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.

Age-Specific Requirements for Providing Ventilator-Dependent Services

Nurses providing PDN services to ventilator-dependent members are required to submit documentation of Medicaid-approved recognition of age-specific skills acquisition demonstrations for the pediatric and/or adult members they serve. Wisconsin Medicaid pediatric PDN enrollment applies to children ages 0-16. Wisconsin Medicaid adult PDN enrollment applies to adults ages 17 and older.

Child to Adult Transition Period Requirements

A transitional ventilator-dependent recipient is a member who is between the ages of 16 and 18.

A nurse who is certified to provide services to ventilator-dependent pediatric members (but not adult members) may continue to submit claims for services to a member for whom authorization has been granted prior to the member aging into the transition period. The nurse may continue to serve the member when the member turns 17 and until whichever of the following situations occurs first:

• The date the nurse is required to renew their pediatric skills demonstration
• The member's 19th birthday

At that time, the nurse is required to meet the Wisconsin Medicaid adult certification requirement to continue providing services to the member.

A nurse certified only for pediatric care may not provide PDN to any adult ventilator-dependent member over the age of 17 unless the nurse began providing uninterrupted service to the member before the member's 17th birthday.

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.

Durable Medical Equipment

To be reimbursed for dispensing DME, physicians are required to obtain separate Medicaid enrollment as a Medical Supply and Equipment Vendor. Physicians are required to comply with all federal laws and regulations, including the Stark statute on referrals.

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.

Enrollment and Training Requirements for Nurses Providing Ventilator-Dependent Services

Nurses who are already enrolled as individual NIP but want to provide PDN services to ventilator-dependent members are required to attest that they will meet and follow the enrollment regulations under Wis. Admin. Code § DHS 105.19 using the demographic maintenance tool. Additionally, nurses are required to complete an age-specific respiratory skills acquisition demonstration and report information regarding the demonstration using the demographic maintenance tool.

Note: If nurses allow their certification to provide PDN services to ventilator-dependent members to lapse, they will no longer be enrolled to provide PDN to ventilator-dependent members.

To be reimbursed by Wisconsin Medicaid for PDN services provided to ventilator-dependent members, nurses are required to do the following:

• Become enrolled in Wisconsin Medicaid as an NIP or nurse practitioner.
• Complete an age-specific respiratory skills acquisition demonstration as required by ForwardHealth and indicate the following to ForwardHealth using the demographic maintenance tool:
  • Whether or not they have been recognized by an approved facility in the last two years as having successfully demonstrated the respiratory care skills required by ForwardHealth. A link to these requirements can be found on the applicable respiratory care panel in the demographic maintenance tool.
  • Date the respiratory skills acquisition demonstration (declaration of skill acquisition) was completed.
  • Information about where CPR training was received, including the facility's address and the instructor's name.
  • Whether or not they have a CPR card from an approved facility that documents that they successfully completed a CPR course for the professional rescuer within the last two years.
  • CPR card information, including the candidate's name, the issue date, and the renewal/expiration date.
• Submit the following to ForwardHealth upon completion of the respiratory skills acquisition demonstration and before the renewal deadline:
  • Current documentation of their respiratory skills recognition certificate from a hospital accredited by The Joint Commission or proof of age-appropriate respiratory skills acquisition from a nursing home that is state approved for ventilator care.
  • A copy of their valid CPR card (Basic Life Support for Health Care Providers Program from the American Red Cross or American Heart Association).
  
  Providers may submit renewal and training documentation by uploading it through the demographic maintenance tool or mailing it to the following address:

  Wisconsin Medicaid
  Provider Enrollment
  313 Blettner Blvd
  Madison WI 53784

Upon submission of any of the above information, a message will display in the demographic maintenance tool indicating that the providers' information was uploaded successfully. Additionally, an Application Submitted panel will display and indicate next steps. ForwardHealth will verify changes to the information within 10 business days of submission.

If the changes can be verified, ForwardHealth will update providers' files. ForwardHealth will not notify nurse practitioners and NIP that their provider files have been updated. The changed information is not considered approved until 10 business days after the information was changed.

