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INFORMATION UPDATE FORM (PIF) AND ANY ADDITIONAL DOCUMENTS, (Molina Healthcare)

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Virginia Guide to Provider Forms
VA-ALL-PF-21276-22
ACTION
YOU WILL NEED TO COMPLETE THE SECTIONS IDENTIFIED BELOW ON THE PROVIDER
INFORMATION UPDATE FORM (PIF) AND ANY ADDITIONAL DOCUMENTS, AS OUTLINED
PER SECTION. ALL DOCUMENTS MUST BE COMPLETE, WHEN RETURNED FOR PROCESSING
Add a provider to a
group practice
• PIF—Complete Section A and Section L*
• Complete Attachment D (for ALL providers)
• Complete CAQH (for ALL providers)
*Section L can be copied when adding multiple providers
Terming a provider
• PIF—Complete Section A and Section J
•
Term letter on your organization’s letterhead
Closing a service
location
• PIF—Complete Section A and Section H
Change a
phone/fax/email
• PIF—Complete Section A and Section F
Change the pay-
to/billing address
• PIF—Complete Section A and Section I
• Submit a W-9
•
Submit a sample claim form (de-identified)
Add/update services at
existing location(s)
• PIF—Complete Section A
•
Complete Attachment D (for ALL providers)
Change or add a
service location
• PIF—Complete Section A and Section G
• Complete Attachment D (for ALL providers)
•
Complete ADA Attestation Form (for ALL providers)
Group: Add a new
group practice under
the same Tax
Identification Number
(TIN)
• PIF—Complete Section A and Section G
• Submit a W-9
• Complete Attachment D (for ALL providers)
• Submit a sample claim form (de-identified)
Change group name
only
• PIF—Complete Section A and Section D
• Submit a W-9
•
Submit a sample claim form (de-identified)
Change TIN only
•
PIF—Complete Section A and Section B
• Submit a W-9
• Submit a sample claim form (de-identified)
If changing your Group/Practice Name and Tax ID Number, a new contract may be required.
Please contact Molina Healthcare Provider Services at MCCVA-Provider@MolinaHealthcare.com.
Individual name
change
• PIF—Complete Section A and Section E
•
Complete Attachment D (
for ALL providers)
Provider directory
update
• PIF—Complete Section A and Section K
Panel update
• PIF—Complete Section A and Section K
Hospital affiliations
update
• PIF—Complete Section A and Section K
Group/Provider NPI
Change
• PIF—Complete Section A and Section C
Virginia Guide to Provider Forms
VA-ALL-PF-21276-22
FORM
FORM USAGE
Provider Information
Update Form (PIF)
This form is used to communicate changes, deletions and additions regarding participating
providers to Molina Healthcare.
Attachment D
This form is used to determine the types of services the provider offers.
W-9
This document is issued by the U.S. Internal Revenue Service (IRS). Molina Healthcare uses
it to update the TIN owner name, doing business as name, and Tax ID when received with a
PIF.
ADA Attestation Form
Providers use this form to attest to their compliance with American Disabilities Act (ADA)
requirements for each physical service location.
Credentialing—
individual providers
YOU WILL NEED TO…
If you have a CAQH
number
Complete CAQH Provider Data Form, and ensure your CAQH application is complete and up
to date (Attested). You will also need to update and give Molina Healthcare permission to
review. Visit the website at http://www.caqh.org.
If you do not have a
CAQH number
Visit the CAQH website at http://www.caqh.org. Complete the CAQH application
enrollment process. Ensure that your CAQH number has been reported to Molina
Healthcare on provider enrollment forms and rosters. You will also need to give Molina
Healthcare permission to review.
Credentialing—
facilities and Health
Delivery Organizations
(HDO)
YOU WILL NEED TO…
Including hospitals,
ambulatory surgical
centers, home health
agencies, Durable
Medical Equipment
(DME) suppliers, SNFs,
urgent care centers,
behavioral health and
substance abuse
facilities
Email or Fax the completed Organization (HDO) Application(s).
