Fillable IMD Residential SUD Adult FACILITY Update V3

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IMD Residential SUD Adult FACILITY Update V3

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The IMD Residential SUD Adult FACILITY Update V3 form is 41 pages long and contains:

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  • 188 other fields

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Application Checklist for
Medical Assistance Program
FACILITY/ORGANIZATION
If you have any questions, please contact program staff at:
BHU Enrollment - Phone: (410) 767-9732 - Email: dhmh.BHEnrollment@maryland.gov
A completed application will include the following:
Completed and signed
Facility/Organization Provider Application
A copy of your fac
ility’s/organization’s NPI printout from NPPES
Completed and signed Disclosure of Ownership and Control
Completed and signed Provider Attestation
Completed and signed Provider Agreement
Any additional material including application addenda that may be required by specific programs
V3 2017 effective 6/06/17
IMD RESIDENTIAL SUD ADULT
Page 1 of 5
IMD RESIDENTIAL SUD ADULT CHECKLIST
Instructions for Maryland
Medical Assistance Program Application
FACILITY/ORGANIZATION
Page 2 of
5
IMD
RESIDENTIAL SUD ADULT INSTRUCTIONS
INSTRUCTIONS FOR COMPLETING MARYLAND MEDICAID ENROLLMENT FORMS FOR FACILITIES/ORGANIZATIONS
Should you have any questions, please contact the Provider Enrollment Unit at (410) 767-5340
GENERAL INSTRUCTIONS
1. Complete ALL items on the form unless otherwise instructed below. Failure to complete all required fields will result in your enrollment
application being returned to you, which may impact the effective date of your enrollment in Maryland Medicaid.
2. Completion of signature fields is required. Initials or stamped signatures will not be accepted.
3. Please attach a copy of all requested documents.
4. These instructions do not need to be submitted with the application.
MAIL TO
Unless instructed otherwise please mail completed enrollment applications and documentation to:
The Department of Health and Mental Hygiene
Office of Systems and Operations Administration
Provider Enrollment
P.O. Box 17030
Baltimore, MD 21203
TYPE OF REQUEST
NEW ENROLLMENT
The facility/organization attempting to enroll in Maryland Medicaid has never been enrolled with
Maryland Medicaid as a Fee for Service Provider.
RE-ENROLLMENT
The facility/organization has previously been enrolled with Maryland Medicaid as a Fee for Service
Provider, but the facility/organization has been suspended or terminated from Maryland Medicaid.
RE-VALIDATION
The facility/organization is actively enrolled in Maryland Medicaid Fee for Service, but, due to required
law, is verifying their information with Medicaid on or before their five year Maryland Medicaid
enrollment anniversary date.
INFORMATION UPDATE
The facility/organization is actively enrolled in Maryland Medicaid and would like to change the
information that is currently on file with Maryland Medicaid for the facility/organization.
APPLICATION SUBMITTED
DATE
Date filling out the application.
FACILITY/ORGANIZATION INFORMATION
NATIONAL PROVIDER
IDENTIFIER (NPI)
Enter the unique site specific 10-digit NPI (Entity Type 2 Organization) of the facility/organization who
will be providing services to Maryland Medicaid participants. To obtain a NPI, please visit the following
website: https://nppes.cms.hhs.gov/NPPES/Welcome.do Please attach a printout from the previous
website that lists the NPI information. If the facility/organization is an Atypical provider and is not
eligible to obtain a NPI, leave this field blank and Maryland Medicaid will assign a NPI to you.
MARYLAND MEDICAL
ASSISTANCE PROVIDER
NUMBER
This is a unique provider number generated by Maryland Medicaid for each facility/organization. If you
are a new enrollee, please leave this field blank. If you are an existing Maryland Medicaid
facility/organization, please fill in your facility/organization’s 9-digit Maryland Medicaid Number.
FACILITY/ORGANIZATION
PROVIDER TYPE
Enter the two-digit code for the appropriate provider type from the listing provided at the end of these
instructions.
TYPE OF PRACTICE
Enter the two-digit code for the appropriate type of practice from the listing provided at the end of these
instructions.
SPECIALTY CODE
If applicable enter the two-digit code for the appropriate specialty code from the listing provided at the end
of these instructions.
COUNTY CODE
Enter the two-digit code for the appropriate county code from the listing provided at the end of these
instructions.
FACILITY/ORGANIZATION
NAME
Enter the legal name of the facility/organization as it appears on federal tax documents.
DOING BUSINESS AS (NAME)
If the facility/organization operates under a different name than the legal name, enter that name here.
TAX IDENTIFICATION
NUMBER
Enter the 9-digit tax identification number of the facility/organization.
Instructions for Maryland
Medical Assistance Program Application
FACILITY/ORGANIZATION
NAME OF TAX
IDENTIFICATION NUMBER
OWNER
Enter the name to which the tax identification number of the facility/organization is assigned.
MEDICARE PROVIDER
NUMBER
If you participate in Medicare, please list the provider number that has been assigned to you.
MEDICARE FISCAL YEAR
END DATE
Complete this field if the facility/organization is a nursing facility or hospital.
TELEPHONE NUMBER
Enter the best number to reach the facility/organization or contact person who can speak on behalf of the
facility/organization regarding Maryland Medicaid participation.
E-MAIL ADDRESS
Enter the e-mail address of the facility/organization or contact person who can speak on behalf of the
facility/organization regarding Maryland Medicaid participation.
CORRESPONDENCE INFORMATION
CONTACT INFORMATION
If the application is being filled out on behalf of the facility/organization, enter the Name, Position/Title,
Telephone and E-Mail address of the contact person who can speak on behalf of the facility/organization
regarding Maryland Medicaid participation.
FACILITY/ORGANIZATION
ADDRESS
Enter the Street Number, Street Name, Suite, City, State, Zip Code, Telephone number and Fax number of
the primary address of the facility/organization.
