’s Signature:

14. Date:

To the Signatory: Please complete the IHCP Delegated Administrator Addendum if you are not an authorized official with your group. Provider profile maintenance can be processed only if the appropriate signature is present.

| Schedule B


IHCP Rendering Provider Agreement, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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IHCP Rendering Provider Agreement Overview

New Enrollee or New Provider Type:

If the application you completed is a first-time enrollment in the Indiana Health Coverage Programs (IHCP), you are required to complete and sign a Provider Agreement to fulfill your enrollment requirements. Providers whose eligibility has lapsed for one year or greater are required to re-enroll to restore their eligibility. A full enrollment packet must be submitted for processing. An owner or official with your business must sign the IHCP Provider Agreement. An original signature is required. A new IHCP number is assigned to each Provider Type enrolled in the IHCP.

Additional Service Location:

If the application you completed was used to enroll an additional service location to your existing business, you are not required to sign an IHCP Provider Agreement.

Provider Agreement Summary:

The Agreement details the requirements for participation in the IHCP. Included are provider responsibilities regarding updating provider information, protecting patient health information, requirements for claims processing, overpayments, and record retention. In addition, the Agreement details obligations regarding the appeals process, civil rights regulation compliance, utilization, control, and disclosure rules. The entire Agreement must be read, signed, and returned with the application. A signed copy must be retained by the provider.

| Overview

IHCP Provider Agreement www.indianamedicaid.com | Overview IHCP Rendering Provider Agreement www.indianamedicaid.com

IHCP Rendering Provider Agreement EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263

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This agreement must be completed, signed, and returned to EDS for processing.

By execution of this Agreement, the undersigned entity (“Provider”) requests enrollment as a provider in the Indiana Health Coverage Programs. As an enrolled provider in the Indiana Health Coverage Programs, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members. As a condition of enrollment, this agreement cannot be altered and the Provider agrees to all of the following:

1. To comply, on a continuing basis, with all enrollment requirements established under rules adopted by the state of Indiana Family and Social Services Administration (“IFSSA”).

2. To comply with all federal and state statutes and regulations pertaining to the Indiana Health Coverage Programs, as they may be amended from time to time.

3. To meet, on a continuing basis, the state and federal licensure, certification or other regulatory requirements for Provider’s specialty including all provisions of the state of Indiana Medical Assistance law, state of Indiana Children’s Health Insurance Program law, or any rule or regulation promulgated pursuant thereto.

4. To notify IFSSA or its agent within ten (10) days of any change in the status of Provider’s license, certification, or permit to provide its services to the public in the state of Indiana.

5. To provide covered services and/or supplies for which federal financial participation is available for Indiana Health Coverage Program members pursuant to all applicable federal and state statutes and regulations.

6. To safeguard information about Indiana Health Coverage Program members including at a minimum:

a. members’ name, address, and social and economic circumstances;

b. medical services provided to members;

c. members’ medical data, including diagnosis and past history of disease or disability;

d. any information received for verifying members’ income eligibility and amount of medical assistance payments;

e. any information received in connection with the identification of legally liable third party resources.

7. To release information about Indiana Health Coverage Program members only to the IFSSA or its agent and only when in connection with:

a. providing services for members; and

b. conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the provision of Indiana Health Coverage Program covered services.

8. To maintain a written contract with all subcontractors, which fulfills the requirements that are appropriate to the service or activity delegated under the subcontract. No subcontract, however, terminates the legal responsibility of the contractor to the agency to assure that all activities under the contract are carried out.

9. Provider also agrees to notify the IHCP in writing of the name, address, and phone number of any entity acting on Provider’s behalf for electronic submission of Provider’s claims. Provider understands that the State requires 30-days prior written notice of any changes concerning Provider’s use of entities acting on Provider’s behalf for electronic submission of Provider’s claims and that such notice shall be provided to the IHCP.

