470 0254 Form – Fill Out and Use This PDF

Iowa Medicaid Universal Provider Enrollment Application

CHECKLIST

To avoid delays in the enrollment process, please use this checklist to ensure all required documents and supporting documentation are submitted:

New enrollees and those with a new Tax Identification Number (ID):

If you are enrolling in the Iowa Medicaid program for the first time or are already enrolled, but have a new Tax ID, the following forms are required:

Form 470-0254, Iowa Medicaid Universal Provider Enrollment Application – Attach a photocopy of all certifications, licenses, or accreditation documents (See page 9 for a complete list of required supporting documentation.)

Form 470-2965, Iowa Medicaid Provider Agreement General Terms – Last page must be completed

Form 470-4202, Electronic Fund Transfer (EFT) Authorization – Must attach voided check or bank letter (EFT is the only payment method available through the Iowa Medicaid Enterprise)

IRS Form W-9

Form 470-5112, Designated Contact Person – Must attach copy of driver license or state issued

ID

Adding an individual or sub-part to your organization:

If the Tax ID is already enrolled and active, the following form is required:

Form 470-0254, Iowa Medicaid Universal Provider Enrollment Application (Section B) – Attach a photocopy of all certifications, licenses, or accreditation documents

Only if applicable:

Form 470-3174, Addendum to Dental Provider Agreement for Orthodontia

Form 470-3748, Verification of Ambulance Compliance

Form 470-5100, Iowa Medicaid Health Home Agreement

Form 470-3747, Point of Sale (POS) Agreement – Pharmacies only

LEA Agreement (Local Education Agency)

I/T Contract (Early Access Service Coordinator)

•Complete and submit all required forms and documentation.

•If extra space is needed to answer any questions, please attach any additional pages.

•Type or print all information so that it is legible. Do not use a pencil.

•If any field is not applicable, please enter N/A.

•An incomplete form will delay the application approval process.

•Attach all required and current supporting documentation.

Send the completed Provider Application and all applicable attachments to:

Iowa Medicaid Enterprise

Attn: Provider Enrollment

PO Box 36450

Des Moines, IA 50315

470-0254 (Rev. 11/19)

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Instructions for Completing the Iowa Department of Human Services

Iowa Medicaid Universal Provider Enrollment Application

Reason for Application: Check one box.

Managed Care Organization (MCO and/or Dental Carrier): Check the box next to each MCO plan or Dental Carrier that you want your enrollment application submitted to. This step does not enroll you with the MCO or Dental Carrier.

Section A: Organizational Data

This section is completed only for Tax Identification Numbers (IDs) enrolling with Iowa Medicaid for the first time.

1.Enter the full name of the practice as it appears on your income tax return.

2.Enter the nine-digit Federal Employer Identification Number (FEIN) of the business or the Social Security Number (SSN) of the individual for which this application is being filed. Note: If you are adding an individual to an existing group, enter the FEIN of the group. Check the box to indicate which number you are listing.

3.Enter your Primary Organizational National Provider Identifier (NPI). This is the NPI you will use to bill Iowa Medicaid. If you are not a “health care provider” as defined at 45 C.F.R. §160.103, please complete the Atypical Provider Declaration, form 470-4457, found on the DHS webpage at: http://dhs.iowa.gov/ime/providers/forms.

4.Primary physical location:

a.Enter the street number of your primary office location.

b.Enter your suite or apartment number.

c.Enter the city name.

d.Enter the state name.

e.Enter the zip code.

5.Enter the county name.

6.Enter the phone number.

7.Enter the fax number.

8.Check the box that best matches the type of business being enrolled:

a.Check the appropriate box.

b.The 340B Drug Pricing Program resulted from the enactment of the Veterans Health Care Act of 1992, which is Section 340B of the Public Health Service Act. A 340B provider is able to acquire drugs through that program at significant discounted rates. Because of the discounted acquisition cost on these drugs, such are not eligible for the Medicaid drug rebate. State Medicaid programs are obligated to ensure that rebates are not claimed on these drugs. Please refer to Informational Letter 699 for more information. If yes, enter the effective date.