CORRESPONDENCE ADDRESS
Enter the Street Number, Street Name, Suite, City, State, Zip Code, Telephone number and Fax number of
the address where any letters or correspondence should be sent. This address must be kept up to date.
Requests to Re-Validate or Update Information are NOT issued electronically and will be sent to this
address.
PAY TO ADDRESS
Enter the Street Number, Street Name, Suite, City, State, Zip Code, Telephone number and Fax number of
the address where any paper checks and paper remittance advices should be sent.
ELECTRONIC
CORRESPONDENCE
If you prefer to receive electronic correspondence and Remittance Advice through an established
eMedicaid account, check Yes.
LICENSE/PERMIT INFORMATION
If applicable attach a copy of each license or certificate that is listed.
CLINICAL LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
NUMBER*
Enter your CLIA ID Number, beginning effective date, and expiration date.
DRUG ENFORCEMENT
ADMINISTRATION (DEA)
Enter your Drug Enforcement Administration number if applicable.
HOSPITAL FACILITY
LICENSE
Enter your Office of Health Care Quality (OHCQ) issued hospital license number, beginning effective
date, and expiration date.
MARYLAND LABORATORY
PERMIT (MDLAB) OR
LETTER OF PERMIT
EXCEPTION NUMBER*
Enter your Office of Health Care Quality (OHCQ) issued MDLAB Number, beginning effective date, and
expiration date. OR enter your OHCQ issued Letter of Permit Exception Number, beginning effective
date, and expiration date.
NATIONAL COUNCIL FOR
PRESCRIPTION DRUG
PROGRAM (NCPDP)
Enter your NCPDP number if applicable.
PHARMACY
Enter your state issued license number if applicable.
RESIDENTIAL SERVICE
AGENCY (RSA)
Enter your OHCQ issued license number if applicable.
OTHER
Enter any other license information as required.
*Medical laboratory providers: Practitioners and other providers that perform medical laboratory services MUST COMPLETE and SUPPLY
a copy of their CLIA and MDLAB Permit/Letter of Permit Exception. Out-of-state providers that do not receive specimens originating in
Maryland do not have to supply Maryland certification information but do have to state that they do not receive specimens originating in
Maryland. Practitioners providing laboratory services to OTHER THAN THEIR OWN PATIENTS MUST enroll as medical laboratory
providers.
Page 3
of 5
IMD RESIDENTIAL SUD ADULT INSTRUCTIONS
Instructions for Maryland
Medical Assistance Program Application
FACILITY/ORGANIZATION
Page 4 of 5
IMD RESIDENTIAL SUD ADULT INSTRUCTIONS
ADDITIONAL INFORMATION
FACILITY/ORGANIZATION
INFORMATION
If the facility/organization is affiliated with a healthcare institution or medical school, please fill in the
required fields and attach the required documentation.
LABORATORY
INFORMATION
Answer the three questions listed in this section.
INSTITUTIONAL BED DATA
Complete all fields as appropriate for your provider type.
DIALYSIS FACILITIES
Complete this section if applicable.
AUTHORIZATION
Please have the administrator or authorized professional representative sign and date the application.
DISCLOSURE OF
OWNERSHIP AND
CONTROL
Maryland Medicaid is required to obtain disclosures on ownership and control from disclosing entities, fiscal
agents, and managed care entities. Please fill out the six (6) sections and sign and date the Disclosure of
Ownership and Control addendum. Failure to complete all required sections will result in your enrollment
application being returned to you, which may impact the effective date of your enrollment in Maryland
Medicaid.
PROVIDER AGREEMENT
Failure to complete the provider agreement will result in your enrollment application being returned to you,
which may impact the effective date of your enrollment in Maryland Medicaid.
PROVIDER ADDENDUM
If applicable to your provider type, please complete the attached addendum.
Instructions for Maryland
Medical Assistance Program Application
FACILITY/ORGANIZATION
Page 5 of 5
IMD RESIDENTIAL SUD ADULT INSTRUCTIONS
TYPE OF PRACTICE CODES
HMO
PHARMACY, HOSPITAL BASED
23
NURSING HOME
PHARMACY, NURSING HOME BASED
24
PHARMACY, SINGLE STORE
PHARMACY, TAX SUPPORTED
25
PHARMACY CHAIN, 2-10 STORES
OTHER
99
PHARMACY CHAIN, 11+ STORES
COUNTY CODE
ALLEGANY
01
DORCHESTER
SOMERSET
19
ANNE ARUNDEL
02
FREDERICK
ST. MARY'S
18
BALTIMORE CITY
30
GARRETT
TALBOT
20
BALTIMORE COUNTY
03
HARFORD
WASHINGTON
21
CALVERT
04
HOWARD
WASHINGTON, DC
40
CAROLINE
05
KENT
WICOMICO
22
CARROLL
06
MONTGOMERY
WORCESTER
23
CECIL
07
PRINCE GEORGE'S
OTHER STATE
99
CHARLES
08
QUEEN ANNE'S
PHARMACY SPECIALTY CODES
KIDNEY DISEASE PROGRAM
HOME IV THERAPY 147 DIALYSIS FACILITY K3
HOSPITAL OUTPATIENT PHARMACY
151
HOSPITAL-INPATIENT
K6
INSTITUTIONAL PHARMACY
156
HOSPITAL-OUTPATIENT
K5
MULTI-SPECIALTY PHARMACY
168
MEDICAL LABORATORY
K7
RETAIL CHAIN PHARMACY
202
PHARMACY
K2
RETAIL SINGLE PHARMACY
204
PHYSICIAN
K1
OTHER PHARMACY
184
OTHER (DENTAL, VISION)
K8
PROVIDER TYPE CODES
1915(i) WAIVER
89
