23 Miss. Code. R. 200-4.8

Current through December 10, 2024

Rule 23-200-4.8 - Requirements for All Providers

A. All providers are required to submit the following documentation:

1. Mississippi Medicaid Provider Enrollment Application

a) Individuals and Sole Proprietor applications must be signed by the individual provider.

b) Business/Entity applications must be signed by the Authorized Official.

2. Medical Assistance Participation Agreement (Provider Agreement)

3. Direct Deposit Authorization/Agreement Form

a) Include a copy of a voided check, deposit slip, or letter from the bank noting the account number and transit routing number.

b) Starter checks and counter deposit slips are not acceptable.

4. W-9

a) Name on the W-9 should match the written confirmation from the IRS confirming your Tax Identification Number with the legal business name/legal name as noted in Section 1 of the Mississippi Medicaid Provider Enrollment Application. Note: This information is needed if enrolling as a professional corporation or limited liability company, or enrolling as a sole proprietor using the Employer Identification Number.

b) Name on the W-9 should match the documentation to confirm the social security number verification for any provider enrolling as an individual sole proprietor.

5. EDI Provider Agreement and Enrollment Form is required if the intent is to submit electronically.

6. Civil Rights Compliance Information Request Packet including the following:

a) A copy of the provider's Nondiscrimination Policy.

b) A copy of the provider's Limited English Proficiency Policy.

c) A copy of the provider's Sensory and Speech Impairment Policy.

d) A copy of the provider's Notice of Program Accessibility Policy.

e) Statement of compliance, signature required. A copy of the DHHS Office of Civil Rights letter of compliance may be submitted in lieu of completing the Division of Medicaid's compliance packet.

f) A copy of the provider's published newspaper article stating the provider's non-discrimination policy, required only for healthcare facilities.

7. Providers who have changes of information which are not considered a CHOW must submit the following forms, if applicable:

a) W9 form for a provider name change,

b) Change of Address form for provider mailing and/or business addresses, e-mail contact information or telephone number changes,

c) Electronic Funds Transfer (EFT) form for provider banking information changes, and/or

d) Provider Disclosure Form for any other applicable changes.

8. Certain disclosures are required for participation as a provider in the Mississippi Division of Medicaid.

a) The Division of Medicaid requires use of the Mississippi Medicaid Provider Disclosure Form in the following instances:

1) Upon the provider's submission of the provider enrollment application,

2) Upon request of the Division of Medicaid during the re-validation of enrollment process, and

3) Within thirty-five (35) days after any change in ownership of the provider.

b) Required disclosures include:

1) The name and address of any individual or corporation with an ownership or control interest in the provider. The address for corporate entities must include an applicable primary business address, every business location, every P. O. Box address, and/or other mailing address.

2) Date of birth and Social Security Number (in the case of an individual).

3) Other tax identification number (in the case of an organization) with an ownership or control interest in the provider or in any subcontractor in which the disclosing entity has a five percent (5%) or more interest.

4) Whether the person (individual or corporation) with an ownership or control interest in the provider is related to another person with ownership or control interest in the provider as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity has a five percent (5%) or more ownership interest is related to another person with ownership or control interest in the provider as a spouse, parent, or sibling.

5) The name of any other provider in which the ownership of the provider has an ownership or control interest.

6) The name address, date of birth, and Social Security Number of any managing employee, authorized official, and delegated official of the provider.

7) Any additional disclosures as required and enumerated by state and/or federal law.

B. Failure to comply with the terms of this rule may result in rejection of the Provider Enrollment Application, revocation of provider enrollment, or a suspension in the payment of claims.

23 Miss. Code. R. 200-4.8

42 C.F.R. §§ 455.104, 455.414; Miss. Code Ann. § 43-13-121.

Amended 9/1/2020