9.Mailing address for Medicaid-related correspondence:

a.Enter the mailing address if it is different from the address provided in box 4.

b.Enter the city name.

c.Enter the state name.

d.Enter the zip code.

10.Enter the email address for Medicaid-related correspondence.

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1099 Mailing Address

11. Enter the pay to address used for mailing 1099s.

Pharmacies Only

12.Pharmacies only enter:

a.The National Council for Prescription Drug (NCPDP) number.

b.Acknowledgement: If you are a pharmacy that is located outside of the state of Iowa, check one box.

Independent Labs Only

13.Independent labs enter:

a.The 10-digit Clinical Laboratory Improvement Amendments (CLIA) certification code. Please attach a copy of your current CLIA certification.

b.The effective date.

c.The termination date.

Note: If you are enrolling more than one location, please attach CLIA certification for each location.

14.Leave blank. (For future use.)

15.Leave blank. (For future use.)

Page 9 is a listing of Iowa Medicaid provider types. Use this list to identify your provider type code, if an application fee is applicable and to determine whether additional certifications are required for enrollment. Enter the type code in box 16 of the application. Attach the required additional certification to your application.

Note: Only the individuals or institutional categories listed by the business on this form are eligible for Medicaid reimbursement.

Section B: Identifying Information

Managed Care Organization (MCO and/or Dental Carrier): Check the box next to each MCO plan or Dental Carrier that you want your enrollment application submitted to.

Section B is used to enroll individual/group professional or institutional categories (from the listing) that are part of the business and subject to the Iowa Medicaid Provider Agreement. Additional copies of Section B must be completed for each individual within the organization who is being enrolled.

16.Enter the type code from the list on page 9.

17.Enter the licensee or “doing-business-as” name. For individuals that are part of an organization, list the individual’s name.

18.a. Tax ID: Enter the Tax ID of the entity or pharmacy to which payment will be made.

b.Social Security Number (SSN): Enter the nine-digit SSN for the individual entered in box 17. No entry is required if provider is an organization.

c.Date of birth: Enter the DOB for the individual entered in box 17. No entry is required if it is an organization.

19.Enter the requested effective date of the enrollment.

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20.Enter the physical address of the service location. Note that each service location must be listed for which medical records are stored. Print additional pages of Section B as needed to indicate more than three service locations.

a.Enter the primary service address.

(i)Enter the phone number, fax number, and email address of the service location for which the application is being made.

b.Enter an additional service location, if any.

(i)Enter the phone number, fax number, and email address of the additional service location.

c.Enter a third additional service address, if any.

(i)Enter the phone number, fax number, and email address of the additional service location.

21.Enter the pay to address. The address is only needed if the NPI being enrolled will be the pay to provider.

22.Enter the mailing address.

23.Enter the NPI.

a.Enter the NPI of the individual or organization named in box 17.

b.Enter the taxonomy code of the billing provider. Note: If the individual listed in box 17 is a member of a group, this box is not required and may be left blank.

24.Primary professional license or certification number:

a.Enter the primary professional license or certification number and attach a copy of your license or certification documents, as listed on page 9 for the type code listed in box 16.

b.Enter the 10-digit CLIA Certification code. If you are providing lab services which require CLIA certification, submit a copy of your current CLIA certification.

c.Enter the state in which this license or certification was issued.

d.Enter the initial effective date of the license listed in box 24a.

e.Enter the license expiration date for the license listed box 24a.

f.Enter the effective date for the CLIA certificate listed in box 24b.

g.Enter the expiration date for the CLIA certificate listed in box 24b.

25.Enter the Drug Enforcement Agency (DEA) number. If the provider does not have a DEA number, enter N/A. If the provider is a physician, the number must be entered.

26.For physicians only: Enter the primary specialty, if applicable.

27.For physicians only: Enter the secondary specialty, if applicable.

28.Medication coverage for medication assisted treatment (MAT). Select one or more options that define your program.

29.Authorized pharmacist: Required fields – check applicable boxes.