EPSDT THERAPEUTIC NURSERY
MEDICAL DAY CARE - CHILDREN
ADAA CERTIFIED PROGRAM
50
FREESTANDING BIRTH CENTERS
MENTAL HEALTH CASE MANAGEMENT
PROVIDER
AMBULANCE COMPANY
T1
FREESTANDING ONCOLOGY CENTERS
MENTAL HEALTH CLINIC
AMBULATORY SURGERY CENTERS
39
HEALTHCHOICE MANAGED CARE
ORGANIZATIONS
MOBILE TREATMENT PROGRAM
AUDIOLOGY PROVIDERS
19
HMO/PACE
NURSING FACILITY
BRAIN INJURY WAIVER
86
HOME AND COMMUNITY BASED
SERVICES, OTHER
OLDER ADULT WAIVER
CASE MANAGEMENT - NOT ELSEWHERE
CLASSIFIED
81
HOME HEALTH AGENCIES
OXYGEN PROVIDERS
CLINIC, ABORTION
30
HOSPICE PROVIDERS
PARTIAL HOSPITALIZATION PROGRAM
CLINIC, DRUG
32
HOSPITALS - ACUTE
PERSONAL CARE AGENCY
CLINIC, FAMILY PLANNING
33
HOSPITALS - ACUTE REHABILITATION
PERSONAL CARE MONITOR
CLINIC, FEDERALLY QUALIFIED HEALTH
CENTER
34
HOSPITALS - CHRONIC
PHARMACY
CLINIC, GENERAL
38
HOSPITALS - CHRONIC REHABILITATION
PORTABLE X-RAY
CLINIC, LOCAL HEALTH DEPARTMENT
35
HOSPITALS - SPECIAL OTHER ACUTE
PSYCHIATRIC REHAB SERVICES FACILITY
CLINIC, RURAL
37
HOSPITALS - SPECIAL OTHER CHRONIC
REM PROVIDERS
DDA SERVICES PROVIDER
90
INTERMEDIATE CARE FACILITY -
ADDICTION
RESIDENTIAL SERVICE/HOME HEALTH
AIDE AGENCY
DIAGNOSTIC SERVICES, OTHER
60
INTERMEDIATE CARE FACILITY - ID
RESIDENTIAL TREATMENT CENTER
DIALYSIS FACILITIES
61
LABORATORIES
URGENT CARE CENTERS
DMS/DME PROVIDERS
62
LOCAL EDUCATION AGENCIES/LOCAL
LEAD AGENCIES
VISION CARE PROVIDERS
EPSDT THERAPEUTIC BEHAVIORAL
SERVICES
51
MEDICAL DAY CARE - ADULTS
THIS PAGE INTENTIONALLY LEFT
BLANK
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 1 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
IMPORTANT: PLEASE READ ATTACHED INSTRUCTIONS
BEFORE COMPLETING APPLICATION
Unless Instructed Otherwise, Mail to:
The Department of Health and Mental Hygiene
Office of Systems and Operations Administration
Provider Enrollment
P.O. Box 17030
Baltimore, MD 21203
TYPE OF REQUEST
Please select one.
NEW ENROLLMENT
(Applicant has never enrolled
with Maryland Medical
Assistance)
RE-ENROLLMENT
(Provider is currently
excluded/terminated from the
Maryland Medicaid Program)
RE-VALIDATION
(Provider is enrolled and
requir
ed to revalidate)
INFORMATION
UPDATE
(Provider is enrolled and
updating information to the
provider’s file)
FACILITY/ORGANIZATION INFORMATION
NPI (Organization)
Maryland Medical Assistance Provider Number (If existing provider)
Provider Type (Refer to instructions for appropriate codes.)
Type of Practice (Refer to instructions for appropriate codes.)
Specialty Code (Refer to instructions for appropriate codes.)
County Code (Refer to instructions for appropriate codes.)
Facility/Organization Name
Doing Business As (DBA)
Tax Identification Number
Name of Tax Identification Number Owner
Medicare Provider Number
Medicare Fiscal Year End Date
Telephone Number + extension
E-Mail Address
CONTACT INFORMATION
The contact name and email relate to the person who can answer questions about the information provided in this packet.
Contact Name
Position/Title
Telephone
E-Mail Address
FACILITY/ORGANIZATION ADDRESS
Street Address
Suite/Department/Floor
City
State
Zip Code (9 Digit)
Telephone Number + extension
Fax Number
Application Submitted Date
IMD RESIDENTIAL SUD ADULT
54
99
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 2 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
CORRESPONDENCE ADDRESS
Please indicate where letters and claims forms, if any, should be sent.
Street Address
Suite/Department/Floor
City
State
Zip Code (9 Digit)
Telephone Number + extension
Fax Number
PAY TO ADDRESS
Please indicate where checks & remittance statements should be sent.
Street Address
Suite/Department/Floor
City
State
Zip Code (9 Digit)
Telephone Number + extension
Fax Number
ELECTRONIC CORRESPONDENCE
Would you prefer to receive electronic correspondence in lieu of paper when available?
YES
NO
LICENSE/PERMIT INFORMATION
A copy of the license or certificate from the appropriate board or authority must be included as an attachment to this application. If more
space is needed, please attach additional pages.
CLIA
State Issued
License Number
Date Issued
Expiration Date
DEA
State Issued
License Number
Date Issued
Expiration Date
Hospital Facility
License
State Issued
License Number
Date Issued
Expiration Date
MDLAB
State Issued
License Number
Date Issued
Expiration Date
NCPDP
State Issued
License Number
Date Issued
Expiration Date
Pharmacy
State Issued
License Number
Date Issued
Expiration Date
RSA
State Issued
License Number
Date Issued
Expiration Date
Other
State Issued
License Number
Date Issued
Expiration Date
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Pag
e 3 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
FACILITY/ORGANIZATION INFORMATION
If your facility/organization is affiliated with a health care ins
titution or medical school, please enter the
name and full address of the institution or school, your title and a brief explanation of your group’s duties.
