Optum Provider Entity Disclosure Form 01/01/2016
Provider Entity: an individual or entity who operates as a Medicaid provider and is engaged in the delivery of health care services and is legally
authorized to do so by the state in which it delivers the services. For purposes of this Statement, the Provider Entity is the individual or entity
identified on this form as the disclosing entity
HCBS Provider: a provider of Home and Community Based Services for Medicaid beneficiaries.
Ownership or Control Interest: an individual or corporation that—
(a) Has an ownership interest totaling 5 percent or more in a disclosing entity;
(b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
(c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;
(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing
entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;
(e) Is an officer or director of a disclosing entity that is organized as a corporation; or
(f) Is a partner in a disclosing entity that is organized as a partnership.
Direct Ownership Interest: the possession of equity in the capital, the stock, or the profits of the disclosing entity.
Indirect Ownership Interest: an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an
ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Controlling Interest: defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the
following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity; the ability or authority to nominate or
name members of the Board of Directors or Trustees; the ability or authority, expressed or reserved to amend or change the by-laws, constitution, or
other operating or management direction; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber
such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new
Determination of ownership or control percentages :(a) 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.
(b) 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 interest owned in the obligation is multiplied by 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.
Other Disclosing Entity: any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain
ownership and control information because of participation in any of the programs established under title V, XV III, or XX of the Act. This includes:
(a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health
clinic, or health maintenance organization that participates in Medicare (title XV III);
(b) Any Medicare intermediary or carrier; and
(c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of,
health-related services for which it claims payment under any plan or program established under title V or title XX of the Act.
Significant Business Transaction: any business transaction or series of related that, during any one fiscal year, exceeds the lesser of twenty-five
thousand ($25,000) or five percent (5 %) of a Provider Entity’s total operating expenses.
Subcontractor: (a) an individual, agency, or organization to which a Provider Entity has contracted or delegated some of its management functions
or responsibilities of providing medical care to
its patients; or
(b) an individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease to obtain space,
supplies, equipment, or services provided under the Medicaid agreement.
Supplier: an individual, agency, or organization from which a provider purchases goods or services used in carrying out its responsibilities under
Medicaid (e.g., a commercial laundry, manufacturer of hospital beds, or pharmaceutical firm).
Wholly Owned Supplier: a Supplier whose total ownership interest is held by the Provider Entity or by a person(s) or other entity with an ownership
or control interest in the Provider Entity.
any person who has been delegated the authority to obligate or act on behalf of a Provider Entity.
a general manager, business manager, administrator, director, or other individual who exercises operational or
managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.