30.a. Check the yes box if there has ever been disciplinary action against this provider’s license by a licensing board in any state and attach an explanation. Check no if there has not been any disciplinary action.

b.Check the yes box if Medicare or any state health program has ever sanctioned the provider and attach an explanation. Check no is there have not been sanctions.

c.Check the yes box if convicted of a criminal offense and attach an explanation. In your explanation, clearly identify any convictions related to your involvement in any program under Medicare, Medicaid or the Title XXI services program. Check no if there have not been any convictions.

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31.Group linkage information: If the individual referenced in box 17 will be linked to a group or

pharmacy, enter the group information here. Note: If the NPI, taxonomy, and zip code provided do not match a group or pharmacy already enrolled in Iowa Medicaid, the application will be returned for corrections. Section B must be completed to enroll a group or pharmacy.

a.Enter the organization NPI with which the individual profession is associated. This is the NPI under which payments will be made.

b.Enter the organizational taxonomy code.

c.Enter the organizational zip code.

32.Check yes or no if you are enrolled in another state’s Medicaid or CHIP program. If yes, please list the states and the program.

33.Check yes or no if you are enrolled with Medicare.

Certify: Print name of owner/registered/authorized agent, date, signature, and title.

Section C: Additional Information: Individual Providers Only

Note: Council for Affordable Quality Healthcare (CAQH) users do not need to complete this section. All other providers must complete boxes 34 through 53 unless optional is shown below.

34.Provide the home address of the provider (optional).

35.Provide all state licenses, DEA Registration and State Controlled Dangerous Substance (CDS) certification numbers.

36.Include any additional completed training.

37.Provide the undergraduate school name and information.

38.Provide the professional school name and information.

39.Provide practice interest information for the provider (optional).

40.Credentialing contact information (optional).

41.Office contact information.

42.Disclose the office hours for the location.

43.List all non-English languages spoken at the office location.

44.Check yes or no regarding ADA accessibility requirements.

45.Disclose practice status on accepting new Medicaid and Iowa Wellness patients.

46.If yes to 45, complete 46.

Provide information on any mid-level practitioners that care for patients within the practice. If more than three, send information on an attachment.

47.Mid-Level Practitioners. Check yes or no. If yes, please provide information in the boxes provided.

48.Please check yes or no to all services that apply at this location (optional).

49.Please check yes or no. If no, please explain.

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50.Provide applicable malpractice insurance information. If yes, then complete all fields.

51.Provide 10 years of work history starting with graduation (optional). Please check yes or no for active military duty or reserve.

52.List three professional references.

53.Complete all disclosure questions. If yes to any, include a brief description.

Note: If a new Tax ID is being enrolled with Iowa Medicaid for the first time, the Ownership and Control Disclosure must be completed online before your Tax ID will be activated. To start this task, it is necessary to designate a contact person for your organization using form 470-5112. This will provide access to the online tool used to disclose ownership and control.

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Section A: Organizational Data

Reason for Application: Check one box.

Please indicate which MCOs and/or Dental Carriers the IME should share your application with:

By checking the box above I authorize the Iowa Medicaid program to share this application and all information contained herein with each MCO and/or Dental Carrier indicated. Checking the box does not enroll you with the MCO or Dental Carrier.

Practice Information

1.Legal Name (as it appears on your income tax return)

2.Taxpayer Identification Number (TIN): Enter the nine-digit Federal Employer Identification Number (FEIN) of the business or the Social Security Number (SSN) of the individual for which this application is being filed. This is the number under which all income will be reported to the Internal Revenue Service for Federal 1099 purposes.

3.For Healthcare Providers: Primary Organizational NPI

8a. Check Appropriate Box

10.Email Address for Medicaid-Related Correspondence

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Please print this section and complete for each individual professional and institutional category.

Section B: Identifying Information

Please indicate which MCOs and/or Dental Carriers the IME should share your application with:

By checking the box above I authorize the Iowa Medicaid program to share this application and all information contained herein with each MCO and/or Dental Carrier indicated. This step does not enroll you with the MCO or Dental Carrier.

Reason for Application: Check one box.

