Provider Enrollment and Ongoing Responsibilities : Provider Enrollment

Advanced Practice Nurse Prescribers

APNPs with a psychiatric specialty and psychiatrists are the only mental health providers who can submit claims for psychotherapy services that include a medical E&M component. Additionally, APNPs with a psychiatric specialty are required to be separately enrolled in Medicaid as a nurse practitioner in order to be reimbursed for an E&M service.

Agency Requirements

Prior to obtaining Wisconsin Medicaid enrollment, mental health and substance abuse providers are required to be certified by the Wisconsin DHS, DQA. Income maintenance or tribal agencies that request billing-only status do not need to be certified by the DQA.

The following enrollment requirements for outpatient mental health services include tables for Central Nervous System Assessments/Tests and Health and Behavior Assessment/Intervention. These additional services are included because mental health and substance abuse service providers sometimes provide these services to members.

Outpatient Mental Health Services (Evaluation, Psychotherapy)

Central Nervous System Assessments/Tests

Health and Behavior Assessment/Intervention

* These are sections of the Medicaid Mental Health/Substance Abuse Agency Enrollment Application.

Outpatient Mental Health Services for Children When Provided in the Home

Allowable provider types for outpatient mental health services for children provided in the home are the same as the allowable provider types for outpatient mental health services provided in a clinic setting. Outpatient mental health services for children provided in the home must be provided by a Medicaid-enrolled mental health provider working through a DHS 35-certified outpatient mental health clinic. Providers not working through a DHS 35-certified clinic may not receive reimbursement for outpatient mental health services provided in the home. Since a provider must be working through a DHS 35-certified outpatient mental health clinic, all the requirements indicated in Wis. Admin. Code ch. DHS 35, apply, including the requirement that a clinic providing services to persons 13 years of age and younger must have qualified staff with appropriate training and experience available to work with children and adolescents.

When submitting a claim for outpatient mental health services for children provided in the home, providers should list the NPI of the DHS 35-certified outpatient mental health clinic as the biller. If the rendering provider's NPI is different from the billing provider's NPI, providers should also list the NPI of the rendering provider on the claim.

CLIA Certification or Waiver

Congress implemented CLIA to improve the quality and safety of laboratory services. CLIA requires all laboratories and providers that perform tests (including waived tests) for health assessment or for the diagnosis, prevention, or treatment of disease or health impairment to comply with specific federal quality standards. This requirement applies even if only a single test is being performed.

CLIA Enrollment

The federal CMS sends CLIA enrollment information to ForwardHealth. The enrollment information includes CLIA identification numbers for all current laboratory sites. ForwardHealth verifies that laboratories are CLIA certified before Medicaid grants enrollment.

CLIA Regulations

ForwardHealth complies with the following federal regulations as initially published and subsequently updated:

• Public Health Service Clinical Laboratory Improvement Amendments of 1988
• Title 42 CFR Part 493, Laboratory Requirements

Scope of CLIA

CLIA governs all laboratory operations including the following:

• Accreditation
• Certification
• Fees
• Patient test management
• Personnel qualifications
• Proficiency testing
• Quality assurance.
• Quality control
• Records and information systems
• Sanctions
• Test methods, equipment, instrumentation, reagents, materials, supplies
• Tests performed

CLIA regulations apply to all providers who perform CLIA-monitored laboratory services, including, but not limited to, the following:

• Clinics
• HealthCheck providers
• Independent clinical laboratories
• Nurse midwives
• Nurse practitioners
• Osteopaths
• Physician assistants
• Physicians
• Rural health clinics

CLIA Certification Types

The CMS regulations require providers to have a CLIA certificate that indicates the laboratory is qualified to perform a category of tests.