10. To submit claims for services rendered by the Provider or employees of the Provider and not to submit claims for services rendered by contractors unless the provider is a healthcare facility (such as hospital, ICF-MR, or nursing home), or a government agency with a contract that meets the requirements described in item 8 of this Agreement. Healthcare facilities and government agencies may, under circumstances permitted in federal law, subcontract with other entities or individuals to provide Indiana Health Coverage Program covered services rendered pursuant to this Agreement.

11. To comply, if a hospital, nursing facility, provider of home health care and personal care services, hospice, or HMO; with advance directive requirements as required by 42 Code of Federal Regulations, parts 489, subpart I, and 417.436.

12. To abide by the Indiana Health Coverage Programs Provider Manual, as amended from time to time, as well as all provider bulletins and notices. Any amendments to the provider manual, as well as provider bulletins and notices, communicated to Provider shall be binding upon receipt. Receipt of amendments, bulletins and notices


IHCP Rendering Provider Agreement www.indianamedicaid.com






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by Provider shall be presumed when mailed to the billing Provider’s current “mail to” address on file with IFSSA or its fiscal agent.

13. To submit timely billing on Indiana Health Coverage Program approved claim forms, as outlined in the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages, in an amount no greater than Provider’s usual and customary charge to the general public for the same service.

14. To be responsible and accountable for the completion, accuracy, and validity of all claims filed under the provider number issued, including claims filed by the Provider, the Provider’s employees, or the Provider’s agents. Provider understands that the submission of false claims, statements, and documents or the concealment of material fact may be prosecuted under the applicable federal and/or state law.

15. To submit claim(s) for Indiana Health Coverage Program reimbursement only after first exhausting all other sources of reimbursement as required by the Indiana Health Coverage Programs Provider Manual, bulletins, and banner pages.

16. To submit claim(s) for Indiana Health Coverage Program reimbursement utilizing the appropriate claim forms and codes as specified in the provider manual, bulletins and notices.

17. To submit claims that can be documented by Provider as being strictly for:

a. medically necessary medical assistance services;

b. medical assistance services actually provided to the person in whose name the claim is being made; and

c. compensation that Provider is legally entitled to receive.

18. To accept payment as payment in full the amounts determined by IFSSA or its fiscal agent, in accordance with federal and state statutes and regulations as the appropriate payment for Indiana Health Coverage Program covered services provided to Indiana Health Coverage Program members (recipients). Provider agrees not to bill members, or any member of a recipient’s family, for any additional charge for Indiana Health Coverage Program covered services, excluding any co-payment permitted by law.

19. To refund within fifteen (15) days of receipt, to IFSSA or its fiscal agent any duplicate or erroneous payment received.

20. To make repayments to IFSSA or its fiscal agent, or arrange to have future payments from the Indiana Health Coverage Program withheld, within sixty (60) days of receipt of notice from IFSSA or its fiscal agent that an investigation or audit has determined that an overpayment to Provider has been made, unless an appeal of the determination is pending.

21. To pay interest on overpayments in accordance with IC 12-15-13-3, IC 12-15-21-3, and IC 12-15-23-3.

22. To make full reimbursement to IFSSA or its fiscal agent of any federal disallowance incurred by IFSSA when such disallowance relates to payments previously made to Provider under the Indiana Health Coverage Programs.

23. To fully cooperate with federal and state officials and their agents as they conduct periodic inspections, reviews and audits.