This form can be found on our website MCCofVA.com under the Provider Contracting and
Credentialing Forms section.
In addition, complete Attachment D, for each service location.
Email: MCCVA-Provider@MolinaHealthcare.com
Fax: (888) 656-5098
CONTACT
INFORMATION
If you have additional questions, please contact Molina Healthcare’s Provider Services
department at (800) 424-4524, between the hours of 8 a.m. to 5 p.m. EST, Monday
through Friday. You many also email:
MCCVA-Provider@MolinaHealthcare.com.
Provider Information Update Form (PIF)
VA-ALL-PF-21276-22
Submission date: / /
This form and the associated documentation are required to notify Molina Complete Care of any changes to your
group/practice information and/or to begin the credentialing process. This form is also available at
www.MCCofVA.com.
Name of person completing this form:
Contact phone and email (for questions regarding form):
Type of group/provider (select all that apply):
☐ PCP
☐ Specialist
☐ ARTS
☐ Medical Group
☐ Ancillary
☐ LTSS
☐ FQHC/RHC
☐ Hospital ☐ Other
SECTION A
Current group/practice information (All fields in this section are required)
Group/practice name:
Group/practice tax ID: Group/practice Medicaid ID:
Group/practice NPI: Contact phone number:
Email address: Contact name:
If changing your group/practice name and Tax ID Number, a new contract may be required.
Please contact Molina Healthcare Provider Services at MCCVA-Provider@MolinaHealthcare.com.
SECTION B
Tax ID Number Change Effective date: / /
Previous Tax ID Number: New Tax ID Number:
SECTION C
Group/Individual NPI Change or Addition Effective date: / /
☐
Group
☐
Individual
(If adding an NPI, do not fill out “Previous NPI” line.)
Group/individual name:
Previous NPI: New NPI:
SECTION D
Group/practice name change Effective date: / /
Previous group/practice name: Medicaid ID:
New group/practice name: Medicaid ID:
Provider Information Update Form (PIF)
VA-ALL-PF-21276-22
SECTION E
Individual practitioner name change Effective date: / /
Previous name: New name:
Practitioner NPI:
SECTION F
Change phone/fax/email Effective date: / /
Previous phone number: New phone number:
Previous fax number: New fax number:
Previous email: New email:
Affected address: City/State/Zip:
SECTION G
☐
Add service location
☐
Change service location Effective date: / /
☐
Add a provider to a service location
☐
Change service location for a provider
Also complete the ADA Attestation Form for all new service locations.
Previous address New address
Service location name: Service location name:
Address 1: Address 1:
Address 2: Address 2:
City/State/Zip: City/State/Zip:
Phone number: Phone number:
Fax number: Fax number:
Email: Email:
Is telehealth offered at new location?
☐
Yes
☐
No
Practice website:
Office hours (new location):
Provider Information Update Form (PIF)
VA-ALL-PF-21276-22
SECTION H
Closing a service location Effective date: / /
Address 1:
Address 2:
City/State/Zip:
Reason:
Authorized signatory (printed):
Authorized signatory (sign):
Phone number: Fax number:
Email: Date signed: / /
SECTION I (Billing address change)
Effective date:
/ /
Previous billing information New billing information
Billing Contact: Billing Contact:
Address 1: Address 1:
Address 2: Address 2:
City/State/Zip: City/State/Zip:
Phone number: Phone number:
Fax number: Fax number:
Email:
Is this a notice address change? ☐ Yes ☐ No
Email:
The notice address is the particular party’s address for delivery or mailing of notice purposes.
SECTION J
Terminating a provider
A termination letter is required on company letterhead and must include the following: group name, group tax ID,
group NPI, name of the provider to be termed, provider NPI, effective date of termination, reason for termination,
and address of practice location(s). (Please attach letter to this form, upon submission)
If terming provider is a PCP, who will assume patient panel?