If the changes cannot be verified within 10 business days, ForwardHealth will notify nurse practitioners and NIP by mail that their provider files were not updated. Nurse practitioners and NIP will need to make corrections using the demographic maintenance tool.

Demonstration Renewals

Nurses are required to renew their respiratory skills acquisition demonstration within 24 months of the date of their last demonstration, or they will no longer be enrolled to provide private duty nursing to ventilator-dependent members.

It is the nurse's responsibility to repeat the respiratory skills acquisition demonstration and submit the required information and upload the certificate to ForwardHealth by the renewal deadline.

Express Enrollment for Pregnant Women Benefit

Physicians, physician assistants, nurse practitioners, and nurse midwives may become Medicaid-enrolled EE providers. EE for Pregnant Women Benefit providers determine whether a pregnant woman may be eligible for BadgerCare Plus. The EE for Pregnant Women Benefit is a limited benefit category that allows an uninsured or underinsured (i.e., insured without prenatal coverage) pregnant woman to receive immediate pregnancy-related outpatient services while their application for full-benefit BadgerCare Plus is processed.

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.

Nurse Practitioners

Nurse practitioners who treat ForwardHealth members are required to be Medicaid-enrolled to receive reimbursement. This applies to nurse practitioners whose services are reimbursed under a physician's or clinic's NPI, as well as to those who independently submit claims to ForwardHealth.

Medicaid services performed by nurse practitioners must be within the legal scope of practice as defined under the Wisconsin Board of Nursing licensure or certification. Services performed must be included in the individual nurse practitioner's protocols or a collaborative relationship with a physician as defined by the Board of Nursing.

Most advanced practice nurse prescribers who apply for Medicaid enrollment are enrolled as nurse practitioners (except for non-Master's degree-prepared nurse midwives and certified registered nurse anesthetists).

Pursuant to Board of Nursing Wis. Admin. Code § N 8.10(7), advanced practice nurse prescribers work in a collaborative relationship with a physician. (The collaborative relationship is defined as an advanced practice nurse prescriber works with a physician, "in each other's presence when necessary, to deliver health care services within the scope of the practitioner's professional expertise.")

Advanced practice nurse prescribers who dispense drugs in addition to prescribing them should obtain the appropriate ForwardHealth pharmacy publications. Providers may also call Provider Services for more information.

Medicaid-enrolled nurse practitioners who provide delegated medical care under the general supervision of a physician are required to be supervised only to the extent required pursuant to Board of Nursing Wis. Admin. Code § N 6.02(7). (Chapter N 6 defines general supervision as the regular coordination, direction, and inspection of the practice of another and does not require the physician to be on site.)

Note: Medicaid enrollment is not required for nurse practitioners working in family planning clinics or as psychiatric nurse practitioners/clinical nurse specialists. Family planning clinics and psychiatric nurse practitioners/clinical nurse specialists should refer to their service-specific areas of this Web site for information on covered services and related limitations.

Services provided by registered nurses who do not meet Medicaid nurse practitioner enrollment requirements may be reimbursed as services provided by ancillary providers.

Protocols/Collaborative Agreements

Pursuant to Wis. Admin. Code § N 8.10(7), advanced practice nurse prescribers work in a collaborative relationship with a physician. The advanced practice nurse prescriber and the physician must document this relationship.

Pursuant to the requirements of Wis. Admin. Code § N 6.03(2), nurse practitioners may only perform those delegated medical acts for which there are protocols or written or verbal orders, and which the nurse practitioner is competent to perform based on his or her nursing education, training, or experience. Nurse practitioners may perform delegated medical acts under the general supervision or direction of a physician, podiatrist, dentist, or optometrist. In addition, nurse practitioners are required to consult with a physician, podiatrist, dentist, or optometrist in cases where the nurse practitioner knows or should know a delegated medical act may harm a patient.

For purposes of Medicaid enrollment, no service which is a medical act and is listed as an allowable physician service may be performed without a collaborative practice agreement as required for advanced practice nurse prescribers (pursuant to Wis. Admin. Code § N 8.10(7)) or protocols, and written or verbal orders for other Medicaid-enrolled nurse practitioners pursuant to Wis. Admin. Code § N 6.03(1).

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.