24. To make available upon demand by federal and state officials and their agents all records and information necessary to assure the appropriateness of Indiana Health Coverage Program payments made to Provider, to assure the proper administration of the Indiana Health Coverage Program and to assure Provider’s compliance with all applicable statutes and regulations. Such records and information are specified in 405 IAC 1-5 and in the Indiana Health Coverage Programs Provider Manual, and shall include, without being limited to, the following:

a. medical records as specified by Section 1902(a)(27) of Title XIX of the Social Security Act, and any amendments thereto;

b. records of all treatments, drugs and services for which vendor payments have been made, or are to be made under the Title XIX or Title XXI Program, including the authority for and the date of administration of such treatment, drugs or services;

c. any records determined by IFSSA or its representative to be necessary to fully disclose and document the extent of services provided to individuals receiving assistance under the provisions of the Indiana Health Coverage Program;

d. documentation in each patient’s record that will enable the IFSSA or its agent to verify that each charge is due and proper;

e. financial records maintained in the standard, specified form;

f. all other records as may be found necessary by the IFSSA or its agent in determining compliance with any federal or state law, rule, or regulation promulgated by the United States Department of Health and Human Services or by the IFSSA; and

g. any other information regarding payments claimed by the provider for furnishing services to the plan.


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25. To cease any conduct that IFSSA or its representative deems to be abusive of the Indiana Health Coverage Program.

26. To promptly correct deficiencies in Provider’s operations upon request by IFSSA or its fiscal agent.

27. To make a good faith effort to provide and maintain a drug-free workplace. Provider will give written notice to the State within ten (10) days after receiving actual notice that the provider or an employee of the provider has been convicted of a criminal drug violation occurring in the provider’s workplace.

28. To file all appeal requests within the time limits listed below. Appeal requests must state facts demonstrating that:

a. the petitioner is a person to whom the order is specifically directed;

b. the petitioner is aggrieved and, or adversely affected by the order;

c. the petitioner is entitled to review under the law.

29. Provider must file a statement of issues within the time limits listed below, setting out in detail:

30. the specific findings, actions, or determinations of IFSSA from which Provider is appealing;

31. with respect to each finding, action or determination, all statutes or rules supporting Provider’s contentions of error.

32. Time limits for filing an appeal and the statement of issues are as follows:

a. A provider must file an appeal of any of the following actions within sixty days of receipt of IFSSA’s determination:

(1) A notice of program reimbursement or equivalent determination regarding reimbursement or a year end cost settlement.

(2) A notice of overpayment.

(3) The statement if issues must be filed with the request for appeal.

b. All appeals of actions not described in (a) must be filed within 15 days of receipt of IFSSA’s determination. The statement of issues must be filed within 45 days of receipt of IFSSA’s determination.

33. To cooperate with IFSSA or its agent in the application of utilization controls as provided in federal and state statutes and regulations as they may be amended from time to time.

46. To comply with the advance directives requirements as specified in 42 C.F.R. part 489, subpart I, and 42 C.F.R. 417.436(d), as applicable.

34. To comply with civil rights requirements as mandated by federal and state statutes and regulation by ensuring that no person shall, on the basis of race, color, national origin, ancestry, disability, age, sex or religion, be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination in the provision of a Indiana Health Coverage Program covered service.

35. The Provider and its agents shall abide by all ethical requirements that apply to persons who have a business relationship with the State, as set forth in Indiana Code § 4-2-6 et seq., Indiana Code § 4-2-7, et seq., the regulations promulgated thereunder, and Executive Order 04-08, dated April 27, 2004. If the Provider is not familiar with these ethical requirements, the Provider should refer any questions to the Indiana State Ethics

Commission, or visit the Indiana State Ethics Commission Web site at <<<http://www.in.gov/ethics/>>>. If the Provider or its agents violate any applicable ethical standards, the State may, in its sole discretion, terminate this Agreement immediately upon notice to the Provider. In addition, the Provider may be subject to penalties under Indiana Code § 4-2-6, 4-2-7, 35-44-1-3, and under any other applicable laws.

36. To disclose information on ownership and control, information related to business transactions, information on change of ownership, and information on persons convicted of crimes in accordance with 42 Code of Federal Regulations, part 455, subpart B, and 405 IAC 1-19. Long term care providers must comply with additional requirements found in 405 IAC 1-20. Pursuant to 42 Code of Federal Regulations, part 455.104(c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law.