Provider name (Last, First, MI): Provider NPI:
Provider Information Update Form (PIF)
VA-ALL-PF-21276-22
SECTION K
Provider name: Provider NPI:
Address: City/State/Zip:
☐ PCP ☐ Specialist
K.1: Panel update Effective date: / /
☐ Existing patients only Close panel to all members
☐
Open panel
Reason (required):
K.2: Provider directory update Effective date: / /
☐ Include in provider directory ☐ Exclude from provider directory
Reason (required):
K.3: Hospital affiliations update Effective date: / /
☐ Add hospital affiliation(s) ☐ Remove hospital affiliation(s)
Name of hospital(s):
SECTION L
Provider joining a group/practice Effective date: / /
Locum tenen? ☐ Yes ☐ No
Provider name (Last, First, MI):
Provider type (MD, DO, DC, PHD, DPM, etc.): Date of birth:
Last four digits of Social Security #: Individual NPI: CAQH Provider Number:
Provider ethnicity: ☐ African American ☐ Asian/Pacific Islander ☐ Alaskan/American Indian
☐ Caucasian ☐ Hispanic ☐ Other
Group/practice name:
Group/practice address:
City/State/Zip:
Phone number: Fax number:
Email address:
Office hours: Include in directory? ☐ Yes ☐ No
Provider Information Update Form (PIF)
VA-ALL-PF-21276-22
SECTION L (Provider Joining a Group Practice continued)
VA Medicaid provider ID: Medicare provider ID:
Provider must be registered with DMAS to provide Medicaid services. Please visit virginiamedicaid.dmas.virginia.gov,
for registration information.
Provider specialty: Secondary specialty:
Provider specialty must align with registered taxonomy for NPI.
Applying as: ☐ PCP ☐ Specialist ☐ Hospitalist ☐ Other If PCP, list requested panel size (max. 1,500)
Note: Please ensure the provider has completed and/or re-attested to the CAQH application and has authorized
Molina Healthcare to access the CAQH record.
Are you individually accessible by appointment? ☐ Yes ☐ No
Board certified? ☐ Yes ☐ No
Effective date: / / Expiration date: / /
Certification board:
Age restrictions: Gender restrictions:
Languages spoken:
For Nurse Practitioners,
Physician Assistants
and nurse midwives
only:
Supervising physician name & degree:
Supervising physician NPI and
specialty:
For additional questions, please visit our website at www.MCCofVA.com, or call Provider Services at
(800) 424-4524. Representatives are available to assist you Monday through Friday, from 8 a.m. to 5 p.m. EST.
Please email or fax this form and supporting documentation to:
Email: MCCVA-Provider@MolinaHealthcare.com
Fax: (888) 656-5098
Attachment D: Services Provided
Virginia
VA-ALL-PF-21276-22
Provider/group name:
Group Tax ID Number: Location NPI:
If completing services for individual practitioner/staff member, list:
Practitioner name: Individual NPI:
General provider designation (check all that apply, as licensed)
☐ PCP (01) ☐ Outpatient Mental Health—traditional services (07)
☐ Pediatrician (02) ☐ ARTS: Addiction, Recovery and Treatment Services* (08)
☐ OB-GYN (25) ☐ Mental Health Services* (09)
☐ Specialist (03), list specialty: ☐ Psychiatric Hospital* (10)
☐ Health Department (04) ☐ CSB: Community Services Board* (27)
☐ Hospice (05) ☐ Transportation (23)
☐ LTSS: Long Term Services and Supports* (06)
☐ Home Health (19) ☐ DME: Durable Medical Equipment and Supplies (17)
☐ General Hospital (11) ☐ Urgent Care (13)
☐ Physical Rehabilitation Hospital (12) ☐ Nursing Facility (14)
☐ Outpatient Rehabilitation (16) ☐ Vision (22)
☐ Radiology (18) ☐ Laboratory (20)
☐ RHC: Rural Health Clinic (28) ☐ Pharmacy (21)
☐ FQHC: Federally Qualified Health Center (FQHC) (26)
☐ Other (24): Please describe
(*For ARTS, Community Mental Health Services and LTSS, please also complete the appropriate sections
below— in addition to General Provider Designation)
Regions Served (Check all served by this Location NPI) ☐ Statewide
☐ Central ☐ Charlottesville/Western ☐ Northern/Winchester ☐ Roanoke/Alleghany ☐ Far Southwest ☐ Tidewater
LTSS: Long Term Services and Supports
Please complete this additional section, for all applicable LTSS services. For all services, provider(s) must also be
licensed and approved by our credentialing department, prior to rendering these services to our members. In addition,
ensure that an accompanying Provider Information Update Form is submitted for each location within your
organization.