NOT APPLICABLE
Name of Institution
Title
Duties
Street Address
Suite/Department/Floor
City
State
Zip Code (9 Digits)
Certification Date
Certification Number
Is your facility/organization salaried by the above institution?
YES
NO
If you are a M.D. or D.O. will you be dispensing pharmaceuticals other than samples (as
pharmacy)?
YES
NO
If you are an O.D., are you practicing optometry exclusively?
YES
NO
Or optometry as well as preparing and dispensing eyeglasses (as an optician)?
YES
NO
Is your facility/organization operating a Local Health Department Clinic?
YES
NO
Is your facility/organization operating a Freestanding Clinic?
YES
NO
LABORATORY INFORMATION
Reimbursement for medical laboratory services you provide to eligible recipients are dependent on answering the following questions and
supplying copies of CLIA Certificate and, when required, Maryland Laboratory Permits or Letters of Permit Exception. Practitioner providers
cannot be reimbursed for services referred to medical laboratories or other practices. Those laboratories or practices must bill.
Do you provide medical laboratory services
for your own patients?
YES
NO
Do you provide medical laboratory services
for other than your own patients?
YES
NO
Do you receive specimens that are obtained
from other sites located in Maryland?
YES
NO
All Maryland laboratories are required to have a Maryland Laboratory Permit or Letter of Permit Exception Number (§Health General
Article §17-
205, Annotated Code of Maryland) and CLIA Certificate Number (Clinical Laboratory Improvement of 1988 Public Law
100-578) to perform laboratory services. Out-of-state providers are only required to provide their CLIA Certificate Number, if they do
not receive specimens that originate in Maryland.
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 4 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
INSTITUTIONAL BED DATA
Acute Inpatient (INP) Number of Beds
Assisted Living Facilities
Chronic Hospital (CHB) Number of Beds
Intellectual Disability (ID)
Number of Beds Nursing Facility (NF) Number of Beds
Other (OTH) Number of Beds
DIALYSIS FACILITIES
Please attach a copy of letter with assigned Medicare Provider Number and a copy of the letter(s) from your intermediary showing all
approved services. You will be paid ONLY for the services that are rendered and appear in this/these letter(s).
Medicare Provider Number
AUTHORIZATION
I, the administrator or authorized professional representative of this facility/organization, hereby affirm that this information given by me is
true and complete to the best of my knowledge and belief. I understand that if I or my facility/organization is salaried by a hospital or other
institution for patient care, that I or
my group will not bill the Maryland Medical Care Program for those services for which I or my
facility/organization is salaried.
Signature of Administrator or Authorized Professional
Date
Responsible for the Quality of Patient Care (No stamps)
Name of Administrator or Authorized Professional Date
Responsible for the Quality of Patient Care (Type or Print)
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 5 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
DISCLOSURE OF OWNERSHIP AND CONTROL
Completion is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be
returned. Attach additional pages as needed.
SECTION 1:
Disclosing E
ntity/Applicant
(Facility/organization named on page 1 of this application)
Name
NPI (Organization)
Address – Street
City & State
Zip Code (9 Digits)
Federal Employer Identification Number (FEIN)
Ownership in Applicant (Has direct or indirect ownership interest
1
of 5% or more. Include familial relationship to the Applicant and other
Owners (spouse, parent, child, sibling), if any. The address for corporate entities must include every business address. See 42 CFR Part
455.104 (b)(1)(i) for more information.)
Name of Individual or Entity
% of Ownership
NPI (Individual)
Address (Home Address if individual)
City & State
Zip Code (9 Digits)
SSN (if individual)
Federal Employer Identification Number (if entity)
Date of Birth (MM/DD/YYYY)
Familial Relationship (if individual, if any)
1
A) “Ownership interest” means the possession of equity in the capital of, stock in, or of any interest in the profits of the disclosing
entity.
B) “Indirect ownership interest” means any ownership interest in an entity that has ownership interest in the disclosing entity. The
term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
C) “Determination of ownership or control percentage”
1) Indirect ownership interest – the amount of indirect ownership interest is determined by multiplying the percentages of
ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock
of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be
reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing
entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.
2) Person with an ownership or control interest – in order to determine percentage of ownership, mortgage, deed of trust,
note, or other obligation, the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns
10 percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent
and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest
in the provider’s assets equates to 4 percent and need not be reported.
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 6 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
SECTION 2:
Agents and Managin
g Employees (e.g. office manager, administrator, director or other individuals who exercise operational or managerial
control over the day to day operations of the provider. If the applicant is a non-profit organization please include all board members,
directors, and managers. Include familial relationship to the Applicant (spouse, parent, child, sibling), if any. If additional space is needed,
copy form; all entries must be on the form.)
Name
Association Type (see instructions)
Home Address – Street
City & State
Zip Code (9 digits)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
Name
Association Type (see instructions)
Home Address – Street
City & State
Zip Code (9 digits)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
Name
Association Type (see instructions)
Home Address – Street
City & State
Zip Code (9 digits)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
SECTION 3:
Ownership in Other
Disclosing Entities (ODE) (per 42 CFR, Part 455.104 (b)(3)) – (Complete if any identified in Section 1 has an
ownership or control interest in ODE)
Name (from Section 1)
Name of ODE
NPI or Medicaid ID of ODE
Name (from Section 1)
Name of ODE
NPI or Medicaid ID of ODE
Name (from Section 1)
Name of ODE
NPI or Medicaid ID of ODE
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 7 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
SECTION 4:
Ownership in Subc
ontractors
(If the Applicant has an ownership or control interest of 5% or more in a subcontractor and an Owner of the
Applicant also has an ownership or control interest in the subcontractor, complete the boxes below. If those identified in this Section have a
familial relationship with a person with ownership or control interest in one of these subcontractors, complete Section 4).
