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Provider Enrollment Information
 
Change in Ownership
Providers Have 35 Days to Report a 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 & 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(e).

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

Written Notification and a New Enrollment Application Are 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 (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.

Special Requirements for Specific Provider Types

The following 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:

  • Ambulatory surgery centers
  • 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
  • Rural health clinics
  • Tribal federally qualified health centers
Events That ForwardHealth Considers a Change in Ownership

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.

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 (for example, Employer Identification Number).
  • Change (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, ForwardHealth will hold responsible for repayment the provider to whom a transfer of ownership is made prior to the final transfer of ownership. The provider acquiring the business is responsible for contacting ForwardHealth to ascertain if they are liable under this provision.

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

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

Office of the Inspector General
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 Wis. Stat. § 49.45(21) for complete information.

New Prior Authorization Requests Must Be Submitted After a Change in Ownership

Medicaid-enrolled providers are required to submit new prior authorization (PA) requests when there is a change in billing providers. New PA requests 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 provider is required to send the following 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 enddate 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 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
How to Bill for a Hospital Stay That Spans a Change in Ownership

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 dates of service from June 26 to July 2. The hospital submits the claim using the NPI effective July 1.

For Further Questions

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

 
 
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