LTSS service
Service indicator
(for this NPI)
LTSS service
Service indicator
(for this NPI)
Adult Day Health Care
(S5102)
☐ Yes ☐ No
Skilled Nursing Services
(T1002/T1003)
☐ Yes ☐ No
Assistive Technology
(T1999)
☐ Yes ☐ No
PERS: Installation/Monitoring
(S5160/S5161)
☐ Yes ☐ No
Congregate Nursing Services
(T1000/T1001)
☐ Yes ☐ No
PERS: Medication Monitoring
(S5185)
☐ Yes ☐ No
Respite Care (T1005/S9125)
☐ Yes ☐ No
Personal Care (T1019)
☐ Yes ☐ No
Attachment D: Services Provided
Virginia
VA-ALL-PF-21276-22
LTSS service
Service indicator
(for this NPI)
LTSS service
Service indicator
(for this NPI)
Congregate Respite Nursing
(T1030/T1031)
☐
Yes
☐
No
PERS: Nursing Services
(H2021) ☐
Yes
☐
No
Environmental Modifications
(S5165/99199)
☐
Yes
☐
No
Transition Coordination
(H2015) ☐
Yes
☐
No
Service Facilitation (Multiple Codes)
(example: 99509)
☐
Yes
☐
No
ARTS: Addiction, Recovery and Treatment Services
Please complete this additional section, for all applicable ARTS services. For all services, ensure you submit copies of
required licenses and certifications, ARTS attestation(s), and ARTS roster(s). Provider(s) must also be approved by our
credentialing department, prior to rendering these services to our members.
In addition, ensure that an accompanying Provider Information Update Form is submitted for each practitioner within
your organization.
ARTS service
Service
procedure code
Documentation
required
Service indicator
(for location NPI above)
ARTS Peer Support Services (Indv)
T1012
ARTS attestation and
DBHDS license
☐
Yes
☐
No
ARTS Peer Support Services (Grp)
S9445
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Substance Use Case Management
H0006
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Substance Use Care Coordination
G9012
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Early Intervention Services/SBIRT ASAM 0.5
Multiple
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Office-Based Addiction Treatment (OBAT)
Multiple
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Opioid Treatment Services
Multiple
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Outpatient Services ASAM 1.0
Multiple
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Intensive Outpatient Services ASAM 2.1
H0015 or H0015
with rev 0906
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Partial Hospitalization Program ASAM 2.5
S0201 or S0201
with rev 0913
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Clinically Managed Low-Intensity Residential
Services ASAM 3.1
H2034
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Clinically Managed Population-Specific High-
Intensity Residential Services (Adults) ASAM 3.3
H0010, rev 1002
Modifier TG
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Clinically Managed High-Intensity Residential
Services (Adults) / Medium Intensity (Adolescent)
ASAM 3.5
H0010, rev 1002
Modifier-Adults
HB, Adolescents
HA
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Attachment D: Services Provided
Virginia
VA-ALL-PF-21276-22
Medically Monitored Intensive Inpatient Services
(Adult) Medically Monitored High-Intensity
Inpatient Services (Adolescent) ASAM 3.7
H2036, rev 1002
Modifier-Adults
HB, Adolescents
HA
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Medically Managed Intensive Inpatient ASAM 4.0
H0011, rev 1002
ARTS attestation and
DBHDS license
☐
Yes
☐
No
Mental Health Services
Please complete this additional section, for all applicable mental health services. For all services, ensure you submit
copies of required DBHDS licenses, and additional documentation, as noted below. Provider(s) must also be approved by
our credentialing department, prior to rendering these services to our members.