16. Type Code				17. Licensee or DBA Name			18a. Tax ID (for billing entity)
18b. Social Security Number				18c. Date of Birth			19. Requested Effective Date of
							Enrollment*
20a.	Primary Service Address			City			State			9-Digit Zip
20a(i). Primary Address Phone Number				Fax			Email
20b. Additional Service Address				City			State			9-Digit Zip
20b(i). Additional Service Address				Fax			Email
Phone Number
20c.	Additional Service Address*			City			State			9-Digit Zip
20c(i). Additional Service Address				Fax			Email
Phone Number
21. Pay to Address				City			State			9-Digit Zip
22. Mailing Address				City			State			9-Digit Zip
23a.	National Provider Identifier (NPI)					23b. Taxonomy Code (if applicable)
24a.	Primary Professional License or Certification					24b. 10-Digit CLIA Number				24c. State Issued
Number. Please attach a copy of your
license/certification documents.
24d. Initial Effective Date			24e. Current Expiration Date			24f. CLIA Effective Date		24g. CLIA Expiration Date
470-0254 (Rev. 11/19)										Page 10

25.Drug Enforcement Agency (DEA) Number. If the provider does not have a DEA Number, enter N/A.

28.Medication Coverage for Medication Assisted Treatment (MAT) Please check all that apply: (Otherwise leave blank)

We are currently a certified opioid treatment program. (Attach a copy of your certification.)

We are currently accredited by SAMHSA or one of the approved accreditation bodies for providing medication-assistance treatment. (Attach a copy of your accreditation.)

We are provisionally certified working towards accreditation. (Attach a copy of your provisional certification.)

i.If yes, have you completed an organized course of study in a college or school of pharmacy or an ACPE-accredited continuing education program on vaccine administration that meets the requirements of IAC r.657-39.11(3)? (Attach certificate)

ii.If yes, do you have current certification in basic cardiac life support through a training program designated for health care providers that includes hands-on training? (Attach certificate)

iii.If yes, have you completed at least one hour of ACPE-approved continuing education with the ACPE topic designator “06” followed by the letter “P.” (Attach certificate)

i.If yes, have you completed at least one hour of ACPE-approved continuing education related to Naloxone utilization? (Attach certificate)

i.If yes, have you completed at least one hour of ACPE-approved continuing education related to nicotine replacement tobacco cessation product utilization? (Attach certificate)

30a. Has there ever been disciplinary action against this provider’s license by a licensing board in any state?

30b. Has the provider ever been sanctioned by Medicare or any state health program?

30c. Has the provider been convicted of any criminal offense?

Group Linkage Information*

Individual professionals may be associated with an organization. If that is the case, identify the organization in the boxes below.

Pharmacist only:

Enter the pharmacy NPI, Taxonomy code, and location zip code:

470-0254 (Rev. 11/19)

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	31a. Organizational NPI				31b. Organizational Taxonomy			31c. Organization Location Zip
32.		Are you currently enrolled in another state’s Medicaid/CHIP program?
		Yes	No	If yes, please list the state and what program you are enrolled in:
33.		Are you currently enrolled with Medicare?				Yes	No

I certify that the information submitted on this enrollment application is, to the best of my knowledge, true, accurate, and complete and that I have read this entire form before signing. I also understand that payment of claims will be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state law. I hereby attest and warrant that I will immediately notify the Iowa Medicaid Enterprise of any material change to the information I have submitted in the application either during the application process or thereafter.

Please send the completed Universal Provider Enrollment Application and all applicable attachments to:

Iowa Medicaid Enterprise, Attn: Provider Enrollment,

PO Box 36450, Des Moines, Iowa 50315

Or email to: IMEProviderEnrollment@dhs.state.ia.us

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Section C: Additional Information: Individual Providers Only

If in Section B you indicated that the Iowa Medicaid program is to share your application with one or more of the MCOs and/or Dental Carriers and you are an individual, please complete this section.