Owner’s Name (from Section 1)
Subcontractor’s Name
Tax Identification Number
Owner’s Name (from Section 1)
Subcontractor’s Name
Tax Identification Number
Owner’s Name (from Section 1)
Subcontractor’s Name
Tax Identification Number
SECTION 5:
Familial Re
lationship in Subcontractors (Complete if those identified in Section 3 have a familial relationship (parent, child sibling
spouse))
Owner’s Name (from Section 1)
Subcontractor’s Name
Name & Familial Relationship
Owner’s Name (from Section 1)
Subcontractor’s Name
Name & Familial Relationship
Owner’s Name (from Section 1)
Subcontractor’s Name
Name & Familial Relationship
SECTION 6:
Respond to thes
e questions on behalf of: 1. The Applicant
2. All individuals and entities identified in Sections 1& 5.
3. Any entity in which the Applicant has a 5% or more ownership.
1. Have any of the ind
ividuals/entities (1,2 and 3) been terminated, denied enrollment, suspended, restricted by Agreement or otherwise
sanctioned by the Medicaid Program in Maryland or in any other State, Medicare, or any other governmental or private medical
insurance program?
If yes, please l
ist the individuals below (attach additional pages if necessary):
Name: _______________
________
Name: _______________________
Name: _______________
________
YES
NO
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 8 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
2. Have any of the individuals/entities (1,2 and 3) ever been convicted of a crime related to the furnishing of, or billing for, medical care or
supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health
and morals in any State?
If yes, please li
st the individuals below (attach additional pages if necessary):
Name: _________________
______
Name: _________________
______
Name: _______________________
3. Have any of the
individuals/entities (1,2 and 3) ever had their business or professional license or certification, or the license of an entity
in which they had an ownership interested over 5% ever been revoked, suspended, surrendered, or in any way restricted by probation or
agreement by any licensing authority in any State?
If yes, please li
st the individuals below (attach additional pages if necessary):
Name: _________________
______
Name: _________________
______
Name: _________________
______
4. Is there currently pending any proceedings that could result in the above stated sanctions for the individuals/entities (1, 2 and 3)?
If yes, please li
st the individuals below (attach additional pages if necessary):
Name: _________________
______
Name: _______________
________
Name: _________________
______
YES
NO
YES
NO
YES
NO
Application for Participation in Maryland
Medical Assistance Program
FACILITY/ORGANIZATION
Page 9 of 9
IMD RESIDENTIAL SUD ADULT APPLICATION
SIGNATURE AND AFFIRMATION
An application is not considered complete unless the applicant signs below. Failure to provide a signature will cause the application to be
returned.
I hereby affirm
that this information is true and complete to the best of my knowledge and belief, and that the requested information will be
updated as changes occur. I further certify that upon specific request by the Secretary of the Department of Health and Human Services, or
the Maryland Department of Health and Mental Hygiene, full and complete information will be supplied within 35 days of the date of the
request, concerning:
A. The ownership of any subcontractor with which the Title XIX Provider has had, during t
he previous 12 months,
business transactions in an aggregate amount in excess of $25,000.00 and
B. Any signifi
cant business transactions
2
, occurring during the 5 year period ending on the date of such request, between
the Provider and any wholly-owned supplier
3
or any subcontractor.
Authorized Signature (No Stamps) Date
Position (Type or Print)
2
“Significant business transaction” means any business transaction or series of transactions that, during any one fiscal year, exceeds
the lesser of $25,000 or 5 percent of the total operating expense of a provider.
3
“Supplier” means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its
responsibilities under Medicaid (e.g. a commercial laundry, a manufacturer of hospital bed, or a pharmaceutical firm).
THIS PAGE INTENTIONALLY LEFT
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Provider Agree
ment for
Participation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 1 of 6
This Agreement (the “Agreement”), entered into between the Maryland State Department of Health and
Mental Hygiene (the “Department”) and
___________________________________________________
(Provider Name)
the undersigned Provider or Provider Group and its members or Practitioner(s) (hereinafter called the
“Provider”), is made pursuant to Title XIX and Title XXI of the Social Security Act, Health-General,
Title 15, Annotated Code of Maryland and state regulations promulgated thereunder to provide medical,
healthcare, and home- and community-based services and/or remedial care and services (“Service(s)”) to
eligible Maryland Medical Assistance recipients (“Recipient(s)”). On its effective date, this Agreement
supersedes and replaces any existing contracts between the parties related to the provision of Services to
Recipients.
I. THE PR
OVIDER AGREES:
A. To compl
y with all standards of practice, professional standards and levels of Service as set forth
in all applicable federal and state laws, statues, rules and regulations, as well as all administrative
policies, procedures, transmittals, and guidelines issued by the Department, including but not
limited to, verifying Recipient eligibility, obtaining prior authorizations, submitting accurate,
complete and timely claims, and conducting business in such a way the Recipient retains freedom
of choice of providers. The Provider acknowledges his, her or its responsibility to become
familiar with those requirements as they may differ significantly from those of other third party
payor programs;
B. To maintain adequate medical, financial and administrative records that fully justify and describe
the nature and extent of all goods and Services provided to Recipients for a minimum of six years
from the date of payment or longer if required by law. The Provider agrees to provide access
upon request to its business or facility and all related Recipient information and records,
including claims records, to the Department, the Medicaid Fraud Control Unit (MFCU) of the
Maryland Attorney General’s Office, the U.S. Department of Health and Human Services, and/or
any of their respective employees, designees or authorized representatives. This requirement does
not proscribe record requirements by other laws, regulations, or agreements. It is the Provider’s
responsibility to obtain any Recipient consent required to provide the Department, its designee,
the MFCU, federal employees, and/or designees or authorized representatives with requested
information and records or copies of records. Failure to timely submit or failure to retain adequate
documentation for services billed to the Department may result in recovery of payments for
Services not adequately documented, and may result in the termination or suspension of the
Provider from participation as a Medical Assistance provider.
Provider Agreem
ent for
Participation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 2 of 6
1. Origi
nal records must be made available upon request during on-site visits by Department
personnel or personnel of the Department’s designee.