In addition, ensure that an accompanying Provider Information Update Form, or Staff Roster, is submitted for each
practitioner within your organization.
Mental health service
Service procedure
code
Documentation required
Service indicator
(for location NPI above)
Peer Support Services
H0024/H0025
☐
Yes
☐
No
Applied Behavior Analysis (ABA)
97151-97158,
0362T, 0373T
☐
Yes
☐
No
Psychotherapy for Crisis
90839/90840
☐
Yes
☐
No
Functional Family Therapy (FFT)
H0036
MH Outpatient license from DBHDS;
Certificate in FFT
☐
Yes
☐
No
Multisystemic Therapy (MST)
H2033
Intensive In-Home Services license
from DBHDS; Certificate in MST
☐
Yes
☐
No
Community Stabilization
S9482
MH Crisis Stabilization (Non-
Residential) license from DBHDS
☐
Yes
☐
No
Mobile Crisis Response
H2011
MH Crisis Stabilization (Non-
Residential) license from DBHDS
☐
Yes
☐
No
23-Hour Crisis Stabilization
S9485
MH Crisis Stabilization (Non-
Residential) license from DBHDS
☐
Yes
☐
No
Residential Crisis Stabilization
H2018
MH Crisis Stabilization (Non-
Residential) license from DBHDS
☐
Yes
☐
No
Psychosocial Rehabilitation
(PSR)
H2017
Psychosocial Rehab or Clubhouse
Services license from DBHDS
☐
Yes
☐
No
Mental Health Skill-Building
Services (MHSS)
H0046
Licensed by DBHDS as a provider of
Supportive In-Home Services or
Program of Assertive Community
Treatment
☐
Yes
☐
No
Intensive In-Home (IIH)
H2012
Intensive In-Home Services license
from DBHDS
☐
Yes
☐
No
Mental Health Case
Management
H0023
CSB/Behavioral Health Authority
(BHA) member; Case Management
license from DBHDS
☐
Yes
☐
No
Therapeutic Day Treatment
(TDT) - Non School Based
H2016 U7
Therapeutic Day Treatment Services
license from DBHDS
☐
Yes
☐
No
Therapeutic Day Treatment
(TDT) - School Based
H2016
Therapeutic Day Treatment Services
license from DBHDS
☐
Yes
☐
No
Therapeutic Day Treatment
(TDT) - After School
H2016 UG
Therapeutic Day Treatment Services
license from DBHDS
☐
Yes
☐
No
Attachment D: Services Provided
Virginia
VA-ALL-PF-21276-22
Assertive Community Treatment
(ACT) - Base Small Team
H0040 U2
Assertive Community Treatment
license from DBHDS
☐
Yes
☐
No
Assertive Community Treatment
(ACT) - Base Medium Team
H0040 U1
Assertive Community Treatment
license from DBHDS
☐
Yes
☐
No
Assertive Community Treatment
(ACT) - Base Large Team
H0040
Assertive Community Treatment
license from DBHDS
☐
Yes ☐ No
Assertive Community Treatment
(ACT) - High Fidelity Small Team
H0040 U5
Assertive Community Treatment
license from DBHDS
☐
Yes
☐
No
Assertive Community Treatment
(ACT) - High Fidelity Medium
Team
H0040 U4
Assertive Community Treatment
license from DBHDS
☐
Yes
☐
No
Assertive Community Treatment
(ACT) - High Fidelity Large Team
H0040 U3
Assertive Community Treatment
license from DBHDS
☐
Yes
☐
No
Mental Health Partial Hospital
(MH-PHP) - Hospital Based
Mental Health Program
H0035
MH-PHP license from DBHDS, Proof
of Medicare enrollment as a
Hospital, Staffing attestation
☐
Yes
☐
No
Mental Health Partial Hospital
(MH-PHP) - Community
Based Clinic Program
H0035
MH-PHP license from DBHDS, Proof
of Medicare enrollment as a CMHC,
Staffing attestation
☐
Yes ☐ No
Mental Health Intensive
Outpatient Services (MH-IOP)
S9480
MH-IOP license from DBHDS, IOP
Program Accreditation; Staffing
attestation
☐
Yes
☐
No
MH-IOP with Occupational
Therapy
S9480 GO
MH-IOP license from DBHDS, IOP
Program Accreditation; Staffing
attestation
☐
Yes
☐
No
All providers contracted and credentialed for the above services must comply with DMAS requirements, as outlined in
DMAS provider manuals. Providers must ensure appropriate staffing ratios, applicable supervision, and appropriate
licensure, education and training. Failure to adhere to requirements outlined in DMAS provider manuals and Molina
Provider Manual can result in termination from the network. By signing below, you agree to maintain compliance
with requirements outlined by DMAS and Molina.
