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Provider Participation Agreement (Medicaid - Packet) (MAD 335) - New Mexico
| Provider Participation Agreement (Medicaid - Packet) (MAD 335) Form. This is a New Mexico form and can be used in Department Of Human Services Statewide . |
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New Mexico Medicaid Project PO Box 27460 Albuquerque, NM 87125 505-246-9988 or 800-299-7304 Dear Medicaid Provider Applicant: Thank you for your interest in becoming a New Mexico Medicaid provider. Please read the following instructions carefully before completing the agreement(s). The application process takes 6-8 weeks from the date a properly completed provider participation agreement is received. When your agreement is approved, a unique provider identification number will be assigned to you. It is recommended that you not provide services to New Mexico Medicaid clients until your Medicaid provider number has been assigned and you have received your welcome letter. In order for us to process your provider participation agreement in a timely manner, please follow these guidelines: Read the Provider Type & Specialty List available on this website. Determine the provider type and specialty (if applicable) that best suits your practice, license and/or certification. If you are unsure which provider type or specialty to use, please contact the Provider Enrollment Help Desk @ 1-800-299-7304 or 505-246-0710. Gather the required documentation as listed on the Provider Type & Specialty list. The MAD 335 form, PROVIDER PARTICIPATION AGREEMENT must be completed by groups, organizations, or individual applicants to whom payment will be made. Please attach the documents listed in the GENERAL REQUIREMENTS on the Provider Type & Specialty list. The MAD 312 form, PROVIDER PARTICIPATION AGREEMENT INDIVIDUAL APPLICANT WITHIN A GROUP should be completed by individual applicants who perform services within a group or organization. Payments will be made only to the group or organization. No payments will be made directly to the individual. Please do not use "highlighter" or "whiteout" on the agreement(s) or on any of the attachments. Agreements submitted with "highlighter" or "whiteout" will be returned without any further processing. To correct information on the agreement, make one line across the incorrect information and write in the corrected information. The person making the corrections should initial the changes. 1 Revised April 2012 American LegalNet, Inc. www.FormsWorkFlow.com Each page requires the applicant's initials certifying that the information is true & correct. These initials must be original and in blue ink only. The applying provider must sign and date the agreement. Please sign in BLUE INK only! Only an original signature with a date is acceptable. We cannot accept signature stamps or copies of signatures. Applications with signatures that cannot easily be determined as original will be returned for correction. This standard is strictly enforced. Please do not alter, change, amend, or revise the body of this agreement. Any agreement received with unapproved changes will be returned to the provider without review. A new, unaltered application will then be required. New Mexico Medicaid project staff may need to obtain additional information from you in order to process your agreement. Please indicate a contact name and telephone number in the space provided on the agreement. MAD 335 applicants: When applying for a group Medicaid provider number, include an agreement for the group (MAD 335) and individual agreements (MAD 312) for each practitioner who will be a member of the group if they do not already have a Medicaid number. Practitioners, who have enumerated themselves with both an organizational NPI and an individual NPI, must submit a MAD 335 citing the organizational NPI information, and also submit a MAD 312 citing the individual NPI information. Two separate Medicaid provider numbers will be assigned one to be used for the billing entity, and one for the servicing provider entity. For a group that already has an active Medicaid provider number that wishes to enroll an individual within their group, complete an agreement (MAD 312) for the individual only. For individual providers who already have an Active Medicaid provider number, and who wish to be affiliated with a newly enrolling group or a currently active group, submit a letter signed by both the individual practitioner & a group representative, stating that the individual practitioner wishes to be affiliated with the new or currently active group. Please attach a copy of the professional license, current professional or medical liability, or malpractice insurance. If services have already been provided on an emergency basis, enter a requested effective date on page 1 Box 36 of the application. The date requested should be no more than ninety (90) days prior to the date the completed application is received by ACS. All supporting documents submitted with the application must be current for the 2 Revised April 2012 American LegalNet, Inc. www.FormsWorkFlow.com date requested. There is no guarantee that the requested effective date will be granted. The Medical Assistance Division will make the final determination. Applicants using a MAD 335 form must include a completed W-9 form. The W-9 forms can be printed from the website: www.irs.gov When applying as an "individual or sole proprietor" use box 4 on page 1 to enter the individual applicant's name as it appears on the professional license. A business or trade name may also be entered in box 5 on page 1. When applying as a group or organization such as "non-corporate business entity, corporation, limited liability company, partnership, or professional association, or a government entity or public school" use box 5 on page 1 to enter the trade or business name of the group or organization. Use box 6 to enter the group or organization's legal name as it appears on documentation from the IRS. Box 4 may be left blank in the case of group or organization application. All applicants who are a non-corporate business entity, corporation, limited liability company, partnership or professional association, or a government or school entity must enter the Federal tax ID number assigned by the IRS. Please attach a copy of the letter or other proof from the IRS documenting this tax identification number. Every provider who completes a MAD 335 form and who renders services within New Mexico must provide their New Mexico Tax & Revenue identification number. The applicant's Medicare number and DEA number must be included on the agreement, if applicable. Include a copy of the Medicare letter and DEA registration certification with the agreement. If the DEA number and/or Med
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