37. To submit within 35 days of the date of request by the federal or state agency full and complete information about ownership of subcontractors with whom the provider has had more than $25,000 in a twelve month hearing period, and any significant business transactions between the provider and any (1) wholly owned supplier or (2) subcontractor during five-year period ending with the date of request.

38. Long term care providers must comply with additional requirements found in 405 IAC 1-20. Pursuant to 42 Code of Federal Regulations, part 455.104(c), OMPP must terminate an existing provider agreement if a provider fails to disclose ownership or control information as required by federal law.

39. To furnish to IFSSA or its agent, as a prerequisite to the effectiveness of this Agreement, the information and documents set out in Schedules A through I to this Agreement, which are incorporated here by reference, and to update this information as it may be necessary.


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40. That subject to item 32, this Agreement shall be effective as of the date set out in the provider enrollment notification letter.

41. That this Agreement may be terminated as follows:

a. By IFSSA or its fiscal agent for Provider’s breach of any provision of this Agreement as determined by IFSSA; or

b. By IFSSA or its fiscal agent, or by Provider, upon 60 days written notice.

42. That this Agreement has not been altered, and upon execution, supersedes and replaces any provider agreement previously executed by the Provider.

43. For long term care providers involved in a change of ownership, this agreement acts as an amendment to the transferor’s agreement with IHCP to bind the transferee to the terms of the previous agreement; and any existing plan of correction and pending audit findings in accordance with 405 IAC 1-20.

44. For new owners of nursing facilities or intermediate care facilities for the mentally retarded, to accept the assignment of the provider agreement executed by the previous owner(s) as required by 42 CFR 442.14.

45. For any entity that receives or makes annual payments totaling at least $5,000,000 annually as described in 42 U.S.C. 1396a(a)(68), to establish written policies that provide detailed information about federal and state False Claims Acts, whistleblower protections, and entity policies and procedures for preventing and detecting fraud and abuse. In any inspection, review, or audit of the entity by OMPP or its contractors, the entity shall provide copies of the entity’s written policies regarding fraud, waste, and abuse upon request. Entity shall submit to OMPP a corrective action plan within 60 days if the entity is found not to be in compliance with any part of the requirements stated in this paragraph.

46. To verify and maintain proof of verification that no employee or contractor is an excluded individual or entity with the Health and Human Services (HHS) Office of the Inspector General (OIG). Providers shall review the HHS-OIG List of Excluded Individuals/Entities (LEIE) database for excluded parties. This LEIE database is accessible to the general public at http://www.oig.hhs.gov/fraud/exclusions.asp.

THE UNDERSIGNED, BEING THE PROVIDER OR HAVING THE SPECIFIC AUTHORITY TO BIND THE PROVIDER TO THE TERMS OF THIS AGREEMENT, AND HAVING READ THIS AGREEMENT AND UNDERSTANDING IT IN ITS ENTIRETY, DOES HEREBY AGREE TO ABIDE BY AND COMPLY WITH ALL THE STIPULATIONS, CONDITIONS, AND TERMS SET FORTH HEREIN. THE UNDERSIGNED ACKNOWLEDGES THAT THE COMMISSION OF ANY INDIANA HEALTH COVERAGE PROGRAM RELATED OFFENSE AS SET OUT IN 42 USC 1320a-7b MAY BE PUNISHABLE BY A FINE OF UP TO $25,000 OR IMPRISONMENT OF UP TO FIVE YEARS OR BOTH.

Provider Agreement-Authorized Signature – All Schedules and Applicable Addendums The owner or an authorized representative of the business entity directly, or ultimately responsible for operating the business enterprise must complete this section. In addition, all rendering providers must sign this section. Provider’s Business Name (Please Print):

Tax ID:

Authorized Official’s or Rendering Provider's Name (Please Print):

Title:

Authorized Official’s or Rendering Provider's Signature:

Date: