Michigan > Statewide > Department Of Community Health Medicaid
Pharmacy Provider Enrollment And Trading Partner Agreement - Michigan
| Pharmacy Provider Enrollment And Trading Partner Agreement Form. This is a Michigan form and can be used in Department Of Community Health Medicaid Statewide . |
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Michigan Department of Community Health Pharmacy Provider Enrollment & Trading Partner Agreement The Pharmacy Provider Enrollment & Trading Partner Agreement (MSA-1626) is used by the Michigan Department of Community Health (MDCH) Pharmacy Benefits Manager (PBM), Magellan Medicaid Administration, Inc. (MMA, Inc.), to enroll pharmacies in the Fee-For-Service (FFS) Programs for Medicaid, Children's Special Health Care Services (CSHCS), Adult Benefits Waiver (ABW), Maternity Outpatient Medical Services (MOMS), and Plan First! It is very important that you update your information with the National Council for Prescription Drug Programs (NCPDP). NCPDP is the clearinghouse that provides pharmacy contact information to MMA, Inc. and ultimately to MDCH. The web address for NCPDP is www.ncpdp.org . To receive Electronic Funds Transfer (EFT) payments you must complete the MMA, Inc. Electronic Funds Transfer (EFT) Authorization form. You must contact the MMA, Inc. Provider Enrollment Department at 888-868-9219 to obtain this form. To receive an 835, if the Trading Partner has multiple submitters, the Trading Partner must designate one recipient for all 835 electronic remittance advices. Complete the Secure FTP Guidelines document to receive X12 835 electronic transactions found at https://michigan.fhsc.com/ . NOTE: Out-of-state/beyond borderland pharmacies requesting enrollment in the FFS programs for Medicaid, CSHCS, ABW, MOMS and Plan First!, should review additional enrollment information at https://michigan.fhsc.com/ >> Providers >> Forms >> Out of State Providers Bulletin. The effective date of enrollment for a pharmacy provider is the date the Agreement is signed (license permitting) should MMA, Inc. receive the Agreement and all required documentation within 30 days of the signature date. Effective dates for some pharmacy providers are determined by certification requirements or other approval dates. A pharmacy may request retroactive enrollment in writing. This request must contain a valid reason for retroactive enrollment and must accompany this Agreement. Approval for retroactive enrollment is not a waiver for any claim(s) not submitted within the Michigan Medicaid Program billing guidelines. You will be notified when your Agreement has been processed/approved via a "Michigan Medicaid Provider Enrollment Confirmation" welcome letter which will contain your Medicaid enrollment information. Questions concerning enrollment, should be directed to the MMA, Inc. Provider Enrollment Department by phone at (888) 868-9219 or via e-mail mipharmacyenrollment@magellanhealth.com. Magellan Medicaid Administration, Inc. Michigan Medicaid Provider Enrollment Department 4300 Cox Road Glen Allen, VA 23060 The Michigan Department of Community Health is an equal opportunity employer, services and programs provider. MSA-1626 (04/11) Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Pharmacy Provider Enrollment & Trading Partner Agreement Conditions and Provisions IMPORTANT Trading Partner Provisions apply to all electronic billers. Either party, upon thirty (30) days written notice, may cancel this Agreement. In applying for enrollment as a provider or trading partner with Magellan Medicaid Administration, Inc., (MMA, Inc.) and programs for which the Michigan Department of Community Health (MDCH) is the fiscal intermediary, I represent and certify as follows: 1. The applicant and the employer certify that the undersigned have the authority to execute this Agreement. 2. Enrollment in the Medical Assistance program does not guarantee participation in MDCH managed care programs nor does it replace or negate the contract process between a managed care entity and its providers or subcontractors. 3. All information furnished on this Pharmacy Provider Enrollment & Trading Partner Agreement is true and complete. 4. The providers and fiscal agents of ownership and control information will disclose information on a provider's, owners and other persons convicted of criminal offenses against Medicare, Medicaid or the Title XX services program. [42 CFR 455.100] 5. The providers agree to disclose criminal convictions of persons with ownership or control interest in the provider, an agent, or managing employee of the provider related to any federal heath care program (e.g., Medicare (Title XVIII), Medicaid (Title XIX), and other State Health Care Programs (Title V, Title XX, and Title XXI) involvement), [42 CFR 455.106] and to disclose any criminal convictions of those individuals or any other employee [42 U.S.C. § 1320a-7]. 6. Before billing for any pharmacy services that I render, I will read the Michigan Medicaid Provider Manual and the Magellan Medicaid Administration, Inc. Claims Processing Manual. I also agree to comply with: 1) the terms and conditions of participation noted in the Manuals; and 2) MDCH policies and procedures for the Medical Assistance Program contained in the manual, manual updates, provider bulletins and other program notifications. 7. I agree to comply with the provisions of 42 CFR 455.104, 42 CFR 455.105, 42 CFR 431.107 and Act No. 280 of the Public Acts of 1939, as amended, which state the conditions and requirements under which participation with MDCH is allowed. 8. I agree to comply with the requirements of Section 6032 of the Deficit Reduction Act of 2005, codified at Section 1902(a)(68) of the Social Security Act, which relates to the conditions and requirements of "Employee Education About False Claims Recovery." 9. I agree that, upon request and at a reasonable time and place, I will allow authorized state and/or federal government agents to inspect, copy, and/or take any records I maintain pertaining to the delivery of goods and/or services to, or on behalf of, a MDCH beneficiary. These records also include any service contract(s) I have with any billing agent/service or service bureau, billing consultant, and/or other healthcare provider. 10. I agree to include a clause in any contract I enter into which allows authorized state or federal government agents access to the subcontractor's accounting records and other documents needed to verify the nature and extent of costs and services furnished under the contract. 11. I understand that payment for services billed under my provider identification number will be made directly to me, unless Item 19 (below) applies. 12. I am not currently suspended, terminated, disbarred, or excluded from the Medical Assistance Program b
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