34.	Provider Home Address			City			State	Zip
35.	Professional ID/CDS Certification			Certifications (please list all)
Number
36.	Training
37.	Undergraduate School Name			Address
City				State			Zip
38.	Professional School Name			Address
City				State			Zip
39.	Practice Interests
40.	Primary Credentialing Contact Name			Phone Number			Email
41.	Office Manager or Business Office			Phone Number			Email
Contact Name
42.	Office Hours			43. List non-English languages spoken by office personnel
44. Does this office meet ADA Accessibility Requirements?					Yes	No
45.	Practice Status
Are you currently accepting new Medicaid patients?					Yes	No
Are you currently accepting new Iowa Wellness patients?					Yes	No
If yes to either of the above, please complete the below fields:
46.	If yes to 45, answer questions:
	Yes	No	If yes, please explain:
	Gender limitations?
	Yes	No	If yes, please explain:
	Age limitations?
	Yes	No	If yes please explain:
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47.Do mid-level practitioners (nurse practitioners, physician assistants, etc.) care for patients in your practice?

IF YES, PLEASE PROVIDE THE INFORMATION BELOW:

48.Services provided in this location. Please select yes or no to all that apply:

Radiology	Yes	No	Physical therapy	Yes	No
Allergy injections	Yes	No	Allergy skin testing	Yes	No
Laboratory	Yes	No	Flexible sigmoidoscopy	Yes	No
EKGs	Yes	No	IV hydration treatment	Yes	No
Drawing blood	Yes	No	Care of minor lacerations	Yes	No
Asthma treatment	Yes	No	Routine office gynecology	Yes	No
Pulmonary function testing	Yes	No	Tympanometry audiometry screening	Yes	No
Age appropriate immunizations	Yes	No	Cardiac stress test	Yes	No
Osteopathic manipulation	Yes	No
49. Do you have hospital privileges?	Yes	No

If you do not admit patients, please explain what type of admitting arrangements you do have?

If yes, please complete the below fields:

Primary Hospital Name		Service Address		State	9-Digit Zip
Primary Phone Number		Fax		Department Name
Department Director’s Name		Affiliation Start Date		Affiliation End Date
Full unrestricted privileges?		Age privileges temporary?		Of your total annual admission,
Yes	No	Yes	No	what percentage is to this
				hospital?

Admitting privileges status (e.g. none, full, unrestricted, provisional, temporary)?

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(“Currently” means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one’s ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. “Illegal use of drugs” refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It “does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law.” The term does include, however, the unlawful use of prescription controlled substances.)

Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and

perform the functions of your job with reasonable skill and safety?

Yes

No

Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?

Yes No

Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable

accommodation? Yes No

Attestation and Information Release Authorization

All information provided in the application is complete and accurate to the best of my knowledge, and I shall immediately notify the IME and the MCOs of any changes thereto. I understand this application does not entitle me to participation. I authorize the Plan, its medical director, and appropriate representatives to consult with administrators and members of other institutions where I have been associated; including past and present malpractice carriers who may have information bearing on my professional competence, character, and ethical qualifications. I hereby further consent to the inspection by the MCOs, its medical director and appropriate representatives of all records and documents, excluding medical records of non-members of the MCO plans, that may be material to an evaluation of any professional qualifications and competence to carry out the requested duties, as well as my moral and ethical qualification for participating provider status with MCO. I consent and agree that the MCOs will complete a criminal history background check to determine if I or any subcontracted providers have any history of felony convictions, including adjudication withheld on a felony, plea or nolo contendere to a felony or entry into a pretrial for a felony. I agree to obtain any consents or approvals required for my subcontracted provider to undergo such background checks. I hereby release the MCOs and its representatives from liability for their acts performed in good faith and without malice in connection with evaluating my application, credentials, and qualifications. I hereby release any individuals and organizations from any liability that provide information to the MCOs or its staff in good faith and without malice concerning my professional competence, ethics, character, and other qualification, and I hereby consent to the release of such information. By executing this application, I confirm that I am bound by the term and the agreement between me, my group, and MCOs, as such terms may be applicable to me.

I understand that as an applicant for participation in the MCOs, I have the right to review information obtained from primary verification sources during the credentialing process. I further understand that upon notification from the MCOs, I have a right to explain any information obtained that may vary substantially from that provided by me and correct any erroneous information submitted by another party. This shall be accomplished by my submission of a written explanation or by appearance before the credentialing committee, if they so request. I further understand that I may appeal the committee’s decision either in writing or by appearance before the credentialing committee, if they so request.

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