Medicaid-enrolled providers must notify ForwardHealth of a change in ownership within 35 calendar days after the effective date of the change per the Centers for Medicare & Medicaid Services Final Rule 42 C.F.R. § 455.104(c)(1)(iv).

Failure to report a change in ownership within 35 calendar days may result in denial of payment, per 42 C.F.R. § 455.104.

Note: For demographic changes that do not constitute a change in ownership, providers should update their current information using the demographic maintenance tool.

Any time a change in ownership occurs, providers must complete a new Medicaid provider enrollment application on the ForwardHealth Portal. Indicate that this is a change of ownership on the application.

ForwardHealth must receive the change in ownership application, which must include the affected provider number (National Provider Identifier [NPI] or provider ID), within 35 calendar days after the effective date of the change in ownership.

Providers will receive written notification of their new Medicaid enrollment effective date in the mail once their provider file is updated with the change in ownership.

These provider types require Medicare enrollment and/or Wisconsin Division of Quality Assurance certification with current provider information before submitting a Medicaid enrollment change in ownership:

• Three to four bed adult family homes (AFHs)
• Adult day care centers
• Ambulatory surgery centers
• Community-based residential facilities (CBRF)
• Community health centers
• End-stage renal disease services providers
• Home health agencies
• Hospice providers
• Hospitals (inpatient and outpatient)
• Nursing homes
• Outpatient rehabilitation facilities
• Rehabilitation agencies
• Residential care apartment complexes (RCAC)
• Rural health clinics
• Tribal federally qualified health centers

One to two bed AFHs require managed care organization (MCO) or Wisconsin Department of Health Services (DHS) certification with current ownership information prior to applying for Medicaid enrollment.

The following provider types require providers to obtain a home and community-based settings rule Notice of Compliance from DHS with current ownership information prior to applying for Medicaid enrollment:

• Facility-based adult day services
• Facility-based prevocational services
• Group-supported employment providers

Providers required to use electronic visit verification (EVV) when rendering certain services can ensure a successful transition by:

• Reviewing the EVV and Provider Agency Change of Ownership document, P-03819
• Contacting Wisconsin EVV Customer Care at vdxc.contactevv@dhs.wisconsin.gov or 833-931-2035, Monday–Friday, 7 a.m.–6 p.m. Central Time.

ForwardHealth defines a change in ownership as an event where a different party purchases (buys out) or otherwise obtains ownership or effective control over a practice or facility.

These 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 (for example, Employer Identification Number).
• Change (addition or removal) of names identified as owners of the provider.

Examples of a change in ownership include:

• 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.

The end date of the previous owner's enrollment will be one day prior to the effective date for the change in ownership. When DHS is notified of a change in ownership, the original owner's enrollment will automatically be end-dated.

Note: Adult long-term care waiver-only providers who serve members or participants in Family Care, Family Care Partnership, Program of All-Inclusive Care for the Elderly (PACE), and IRIS (Include, Respect, I Self-Direct) must work with MCOs and/or IRIS fiscal employer agents (FEAs) to repay any erroneous payments or overpayments.

Medicaid-enrolled providers who sell or otherwise transfer their business or business assets must repay ForwardHealth for any erroneous payments or overpayments made to them. The new owner's application will be denied if the previous owner does not repay ForwardHealth for any incorrect payments or overpayments.

If necessary, ForwardHealth will hold the provider who receives the transfer of ownership before the final transfer of ownership. The provider acquiring the business is responsible for contacting ForwardHealth to find out if they are liable under this provision.

The provider acquiring the business is responsible for full repayment within 30 days after receiving this notice from ForwardHealth.

Providers may send inquiries about determining any pending liability to:

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

ForwardHealth will automatically recover payments made to providers whose enrollment has ended in the ForwardHealth system due to a change in ownership. This automatic recoupment for previous owners occurs about 45 days after they notify DHS of the change in ownership. The recoupment will apply to all claims processed with dates of service (DOS) after the provider's new end date.

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

The provider must send this information 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 to end date the original PA request (may be a photocopy), which should include:
  • 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 verify with the member 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

The provider acquiring the business may submit claims with DOS on and after the change in ownership effective date.

Additional information on submission of timely filing requests or adjustment reconsideration requests is available.

When a change in hospital ownership occurs, use the NPI that is current on the date of discharge. For example: A change in ownership occurs on July 1. A patient stay has DOS from June 26-July 2. The hospital submits the claim using the NPI effective July 1.

When a change in nursing home ownership occurs, use the NPI that is current on the date of discharge. For example: A change in ownership occurs on July 1. A nursing home patient stay has DOS from June 26-July 2. The nursing home submits the claim using the NPI effective July 1.

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