Authorized signatory (printed):
Authorized signatory (sign):
Email: Date signed: / /
For additional questions, please visit our website at www.MCCofVA.com, or call Provider Services at
(800) 424-4524. Representatives are available to assist you Monday through Friday, from 8 a.m. to 5 p.m. EST.
Please email or fax this form and supporting documentation to:
Email: MCCVA-Provider@MolinaHealthcare.com
Fax: (888) 656-5098
VA-ALL-PF-21276-22
Americans with Disabilities Act
(ADA) Form: Virginia
Please complete the following attestation for each provider service location and return it with your signed contract.
Practice name: Tax ID Number:
Service address: Phone number:
Email address:
The Americans with Disabilities Act (ADA) requires providers make reasonable access and accommodations for all
persons with disabilities. Molina is providing you with the opportunity to self-attest to the below ADA standards, in
order to verify core elements of ADA compliance, to service our members.
If you are not an office-based provider, please check here and proceed to the signature section below: ☐
If you are an office-based provider, please check complete each standard below, as applicable, and have the
designated representative sign and return the attestation to Molina Healthcare.
ADA STANDARDS
RESPONSE
Building has handicap designated parking. Parking spaces are accessible with ramps and curb cutouts
between the parking lot, office, and at drop-off locations.
☐ Yes ☐ No
Building has automatic entry option or alternative access method.
☐ Yes ☐ No
Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the
wheelchair and/or scooter to maneuver.
☐ Yes ☐ No
Restroom is equipped with large stall and safety bars or other reasonable accommodations.
☐ Yes ☐ No
Waiting room (including furniture) can accommodate patients with physical and non-physical
disabilities. The reception and waiting areas have enough room for a wheelchair and/or scooter to
maneuver and turn around.
☐
Yes
☐
No
At least one exam room can accommodate patients with physical and non-physical disabilities.
☐ Yes ☐ No
Signage and way finding is clear (e.g. color, symbol signage, and braille).
☐ Yes ☐ No
Doors to access building, office, and patient rooms are at least 32 inches wide.
☐ Yes ☐ No
The exam table moves up and down to make it easier to get on and off whether standing or using a
wheelchair or scooter.
☐ Yes ☐ No
Diagnostic equipment can accommodate patients with disabilities.
☐ Yes ☐ No
The scale is able to accommodate a wheelchair or scooter.
☐ Yes ☐ No
Provider service locations that attest to being ADA compliant, or have received an in-office assessment and determined
to be ADA compliant, will be published as such in the Molina Complete Care Provider Directory.
I attest to the best of my knowledge that the above information is true, accurate and complete.
Authorized signatory (printed):
Authorized signatory (sign):
Title: Date signed: / /
Please email or fax this form and supporting documentation to:
Email: MCCVA-Provider@MolinaHealthcare.com
Fax: (888) 656-5098
For additional questions, please visit our website at www.MCCofVA.com.
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INFORMATION UPDATE FORM (PIF) AND ANY ADDITIONAL DOCUMENTS, (Molina Healthcare)

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Completed 17 March 2022

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