Clinics or groups with a single group billing certification, but multiple CLIA numbers for different laboratories, may wish to contact Provider Services to discuss various certification options. There are five types of CLIA certificates as defined by CMS:

1. Certificate of Waiver. This certificate is issued to a laboratory to perform only waived tests. The CMS website identifies the most current list of waived procedures. BadgerCare Plus identifies allowable waived procedures in maximum allowable fee schedules.
2. Certificate for Provider-Performed Microscopy Procedures (PPMP). This certificate is issued to a laboratory in which a physician, mid-level practitioner, or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests. The CMS website identifies the most current list of CLIA-allowable provider-performed microscopy procedures. BadgerCare Plus identifies allowable provider-performed microscopy procedures in fee schedules.
3. Certificate of Registration. This certificate is issued to a laboratory and enables the entity to conduct moderate- or high-complexity laboratory testing, or both, until the entity is determined by survey to be in compliance with CLIA regulations.
4. Certificate of Compliance. This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.
5. Certificate of Accreditation. This is a certificate that is issued to a laboratory on the basis of the laboratory's accreditation by an accreditation organization approved by CMS. The six major approved accreditation organizations are:
   • The Joint Commission
   • CAP
   • COLA
   • American Osteopathic Association
   • American Association of Blood Banks
   • ASHI

Applying for CLIA Certification

Use the CMS 116 CLIA application to apply for program certificates. Providers may obtain CMS 116 forms from the CMS website or from the following address:

Division of Quality Assurance
Clinical Laboratory Section
1 W Wilson St
PO Box 2969
Madison WI 53701-2969

Providers Required to Report Changes

Providers are required to notify Provider Enrollment within 30 days of any change(s) in ownership, name, location, or director. Also, providers are required to notify Provider Enrollment of changes in CLIA certificate types immediately and within six months when a specialty/subspecialty is added or deleted.

Providers may notify Provider Enrollment of changes by uploading supporting documentation using the demographic maintenance tool or by mailing supporting documentation to the following address:

Wisconsin Medicaid
Provider Enrollment
313 Blettner Blvd
Madison WI 53784

If a provider has a new certificate type to add to its certification information on file with ForwardHealth, the provider should upload or mail a copy of the new certificate. When a provider sends ForwardHealth a copy of a new CLIA certificate, the effective date on the certificate will become the effective date for CLIA certification on file with ForwardHealth.

Categories of Enrollment

Wisconsin Medicaid enrolls providers in three billing categories. Each billing category has specific designated uses and restrictions. These categories include the following:

• Billing/rendering provider
• Rendering-only provider
• Billing-only provider (including group billing)

Providers should refer to the service-specific information in the Online Handbook or the Information for Specific Provider Types page on the Provider Enrollment Information home page to identify which category of enrollment is applicable.

Billing/Rendering Provider

Enrollment as a billing/rendering provider allows providers to identify themselves on claims (and other forms) as either the provider billing for the services or the provider rendering the services.

Rendering-Only Provider

Enrollment as a rendering-only provider is given to those providers who practice under the professional supervision of another provider (e.g., physician assistants). Providers with a rendering provider enrollment cannot submit claims to ForwardHealth directly, but they have reimbursement rates established for their provider type. Claims for services provided by a rendering provider must include the supervising provider or group provider as the billing provider.

Billing-Only Provider (Including Group Billing)

Enrollment as a billing-only provider is given to certain provider types when a separate rendering provider is required on claims.

Group Billing

Groups of individual practitioners are enrolled as billing-only providers as an accounting convenience. This allows the group to receive one reimbursement, one RA, and the 835 transaction for covered services rendered by individual practitioners within the group.

Providers may not have more than one group practice enrolled in Wisconsin Medicaid with the same ZIP+4 code address, NPI, and taxonomy code combination. Provider group practices located at the same ZIP+4 code address are required to differentiate their enrollment using an NPI or taxonomy code that uniquely identifies each group practice.

Individual practitioners within group practices are required to be Medicaid-enrolled because these groups are required to identify the provider who rendered the service on claims. Claims indicating these group billing providers that are submitted without a rendering provider are denied.

