Map 811 – Fill Out and Use This PDF

Field #

Description

I am enrolling as a:

New Provider

Re-applicant

Change of Ownership

Reinstatement

Will you be contracting with a KY Managed Care organization (MCO)? Yes

No If yes, please indicate which MCO?

Aetna Better Health of KY

Anthem

Humana CareSource

Passport Health Plan

WellCare of Kentucky

1.

Kentucky Medicaid Provider Number:

Check here for N/A

(Complete only if you have indicated Reapplicant, or Reinstatement above.)

2.

Applying As: Please check only one box and print clearly. For individual applicants,

Teaching Facility (PT 01 or 02)

please input any suffixes if applicable.

Yes

No

Individual

Entity

Group

Last:

First:

MI:

Name:

3.

Doing Business As (DBA):

Provider/Owner Email:

4.

Please select:

Public

Private

5. Please select:

Profit

Non-Profit

6.

License/Certification #:

7. Provider Type:

8.

Type of Service:

9. Date Provider Requests Effective Enrollment: ____/____/_____

Provide Telehealth Services?

Yes

No

(Date must be in mm/dd/yyyy format.)

10.

National Provider Identifier (NPI):

11. Primary Taxonomy Code: (Attach extra sheet if necessary. Must match

NEPPS)

12.

SSN:

13. FEIN (Please list

only if you own the FEIN 100%):

14. Date of Birth:

15.

DMS will report all monies paid to the IRS. Please indicate which number you use for tax reporting. (If you are

enrolling as an individual and do not own a FEIN, please check SSN field). (Check one only.)

SSN

FEIN

16.

Tax Structure: Please select only one structure.

Individual

Partnership

Corporation

Government/Non-Profit

Sole Proprietor

Estate/Trust

Public Service Corporation

Limited Liability Company

17.

Agent of Service in Case of Summons (N/A not acceptable).

18. Telephone # of Agent of Service

First Name:

Last Name:

(N/A not acceptable).

19.

PRIMARY PHYSICAL BUSINESS LOCATION:

City:

State:

Zip:

Phone #:

Ext.

Fax #:

County

:

20.

MAILING ADDRESS:

(Check here if same as primary physical business address)

Address:

City:

State:

Zip:

Credentialing Contact Information (Required)

(This individual will be contacted should any information be needed to process the application.)

Note: Your email address will

not be given to any outside party for any reason. DMS may use provider email addresses to send provider letters/notices.

Name:

Email Address:

Phone:

Fax Number:

21.

PAY-TO/1099 ADDRESS:

(Check here if same as primary physical business address)

Address :

City:

State:

Zip:

Contact First Name:

Contact Last Name:

Phone #:

22.

List any Kentucky Medicaid group/facility numbers you have held in the past three years.

Check here for N/A

23.

Please list all Medicare Provider Numbers. (Attach extra sheet if necessary.) Check here for N/A

print or type. Reformatted or altered applications will not be accepted.

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24. Bed Breakdown Check here for N/A

_________ Acute

_________ TCU

_________ Hosp. Swing

_________ ICF/IID

_________ ICU

_________ Nursery

_________ Rehab. Hosp.

_________ Ventilator Unit

_________

Surgical ICU

_________ Neonatal ICU

_________

Psych. Hosp.

_________ Brain Injury

_________

Burn ICU

_________ CCU

_________

PRTF

Unit

_________ NF/Medicaid

_________ NF (Medicare/Medicaid)

_________ Other /specify:

25.

Administrator:

Phone:

Fax:

Check here for N/A

26.

Assistant Administrator:

Phone:

Fax:

Check here for N/A

27.

Controller:

Phone:

Fax:

Check here

for N/A

28.

Accountant or CPA:

Phone:

Fax:

Check here for N/A

29.

Fiscal Year End Date (FYE):

Check here for N/A

(Clinic/Corporation or Facility Name)

(KY Medicaid Provider Number of Clinic/Corporation or Facility)

print or type. Reformatted or altered applications will not be accepted.

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4.

