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Provider Enrollment Information
 
Change in Ownership

Medicaid-enrolled providers are required to notify ForwardHealth of a change in ownership within 35 calendar days after the effective date of the change, in accordance with the Centers for Medicare and Medicaid Services Final Rule 42 CFR 455.104(c)(l)(iv). ForwardHealth defines a change in ownership as follows: when a different party purchases (buys out) or otherwise obtains ownership or effective control over a practice or facility.

Failure to report a change in ownership within 35 calendar days may result in denial of payment, per 42 CFR 455.104(d).

The following provider types require Medicare enrollment and/or Wisconsin Division of Quality Assurance certification for a Medicaid enrollment change in ownership:

  • Ambulatory surgery centers.
  • End-stage renal disease services providers.
  • Federally qualified health centers.
  • Home health agencies.
  • Hospice providers.
  • Hospitals (inpatient and outpatient).
  • Nursing homes.
  • Outpatient rehabilitation facilities.
  • Rehabilitation agencies.
  • Rural health clinics.
Written Notification and New Enrollment Application Required

Any time a change in ownership occurs, providers are required to do one of the following:

ForwardHealth must receive the change in ownership notification, which must include the affected provider number (i.e., National Provider Identifier [NPI] or provider ID), within 35 calendar days after the effective date of the change in ownership. Once their provider file is updated with the change in ownership, providers will receive written notification of their new Medicaid enrollment effective date in the mail.

Providers with questions about changes in ownership may call Provider Services.

Events That Are Considered a Change in Ownership

The following events are considered a change in ownership and require the completion of a new provider enrollment application:

  • Change from one type of business structure to another type of business structure. Business structures include the following:
    • Sole proprietorships.
    • Corporations.
    • Partnerships.
    • Limited Liability Companies.
  • Change of name and tax identification number associated with the provider's submitted enrollment application (e.g., Employer Identification Number).
  • Change (i.e., addition or removal) of names identified as owners of the provider.
Examples of a Change in Ownership

Examples of a change in ownership include the following:

  • A sole proprietorship transfers title and property to another party.
  • Two or more corporate clinics or centers consolidate and a new corporate entity is created.
  • There is an addition, removal, or substitution of a partner in a partnership.
  • An incorporated entity merges with another incorporated entity.
  • An unincorporated entity (sole proprietorship or partnership) becomes incorporated.
Repayment Following a Change in Ownership

Medicaid-enrolled providers who sell or otherwise transfer their business or business assets are required to repay ForwardHealth for any erroneous payments or overpayments made to them. If necessary, the provider to whom a transfer of ownership is made will also be held liable by ForwardHealth for repayment. Therefore, prior to final transfer of ownership, the provider acquiring the business is responsible for contacting ForwardHealth to ascertain if he or she is liable under this provision.

The provider acquiring the business is responsible for making payments within 30 days after receiving notice from ForwardHealth that the amount shall be repaid in full.

Providers may send inquiries about the determination of any pending liability on the part of the owner to the following address:

Division of Health Care Access and Accountability
Bureau of Program Integrity
PO Box 309
Madison WI 53701-0309

ForwardHealth has the authority to enforce these provisions within four years following the transfer of a business or business assets. Refer to s. 49.45(21) , Wis. Stats., for complete information.

Submitting New Prior Authorization Requests After a Change in Ownership

Medicaid-enrolled providers are required to submit a new prior authorization (PA) request when there is a change in billing providers. A new PA request must be submitted with the new billing provider's name and billing provider number. The expiration date of the new PA request will remain the same as the original PA request.

The following must be sent to ForwardHealth with the new PA request:

  • A copy of the original PA request, if possible.
  • The new PA request, including the required attachments and supporting documentation indicating the new billing provider's name, address, and billing provider number.
  • A letter requesting the enddating of the original PA request (may be a photocopy), which should include the following information:
    • The previous billing provider's name and billing provider number, if known.
    • The new billing provider's name and billing provider number.
    • The reason for the change of billing provider. (The new billing provider may want to confer with the member to verify that the services from the previous billing provider have ended. The new billing provider may include this verification in the letter.)
    • The requested effective date of the change.
Change of Ownership Billing for Inpatient Hospitals

The date of discharge governs which NPI is used when a change of hospital ownership occurs. For example: A change of ownership occurs on July 1. A patient stay has dates of service from June 26 to July 2. The hospital submits the claim using the NPI effective July 1.

 
 
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