Enrollment Requirements Due to the Affordable Care Act

In 2010, the federal government signed into law the ACA, also known as federal health care reform, which affects several aspects of Wisconsin health care. ForwardHealth has been working toward ACA compliance by implementing some new requirements for providers and provider screening processes. To meet federally mandated requirements, ForwardHealth is implementing changes in phases, the first of which began in 2012. A high-level list of the changes included under ACA is as follows:

• Providers are assigned a risk level of limited, moderate, or high. Most of the risk levels have been established by the federal CMS based on an assessment of potential fraud, waste, and abuse for each provider type.
• Providers are screened according to their assigned risk level. Screenings are conducted during enrollment, reenrollment, and revalidation.
• Certain provider types are subject to an application fee. This fee has been federally mandated and may be adjusted annually. The fee is used to offset the cost of conducting screening activities.
• Providers are required to undergo revalidation every three years.
• All physicians and other professionals who prescribe, refer, or order services are required to be enrolled as a participating Medicaid provider.
• Payment suspensions are imposed on providers based on a credible allegation of fraud.
• Providers are required to submit personal information about all persons with an ownership or controlling interest, agents, and managing employees at the time of enrollment, re-enrollment, and revalidation.

In-State Emergency Providers and Out-of-State Providers

ForwardHealth requires all in-state emergency providers and out-of-state providers who render services to BadgerCare Plus, Medicaid, or SeniorCare members to be enrolled in Wisconsin Medicaid. Information is available regarding the enrollment options for in-state emergency providers and out-of-state providers.

In-state emergency providers and out-of-state providers who dispense covered outpatient drugs will be assigned a professional dispensing fee reimbursement rate of $10.51.

Materials for New Providers

On an ongoing basis, providers should refer to the Online Handbook for the most current BadgerCare Plus, Medicaid, and ADAP information. Future changes to policies and procedures are published in ForwardHealth Updates.

Outpatient Mental Health Enrollment Applications

To be reimbursed for outpatient mental health services, a provider is first required to be certified by the DQA, DHS for outpatient mental health treatment under Wis. Admin. Code ch. DHS 35. For information regarding this certification, providers may contact the DQA, DHS by telephone at 608-261-0656 or by mail at the following address:

Division of Quality Assurance Department of Health Services
Behavioral Health Certification Section
PO Box 2969
Madison WI 53701-2969

Agencies and individual outpatient mental health providers who meet DQA, DHS certification should submit an enrollment application via the ForwardHealth Portal to obtain Medicaid enrollment.

Individual outpatient mental health providers working in Medicaid-enrolled clinics must obtain and maintain individual Medicaid enrollment.

Professional Provider Types and Billing Categories

Individuals providing mental health and substance abuse services should refer to the following to determine their status as either a billing/rendering provider or rendering provider. Providers with billing/rendering status are able to bill Medicaid under their own NPI. Services performed by providers with rendering-only status must be billed under their agency NPI.

Billing/Rendering Providers

Billing/rendering providers include:

• Physicians (that is, psychiatrists)
• APNPs with Psychiatric Specialty
• Ph.D. Psychologists
• Licensed psychotherapists

The above providers may submit claims as well as render mental health and substance abuse services.

Note: APNPs with Psychiatric Specialty may submit claims as well as render services except when working under the Outpatient Mental Health and Substance Abuse Services in the Home and Community for Adults benefit, where they are rendering providers only.

Rendering Providers

Professionals who are rendering providers include:

• Certified psychotherapists
• Substance abuse counselors
• Narcotic treatment nurses
• Qualified treatment trainees

Rendering providers may only provide services that are within the scope of practice outlined in administrative code for their license or certification.

Mental health and substance abuse services performed by the above providers must be billed under the billing NPI of the agency for which they work; their NPI indicates they are the rendering provider.