If you anticipate filing for bankruptcy within the year, enter anticipated date of filing. Date:

Check here for N/A

5.

If this facility is a subsidiary of a parent corporation, enter corporate FEIN #:

Check here for N/A

Name:

Box or Address:

City:

State:

Zip:

ownership or controlling interest in the applicant provider.

(Attach extra page if necessary.)

(N/A not acceptable.) . If you

are applying as an individual, list your information.

Check here if no one owns 5% or more.

Name:

SSN:

Business Address:

FEIN:

DOB:

City:

State:

Zip:

P.O. Box:

City:

State:

Zip:

below.)

Check here for N/A *The entire first name is required. Initials are not accepted.

print or type. Reformatted or altered applications will not be accepted.

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City:

State:

Zip:

lesser of $25,000 or 5% of your total operating expense. (Attach extra page if necessary.)

Check here for N/A

below. (Attach extra page if necessary.)

Check here for N/A

print or type. Reformatted or altered applications will not be accepted.

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print or type. Reformatted or altered applications will not be accepted.

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YES

NO

a.

Has your license, registration or certification to practice in your profession, ever been voluntarily or

involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine,

reprimand, consent order, probation or any conditions or limitations by any state or professional licensing,

registration or certification board?

YES

NO

b.

Has there been any challenge to your licensure, registration or certification?

2. HOSPITAL

PRIVILEGES AND OTHER AFFILIATIONS

YES

NO

a.

Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily

or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary

or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of

care was not adversely affected) or have proceedings toward any of those ends been instituted or

recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

YES

NO

b.

Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while

under investigation?

YES

NO

c.

Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any

disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations

such as IPAs, PHOs)?

3. EDUCATION,

TRAINING AND BOARD CERTIFICATION

YES

NO

a.

Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during

an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in

a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or

asked to resign

YES

NO

b.

Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely

terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or

other clinical education program?

YES

NO

c.

Have any of your board certifications or eligibility ever been revoked?

YES

NO

d.

Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under

investigation

4. DEA OR STATE CONTROLLED SUBSTANCE REGISTRATION

YES

NO

a.

Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or

authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily

or involuntarily relinquished?

5. MEDICARE,

MEDICAID OR OTHER GOVERNMENTAL PROGRAM PARTICIPATION

YES

NO

a.

Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured,

disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in

regard to other federal or state governmental healthcare plans or programs?

6. OTHER SANCTIONS OR INVESTIGATIONS

YES

NO

a.

Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing

entities, education or training program, Medicare or Medicaid program, or any other private, federal or state

health program or a defendant in any civil action that is reasonably related to your qualifications, competence,

functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual

offense or sexual misconduct?

YES

NO

b.

To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data

Bank or Healthcare Integrity and Protection Data Bank?

YES

NO

c.

Have you ever received sanctions from or are you currently the subject of investigation by any regulatory

agencies (e.g., CLIA, OSHA, etc.)?

YES

NO

d.

Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted,

disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual

harassment or other illegal misconduct?

YES

NO

e.

Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a

military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in

exchange for no investigation by a hospital or healthcare facility of any military agency?

print or type. Reformatted or altered applications will not be accepted.

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7.

PROFESSIONAL LIABILITY INSURANCE INFORMATION AND CLAIMS HISTORY

YES

NO

a.

Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier

based on your individual liability history?

YES

NO

b

Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional

liability insurance carrier, based on your individual liability history?

8.

MALPRACTICE

CLAIMS HISTORY

YES

NO

a.

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?

YES

NO

b.

In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor

(excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably

related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act

of violence, child abuse or a sexual offense or sexual misconduct?

YES

NO

c.

Have you ever been court-martialed for actions related to your duties as a medical professional?

10. ABILITY TO PERFORM JOB

YES

NO

a.

Are you currently engaged in the illegal use of drugs?

("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. 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.)

YES

NO

b.

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

c.

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

YES

NO

d.

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

reasonable accommodation?

print or type. Reformatted or altered applications will not be accepted.

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