MassHealth Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Provider Enrollment Checklist Please carefully review the following instructions and the MassHealth regulations to make sure that you have submitted all documentation needed to complete your application. Before returning your application, refer to this list of items that you may need to include with your application. This list is to help ensure that your application is complete. It does not supersede any application requirements in MassHealth regulations. Submitting an incomplete application may result in the delay or denial of your application. -A completed provider application -A signed provider agreement/contract -A signed Federally Required Disclosures (PE-FRD) form -One of the following application fee materials if you are subject to the fee. (ICF-MR State Schools, Acute In-Patient Hospitals, Chronic In-Patient Hospitals, Skilled Nursing Facilities, Psychiatric In-Patient Hospitals, and Semi-Acute In-Patient Hospitals are subject to this requirement.) Also exempt are providers who are enrolled in Medicare or another state’s Medicaid or the Children’s Health Insurance Plan (CHIP) program, and have paid the application fee to a Medicare contractor or another state’s program.) (See www.mass.gov/eohhs/provider/insurance/masshealth/provider-application- fees.html for more information.) -Verification of your payment of the application fee of $532 -Attestation of Application Fee Payment if paid to Medicare or another state’s Medicaid program (PE-AAFP) -Hardship Exception Request if you believe you are not able to pay the application fee (PE-HER) -A Massachusetts Substitute W-9 form, the Request for Taxpayer Identification Number and Certification. (Refer to the W-9 Tips memo when completing this form.) MassHealth does not accept the federal W-9 form. Please Note: If you are an individual enrolling as part of a group practice and will not submit claims for payment under your individual national provider identifier (NPI), you must enroll as a “no pay” provider. Applicants submitting paper applications should write “no pay” in section I of the application to the right of field 11. If you do not indicate “no pay,” then a completed Massachusetts Substitute W-9 form is required. -A tax coupon, Notice of New Employer Identification Number Assigned, or other documentation from the Internal Revenue Service (IRS) verifying your tax identification number. Copies of tax returns do not satisfy this requirement. The verification of your tax identification number must be a document from the IRS. This does not apply to individuals enrolling under their SSN. -A completed Data Collection Form (DCF) Please Note: If you are enrolling as an individual and will solely practice as a rendering provider in a group practice, you must indicate “no pay” on your application, on page 2, section I to the right of field 11. If you do not indicate “no pay,” then a completed Data Collection Form (DCF) is required. -Verification of your national provider identifier (NPI) -A signed Trading Partner Agreement (TPA) Please Note: If you are enrolling as an individual, indicate “no pay” on your application, on page 2, section I to the right of field 11. If you do not indicate “no pay,” then a completed Trading Partner Agreement (TPA) is required. continued -An Authorization for Electronic Funds Transfer (EFT) of MassHealth Payments form (EFT-1), with supporting documentation required. An EFT form is required for all new enrollments unless you are indicating “no pay" as described above. -Evidence of accreditation by an accrediting body that is acceptable to the Centers for Medicare & Medicaid Services (CMS) -Applicants that are durable medical equipment (DME) providers must also submit a Letter of Intent located at www.mass.gov/eohhs/docs/masshealth/provider- services/forms/loi-dme.pdf that requires you to list DME services and equipment offered; a list of the usual charges for the DME services offered; names of the manufacturers from whom these products are purchased; catalogs or price lists that indicate all retail and provider acquisition costs; your Medicare number; and verification of business registration from the city or town in which the business is located. Other provider types eligible to provide DME services, such as pharmacies and prosthetics providers, must submit similar documentation if they want to be approved to provide DME services. (For further details, contact MassHealth Customer Service at 1-800-841-2900.) -Applicants that are imaging centers or portable X-ray providers must also include a copy of their Department of Public Health (DPH) Determination of Need letter or clinic license. If the applicant is exempt from licensure or from a Determination of Need, the applicant must submit a copy of the notice from DPH exempting them from the licensure or determination-of-need requirements. -Applicants who are nurse practitioner or nurse midwife providers must also submit a copy of their collaborative arrangement with their MassHealth supervising physician. This documentation must be signed by both the doctor and the nurse. It must describe the nurse’s responsibilities and how the nurse is supervised. -Applicants that are oxygen and respiratory therapy equipment providers must also submit documentation of Massachusetts licensure of at least one employee as a respiratory care practitioner; and accreditation by one of the following: Joint Commission on Accreditation of Healthcare Organizations (JCAHO); Community Health Accreditation Program (CHAP); or Accreditation Commission for Health Care (ACHC). Other provider types eligible to be oxygen and respiratory therapy equipment providers, such as pharmacy and durable medical equipment providers, must submit the same documentation. -Applicants that are pharmacy providers must also submit documentation of state licensure; Drug Enforcement Administration certification; and if the pharmacy has not yet opened at the time the application is submitted, the opening date of the pharmacy. -Applicants that are transportation providers must also submit -proof of insurance; and -if they provide ambulance services, documentation of Medicare certification and DPH licensure. -Applicants who are therapists or independent nurses must also submit the CORI Request Form. APP-1 (Rev. 04/13)