Provider Addresses

ForwardHealth has the capability to store the following types of addresses and contact information:

• Practice location address and related information. This address is where the provider's office is physically located and where records are normally kept. Additional information for the practice location includes the provider's office telephone number and the telephone number for members' use. With limited exceptions, the practice location and telephone number for members' use are published in a provider directory made available to the public.
• Mailing address. This address is where ForwardHealth will mail general information and correspondence. Providers should indicate accurate address information to aid in proper mail delivery.
• PA address. This address is where ForwardHealth will mail PA information.
• Financial addresses. Two separate financial addresses are stored for ForwardHealth. The checks address is where ForwardHealth will mail paper checks. The 1099 mailing address is where ForwardHealth will mail IRS Form 1099.

Providers may submit additional address information or modify their current information using the demographic maintenance tool.

Note: Providers are cautioned that any changes to their practice location on file with Wisconsin Medicaid may alter their ZIP+4 code information required on transactions. Providers may verify the ZIP+4 code for their address on the U.S. Postal Service website.

Provider Enrollment Information Home Page

ForwardHealth has consolidated all information providers will need for the enrollment process in one location on the ForwardHealth Portal. For information related to enrollment criteria and to complete online provider enrollment applications, providers should refer to the Provider Enrollment Information home page.

The Provider Enrollment Information home page includes enrollment applications for each provider type and specialty eligible for enrollment with Wisconsin Medicaid. Prior to enrolling, providers may consult a provider enrollment criteria menu, which is a reference for each individual provider type detailing the information the provider may need to gather before beginning the enrollment process, including:

• Links to enrollment criteria for each provider type
• Provider terms of reimbursement
• Disclosure information
• Category of enrollment
• Additional documents needed (when applicable)

Providers will also have access to a list of links related to the enrollment process, including:

• General enrollment information
• Regulations and forms
• Provider type-specific enrollment information
• In-state and out-of-state emergency enrollment information
• Contact information

Information regarding enrollment policy and billing instructions may still be found in the Online Handbook.

Provider Type and Specialty Changes

Provider Type

Providers who want to add a provider type or change their current provider type are required to complete a new enrollment application for each provider type they want to add or change to because they need to meet the enrollment criteria for each provider type.

Provider Specialty

Providers who have the option to add or change a provider specialty can do so using the demographic maintenance tool. After adding or changing a specialty, providers may be required to submit documentation to ForwardHealth, either by uploading through the demographic maintenance tool or by mail, supporting the addition or change.

Providers should contact Provider Services with any questions about adding or changing a specialty.

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:

• Mail a change in ownership notification to ForwardHealth. After mailing the notification, providers are required to complete a new Medicaid provider enrollment application on the Portal.
• Upload a change in ownership notification as an attachment when completing a new Medicaid provider enrollment application on the Portal.

ForwardHealth must receive the change in ownership notification, which must include the affected provider number (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 DQA certification with current provider information before submitting a Medicaid enrollment change in ownership:

• Ambulatory surgery centers
• CHCs
• ESRD services providers
• Home health agencies
• Hospice providers
• Hospitals (inpatient and outpatient)
• Nursing homes
• Outpatient rehabilitation facilities
• Rehabilitation agencies
• RHCs
• Tribal FQHCs

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 TIN associated with the provider's submitted enrollment application (for example, EIN)
• 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.

End Date of Previous Owner's Enrollment

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

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 the previous owner does not repay ForwardHealth for any erroneous payments or overpayments, the new owner's application will be denied.

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.

Automatic Recoupment Following a Change in Ownership

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 DHS is notified of the change in ownership. The recoupment will apply to all claims processed with DOS after the provider's new end date.

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

Medicaid-enrolled providers are required to submit new 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

Submitting Claims After a Change in Ownership

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.

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

How to Bill for a Nursing Home Stay That Spans a Change in Ownership

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 to July 2. The nursing home submits the claim using the NPI effective July 1.

For Further Questions

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

Terminology to Know for Provider Enrollment

Due to the ACA, ForwardHealth has adopted new terminology. The following table includes new terminology that will be useful to providers during the provider enrollment and revalidation processes. Providers may refer to the Medicaid rule 42 C.F.R. s. 455.101 for more information.

Note: Providers should note that the federal CMS requires revalidation at least every five years. However, Wisconsin Medicaid will continue to revalidate providers every three years.