2. Copies
of records must be timely forwarded to the Department upon written request;
C. To prot
ect the confidentiality of all Recipient information in accordance with the terms,
conditions and requirements of the health Insurance Portability and Accountability Act (HIPAA)
of 1996, as amended, and regulations adopted thereunder contained in 45 CFR 160, 162 and 164,
and the Maryland Confidentiality of Medical Records Act (Md. Ann. Code, Health-General §§4-
301 et seq.);
D. To provide services on a non-discriminatory basis and to hold harmless, indemnify and defend
the Department from all negligent or intentionally detrimental acts of the Provider, its agents and
employees. The Provider will not discriminate on the basis of race, color, national origin, age,
religion, sex, disabilities, or sexual orientation;
E. To provide
Services in compliance with the Americans with Disabilities Act of 1990, Section 504
of the Rehabilitation Act of 1973, and their respective accompanying regulations, and ensure that
qualified individuals with disabilities are given an opportunity to participate in and benefit from
its Services, including providing interpretive services for the deaf and hard of hearing when
required;
F. To check the Federal List of Excluded Individuals/Entities on the Health and Human Services
(HHS) Office of Inspector General (OIG) website prior to hiring or contracting with individuals
or entities and periodically check the OIG website to determine the participation/exclusion status
of current employees and contractors. To check the Federal System for Award Management
(SAM) prior to hiring or contracting with individuals or entities and periodically check the SAM
website to determine the participation/exclusion status of current employees and contractors. To
che
ck the Maryland Medicaid List of Excluded Providers and Entities prior to hiring or
contracting with individuals or entities and periodically check the website to determine the
participation/exclusion status of current employees and contractors. The Provider further agrees
to not knowingly employ, or contract with a person, partnership, company, corporation or any
other entity or individual that has been disqualified from providing or supplying services to
Medical Assistance Recipients unless the Provider receives prior written approval from the
Department;
Provider Agree
ment for
Participation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 3 of 6
G. To accep
t the Department’s payments as payment in full for covered Services rendered to a
Recipient. The Provider agrees not to bill, retain, or accept any additional payment from any
Recipient. If the Department denies payment or requests payment from the Recipient, or if the
Department denies payment or requests repayment because an otherwise covered Service was not
medically necessary or was not preauthorized (if required), the Provider agrees not to seek
payment from the Recipient for that Service. The Provider further agrees to immediately repay
the Department in full for any claims where the Provider received payment from another party
after being paid by the Department;
H. With the exception of prenatal care or preventive pediatric care, to seek payment from a
Recipient’s other insurances and resources of payment before submitting claims to the
Department, which includes but is not limited to seeking payment from Medicare, private
insurance, medical benefits provided by employers and unions, worker compensation, and any
other third party insurance. If payment is made by both the Department and the Recipient’s other
insurance, the Provider shall refund the Department, within 60 days of receipt, the amount paid
by the Department;
I. To accept
responsibility for the validity and accuracy of all claims submitted to the Department,
whether submitted on paper, electronically or through a billing service;
J. That a
ll claims submitted under his, her or its provider number shall be for medically necessary
Services that were actually provided as described in the claim. The Provider acknowledges that
the submission of false or fraudulent claims could result in criminal prosecution and civil and
administrative sanctions. This may include his, her or its expulsion from the Maryland Medical
Assistance Program and/or referrals by the Department to the HHS OIG for expulsion from the
Medicare program;
K. That if
Provider is a physician, he or she will, upon request, submit the name and applicable
licensure for each physician extender in his or her employment. The Provider is responsible for
knowing and complying with the Maryland Medical Assistance Program’s definition of an
eligible physician extender and for providing supervision as required by the Maryland Medical
Assistance Program;
L. That in case of a group provider, the individual Provider rendering the service shall include his or
her own provider number, as well as the group provider number, on any claim;
Provider Agree
ment for
Participation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 4 of 6
M. To fur
nish the Department, within 35 days of the Department’s request, full and complete
information about:
1. The ow
nership of any subcontractor with who the Provider has had business transactions
totaling more than $25,000 during the 12-month period ending on the date of the request;
2. Any si
gnificant business transaction between the Provider and any wholly-owned supplier,
or between the Provider and any subcontractor, during the 5-year period ending on the date
of the request; and
3. Any ownership interest exceeding 5 percent held by the Provider in any other Medical
Assistance Provider;
N. That b
efore the Department enters into or renews this Agreement, the Provider agrees to disclose
the identity of any person who:
1. Has a
n ownership or control interest in the Provider, or is an agent or managing employee
of the Provider; and
2. Has be
en convicted of a criminal offense related to that person’s involvement in the
Medicaid or Medicare programs;
O. To ex
haust all administrative remedies prior to initiating any litigation against the Department;
P. Upon rece
ipt of notification that the Provider is disqualified through any federal, state and/or
Medicaid administrative action, to not submit claims for payment to the Department for Services
performed after the disqualification date;
Q. Any excessi
ve payments to a Provider may be immediately deducted from future Department
payments to any payee with the Provider’s tax identification number, at the discretion of the
Department;
R. Continuation of this Agreement beyond the current term is subject to and contingent upon
sufficient funds being appropriated, budgeted, and otherwise made available by the State
legislature and/or federal sources. The Department may terminate this Agreement and the
Provider waives any and all claim(s) for damages, effective immediately upon receipt of written
notice (or any date specified therin) if for any reason the Department’s funding from State and/or
federal sources is not appropriated or is withdrawn, limited or impaired;
Provider Ag
reement for
Participation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 5 of 6
S. To com
ply with the Deficit Reduction Act of 2005 (DRA) employee education requirement
imposed upon any entity, including any governmental agency, organization, unit, corporation,
partnership or other business arrangement (including any Medicaid MCO), whether for profit or
not for profit, which receives annual Medicaid Payments of at least $5,000,000.
