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Ohio Health Plans Provider Enrollment Application Or Time Limited Agreement For Organizations - Ohio
| Ohio Health Plans Provider Enrollment Application Or Time Limited Agreement For Organizations Form. This is a Ohio form and can be used in Department Of Development Disabilities Statewide . |
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Submit completed signed application/agreement with required attachments to: (For State Use Only) Provider Network Management Section Provider Enrollment Unit Reset Form P.O. Box 1461 Columbus, OH 43216-1461 Call the Interactive Voice Response (IVR) System at 1-800-686-1516 Ohio Department of Job and Family Services OHIO HEALTH PLANS PROVIDER ENROLLMENT APPLICATION/TIME LIMITED AGREEMENT FOR ORGANIZATIONS Complete all applicable items if you plan to bill Medicaid as a sole proprietor of a business, or if you are a publicly or privately held business with more than one owner. (This does not apply to individual practitioners or practitioner groups.) Organizational Provider Types: - Required Ambulance (82) Ambulatory Surgery Center (46) Ambulette (83) Assisted Living Waiver Provider (74) Durable Medical Equipment (76) End-Stage Renal Disease Dialysis Clinic (59) Family Planning Clinic (54) Federally Qualified Health Center (12) General Hospital (01) Hearing and Speech Clinic (58) Home Health Agency (Medicare Cert.) (60) Mark the ONE appropriate type PACE (08) Pharmacy (70) Portable X-ray Laboratory 81) Primary Care Clinic (50) Professional Dental School Clinic (56) Professional Optometry School Clinic (55) Public Health Department Clinic (52) Rural Health Clinic (05) Targeted Case Management (85) Waiver Service Provider (45) ODMH Certified Comm Mental Hlth Agency Home Health Agency (JC/CHAPS) (16) Hospice (44) Independent Diagnostic Testing Facility (IDTF) (79) Independent Laboratory (80) Medicaid School Program (28) Mental Health Clinic (51) Mental Hospital (02) Optician (75) Outpatient Health Facility (04) Outpatient Rehabilitation Clinic (53) ODADAS Certified/Licensed Treatment Program (Print or type entries) Provider Identification: - Required Organization Name Abbreviated Organization Name (If your name exceeds 30 spaces, indicate preferred abbreviation.) Employer Identification Number You must attach a signed W-9 form Address Information: - Required Physical Location of Business (Applicants: If more than one location, list Primary. Building Name / or / Department / Required field) or / In care of Business Address (Number, Street, Avenue, Route, etc: P.O. and Drop Boxes are not acceptable) Suite Number City County State Zip Code (Zip +4, if possible) Telephone Number "Pay to" Address (Name & Address to which Payment and/or Remittance Advice is to be mailed) or / In care of Building Name / or / Department / Address Suite Number City State Zip Code (Zip + 4, if possible) Mailing/Correspondence Address Building Name / or / Department / (Name & Address to which all other material is to be mailed) or / In care of Address Suite Number City State Zip Code (Zip + 4, if possible) JFS 06751 (Rev. 9/2008) Page American LegalNet, Inc. 1 of 14 www.FormsWorkFlow.com (For State Use Only) National Provider Identifier: If you have received your National Provider Identifier (NPI) number, please report it here: NPI number ** If you had a previous NPI number, please report it here: NPI number ** You must attach a copy of the notice from the NPI Enumerator to verify the National Provider Identifier Number. Medicare Identification Information: - Required if applicable * You must attach copy of CLIA Certificate PIN number* PIN number* DMERC number* *You must attach copy of Department of Health and Human Services Approval Letter. Clinical Laboratory Improvement Act Information - REQUIRED FOR ALL HOSPITALS AND ALL LABORATORIES CLIA number* CLIA number* CLIA number* * You must attach copy of CLIA Certificate * You must attach copy of CLIA Certificate Optional Categories of Service: Provider Type Ambulance (82) Check your Provider Type, and any other Categories of Service you are licensed and/or authorized to provide. Optional Category of Service Ambulette Services (38) Provider Type Outpatient Rehabilitation Clinic (53) Primary Care Clinic (50) Optional Category of Service Supplies & Med Equip (32) End-Stage Renal Disease Dialysis Clinic (59) Family Planning Clinic (54) Prescribed Drugs (30) Supplies & Med Equip (32) Supplies & Med Equip (32) Dental Services (45) Optometric Services (47) Advanced Practice Nurse (21) Supplies and Medical Equip (32) Physician Services (43) EPSDT Services (40) Supplies & Med Equip (32) Dental Services (45) Optometric Services (47) Supplies & Medical Equip (32) General Hospital (01) Ambulance Services (37) Ambulette Services (38) Supplies & Medical Equip(32) Professional Optometry School Clinic (55) Public Health Department Clinic (52) Mental Health Clinic(51) Federally Qualified Health Centers, Rural Health Facilities, Outpatient Health Facilities Providers may be enrolled as only one type of alternative payment clinic. An "alternative payment clinic" shall be defined as an FQHC, rural health clinic (RHC), or outpatient health facility (OHF). Check the appropriate box: Section 330 of Public Health Service Act grants recipient or under a contract with the recipient (include documentation from CMS that identifies the specific service site(s) included in the 330 public health services project) Health and Human Services Certification as a Federally Qualified Health Center (include documentation from US secretary of health and human services confirmation letter that the service site(s) is/are considered an FQHC look-alike with respect to Medicaid coverage) JFS 06751 (Rev. 9/2008) Page 2 of 14 American LegalNet, Inc. www.FormsWorkFlow.com (For State Use Only) Medicaid School Program Medicaid School Program A Medicaid School Program Provider must document effort to coordinate with an eligible child's medical home. The documentation must indicate effort made to obtain a release of information that would allow notation of the eligible child's primary healthcare provider's contact information and/or Medicaid managed care plan in the child's special education record. The release must allow the Medicaid School Program Provider to share health informational records with a child's primary healthcare provider and/or Medicaid managed care plan. Documentation must also include the efforts made to establish protocol for a bilateral exchange of information with the primary healthcare provider or managed care plan consistent with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, as applicable. These efforts should facilitate the coordination and non-duplication of screening, diagnostic, and treatment services for the eligible child. Ohio Department of Education Inter
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