T. For Pr
ovider Groups Only: The Provider Group affirms that it has authority to bind all member
Providers to this Agreement and that it will provide each member Provider with a copy of this
Agreement. The Provider Group also agrees to provide the Department with names and proof of
current licensure for each member Provider as well as the name(s) of individual (s) with authority
to sign billings on behalf of the group. The Provider Group agrees to be jointly responsible with
any member Provider for contractual or administrative sanctions or remedies including, but not
limited to reimbursement, withholding, recovery, suspension, termination or exclusion on any
claims submitted or payment received. Any false claims, statements or documents, concealment
or omission of any material facts may be prosecuted under applicable federal or state laws.
U. To noti
fy the Department within five (5) working days of any of the following:
1. Any
action which may result in the suspension, revocation, condition, limitation,
qualification or other material restriction on a Provider’s licenses, certifications, permits or
staff privileges by any entity under which a Provider is authorized to provide Services
including indictment, arrest, felony conviction or any criminal charge;
2. Chang
e in corporate entity, servicing locations, mailing address or addition to or removal of
practitioners or any other information pertinent to the receipt of Department funds; or
3. Chang
e in ownership including full disclosure of the terms of the sales Agreement. When
there is a change in ownership this Agreement is automatically assigned to the new owner,
and the new owner shall, as a condition of participation, assume liability, jointly and
severally with the prior owner for any and all amounts that may be due, or become due to
the Department, and such amounts may be withheld from the payment of claims submitted
when determined. (NOTE: Section I.S.3 does not apply to Nursing Home Providers)
II. THE DEP
ARTMENT AGREES:
A. To reimburse the Provider for medically necessary Services provided to Recipients that are
covered by the Maryland Medical Assistance Program. Services will be reimbursed in accordance
with all Program regulations and fee schedules as reflected in the Code of Maryland Regulations
or other rules, action transmittals or guidance issued by the Department; and
Provider Agreement for
Pa
rticipation in Maryland
Medical Assistance Program
Maryland Medical Assistance Program – Provider Agreement - Page 6 of 6
B. To provide notice of
changes in Program regulations through publication in the Maryland
Register.
III. THE DEPARTMENT AND PRO
VIDER MUTUALLY AGREE:
A. That except as specif
ically provided otherwise in applicable law and regulations, either party may
terminate this Agreement by giving thirty (30) days notice in writing to the other party. After
termination, the Provider shall notify Recipients, before rendering additional Services, that he or
she is no longer a Maryland Medical Assistance participating Provider;
B. That the effective date of this Agreement shall be ___________, provided that the Department
verifies the information in the Provider’s application. This Agreement shall remain in effect until
either party terminates the Agreement (as described in Section III A). Following termination of
this Agreement, the Provider must continue to retain records and reimburse the Maryland Medical
Assistance Program for overpayments as described in this Agreement and as required by law,
including but not limited to Maryland Health-General § 4-403;
C. That no employee o
f the State of Maryland, whose duties include matters relating to this
Provider’s Agreement, shall at the same time become an employee of the Provider without the
written permission of the Department;
D. That this Agr
eement is not transferable or assignable;
E. That the Provide
r Enrollment Application submitted and signed by the Provider is incorporated
by reference into this Agreement and is a part hereof as though fully set forth herein; and
Provider Signature (No stamps) Date Department Authorization Date
Provider Name (Type or Print) Date Assistant Attorney General Date
Provider Address (Type or Print)
Addendum for Participation in Maryland
Medical Assistance Program Application
FACILITY/ORGANIZATION
Should you have any questions regarding completing this addendum, please contact:
BHU Enrollment - Phone: (410) 767-9732 - Email: dhmh.BHEnrollment@maryland.gov
Please include the following materials with your application:
Adult Residential SUD Provider Attestation Form (attached)
OHCQ
/BHA issued service level certification
**NOTE** To enroll as this provider type, you must have a minimum service level of 3.3
Will y
ou be rendering lab services or drug screenings?
YES NO
If y
es, please include a copy of your CMS issued CLIA and OHCQ issued Maryland Lab Permit. If you do not
have an OHCQ issued Maryland Lab Permit, please include your OHCQ Letter of Permit Exception.
If you
practice in New York or Washington state, please include a copy of you Washington or New York Lab Permit in
lieu of the CLIA.
_______________________________________________________________________________________________
**Please register with Beacon Health Options for authorization after you receive your
Medical Assistance enrollment approval**
To register:
1. Visit http://maryland.beaconhealthoptions.com/index.html
2. Click on “Behavioral Health Providers”
3. Click on “Register”
4. Complete the Provider Online Services Registration form that appears
Should you have any questions regarding Beacon Health Options registration, please contact:
Beacon Provider Relations: Phone: (800) 888-1965 – Email: marylandproviderrelations@beaconhealthoptions.com
Page 1 of 1
IMD RESIDENTIAL SUD ADULT ADDENDUM
STATE OF MARYLAND
DHMH
Maryland Department of Health and Mental Hygiene
Adult Residential SUD Provider Attestation Form
ASAM Levels 3.3 to 3.7-WM
Program/Facility Name:
Facility Address:
City/State/Zip:
NPI Number: _________________________________________________________________________
License Number:
D
epartment of Health and Mental Hygiene (“the Department”) program requirements follow the criteria
defined by the American Society of Addictions Medicine (ASAM) for the provision of substance use
disorder treatment services. Providers shall have a current version of The ASAM Criteria: Treatment
Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed., and provide services that
meet these criteria.
If your organization meets a specific level of care based on the ASAM Criteria, and have trained and
knowledgeable staff in applying the ASAM Criteria, you must complete this Provider Attestation Form
and any additional required credentialing and/or contracting documents.
The Department will inform you if you meet the requirements to be enrolled or credentialed as a
Medicaid provider. Attesting to meeting ASAM Criteria does not guarantee enrollment as a Medicaid
provider.
Program Requirements
By signing this attestation you certify that the program has an active Office of Health Care Quality
(OHCQ) license and complies with all relevant Department regulations including but not limited to
COMAR 10.09.36 and COMAR 10.63.
Residential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 1 of 6
Program Types
By marking “Yes” you attest that the following ASAM Levels of Care (LOC) are offered at your facility,
that you have received licensure from the Office of Health Care Quality for each LOC, and that you are
compliant with all applicable Department regulations for the LOC indicated.
Program Type ASAM LOC Provide Service
Yes
No
Residential Medium Intensity Program
Clinically-managed substance-related disorder
treatment based on a comprehensive assessment.
Provides services in a structured environment in
combination with medium-intensity treatment and
ancillary services to support and promote recovery.
3.3
Residential High Intensity Program
Clinically-managed substance-related disorder
treatment based on a comprehensive assessment.
Provides services in a highly-structured environment, in
combination with moderate- to high-intensity
treatment and ancillary services to support and
promote recovery;
3.5
Residential Intensive Program
Provide medically-monitored, intensive substance-
related disorder treatment based on a comprehensive
assessment. Offers a planned regimen of 24-hour
professionally directed evaluation, care, and treatment
in an inpatient setting;
3.7
Withdrawal Management Service
Offers 24-hour medically supervised evaluation and
withdrawal management.
3.7-WM
R
esidential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 2 of 6
Required Evidence Based Practices
As part of the approval from CMS for the IMD waiver for adults, the State agreed to require
demonstrated competency in and deliver a minimum of three evidence-based practices (EBPs). For
further information, please see the provider manual. By marking “Yes” you attest that the following
EBPs are offered by the program:
Evidence-Based Practice Services
Provide Service
Yes
No
Acceptance and Commitment Therapy (ACT)
Cognitive Behavioral Therapy (CBT)
Medication Assisted Treatment (MAT)
Motivational Enhancement Therapy (MET)
Motivational Interviewing (MI)
Psychoeducation
Psychotherapy
Relapse Prevention (RP)
Solution-Focused Group Therapy (SFGT)
Supportive Expressive Psychotherapy (SE)
Trauma Informed Treatment
The program will demonstrate competence in the aforementioned EPBs through:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
Residential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 3 of 6
Staffing
By marking “Yes” you attest that the program employs, at minimum, the following staff:
ASAM Level 3.3
Employed Staff
Yes
No
Physician, NP and/or PA (on-site 4 hours/week, 1 hour on call)
Psychiatrist or Psychiatric NP (available 3 hours per week)
Nurse RN or LPN (on-site 40 hours per week)
Facility Director (on-site 20 hours per week)
Clinical Supervisor
Certified Counselors (Clinical SUD)
Licensed Mental Health Clinician
Certified Peer Support Staff (Recovery Coach)
Aftercare Coordinator
ASAM Level 3.5
Employed Staff
Yes
No
Physician, NP and/or PA (on-site 1 hour a week)
Psychiatrist or Psychiatric NP (available 1 hour a week)
Facility Director (on-site 20 hours per week)
Clinical Supervisor
Certified Counselors (Clinical SUD)
Licensed Mental Health Clinician
Certified Peer Support Staff (Recovery Coach)
Aftercare Coordinator
ASAM Level 3.7
Employed Staff
Yes
No
Physician, NP and/or PA (on-site 5 hours per week, 2 hours on call)
Psychiatrist or Psychiatric NP (available 10 hours per week)
Nurse RN (on-site 56 hours per week)
Nurse LPN (on-site 112 hours per week)
Facility Director (on-site 20 hours per week)
Clinical Supervisor
Certified Counselors (Clinical SUD)
Licensed Mental Health Clinician
Certified Peer Support Staff (Recovery Coach)
Aftercare Coordinator
Residential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 4 of 6
ASAM Level 3.7-WM
Employed Staff
Yes
No
Physician, NP and/or PA (on-site 20 hours per week, 4 hours on call)
Psychiatrist or Psychiatric NP (available 8 hours per week)
Nurse RN (on-site 56 hours per week)
Nurse LPN (on-site 112 hours per week)
Facility Director (20 hours per week)
Clinical Supervisor
Certified Counselor (Clinical SUD)
Licensed Mental Health Clinician
Certified Peer Support Staff (Recovery Coach)
Aftercare Coordinator
Residential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 5 of 6
I hereby certify that all information contained in this document is true and accurate. I further
understand that any information entered in this document that subsequently is found to be false may
result in termination of any agreement that I have or may enter into with DHMH and/or its contractors.
In compliance with the DHMH Provider Attestation Form, the Facility attests that it will permit only staff
members who are fully licensed and/or meet DHMH program requirements to see and treat Medicaid
eligible members.
I hereby give permission and consent for DHMH and/or its contractors, to obtain and verify information
provided in this form and consent to the release by any person, organization or other entity to DHMH
and/or its contractors, of all information relevant to the evaluation of my ability to render addiction
recovery and treatment services in a cost-effective manner and my moral and ethical qualifications, and
agree to hold harmless any such person or organization from any cause of action based on the release of
such information to DHMH and/or its contractors.
By signing this attestation I agree that all statements are true and agree to abide by any contracted
requirements for the services delivered under the authority of this agreement.
Printed Name:
Title:
Signature: Date:
Providers must include the complete attestation form with the provider enrollment application.
If you have any questions please contact program staff at:
dhmh.BHEnrollment@maryland.gov
Unless instructed otherwise mail signed copy to:
The Department of Health and Mental Hygiene
Office of Systems and Operations Administration
Provider Enrollment
P.O. Box 17030
Baltimore, MD 21203
Residential SUD, Adult (IMD) Provider Attestation Form
Maryland Department of Health and Mental Hygiene
Page 6 of 6
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IMD Residential SUD Adult FACILITY Update V3

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Completed 24 July 2020

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