Instructions for Form HFS2243 "Illinois Medical Assistance Program Provider Enrollment Application" - Illinois

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DO NOT RETURN THIS PAGE
DO NOT RETURN THIS PAGE
INSTRUCTIONS
ILLINOIS MEDICAL ASSISTANCE PROGRAM
PROVIDER ENROLLMENT APPLICATION
Enrollment in the Illinois Medical Assistance Program requires the completion of an application with an original signature of an
individual or if a business entity, an authorized person. All providers are required to complete, sign and date a Provider Agreement.
Enclose additional pages when more information is available than space allows.
Providers are required by the U.S. Postal Service to use a 9-digit zip code for all address. Mail without the 9 digits may be
returned by the U.S. Postal Service
NOTE: When a Change of Name occurs, a new enrollment application, agreement and attachments must be completed and submitted
to the Department.
NOTE: Transportation requires copy of Vehicle Identification Card for all vehicles approved to transport medical clients.
SECTION A: PROVIDER
1.
Check appropriate box for type of enrollment.
2.
PROVIDER TYPE: Enter allocable three (3) digit code from Attachment A.
3.
PROVIDER NAME: Individual Practitioners must enter name in last name, first name format. All other applicants must
enter the complete business name.
4.
PRIMARY OFFICE ADDRESS STREET: Provider must give a physical location, not a PO Box.
6.
COUNTY: For Transportation providers this must reflect the county where vehicle (s) are located.
11. EMAIL ADDRESS: Enter up to three (3) e-mail addresses.
12. NATIONAL PROVIDER IDENTIFICATION # - NPI: Enter ten (10) digit NPI number assigned by Federal Government
to eligible health care providers and provide a copy of NPI approval letter.
15. LICENSE/CERTIFICATION/ENROLLMENT REQUIREMENTS: See Attachment B for specific provider
requirements.
16. DRUG ENFORCEMENT ACT NUMBER: Enter the DEA number issued to the above identified address and any
additional DEA numbers issued.
17. MEDICARE PART A NUMBER: Enclose documentation of Medicare Certification.
18. ORGANIZATION TYPE: Enter the one (1) digit number to indicate the type of ownership: (1) SOLE PROPRIETARY (2)
PARTNERSHIP (3) CORPORATION.
19. CONTROL OF FACILITY: Enter the one (1) digit number to indicate the type of facility control: (1)
STATE/COUNTY/CITY (2) PARTNERSHIP (3) CORPORATION.
20. FISCAL YEAR: Enter the end date of your Business Fiscal Year (MM/DD/YYYY.
21. CLINICAL LABORATORY IMPROVEMENT ACT NUMBER: Enter appropriate CLIA number documenting the
approval to provide laboratory services.
SECTION B: SERVICE/SPECIALTY
22. CATEGORY OF SERVICE: Enter all applicable three (3) digit codes (s) from Attachment C.
23. PROVIDER SPECIALTY: See Attachment D-1.
24. PHYSICIAN UPIN NO: Unique Physicians Identification Number.
25. OMNIBUS BUDGET RECONCILIATION ACT (OBRA) QUALIFICATION: (Physician only) OBRA’90 mandates
that physicians being reimbursed for services to children under the age of 21 meet certain qualifications. Enter each three
digit alpha code from Attachment D-2 which applies.
27. PHARMACY LOCATION: Enter the one (1) digit number which best describes the location of the pharmacy. (1) Hospital
based (2) Long Term Care based (3) Other.
32. PHARMACY NCPDP #: Enter seven (7) digit National Council for Prescription Drug Program Number.
33. TRANSPORTATION (only): Usual and Customary rates: TAXI: Enter usual and customary base, meter, or flag and
mileage rate. Enclose a copy of documentation approving your municipality rate, if applicable.
36. LONG TERM CARE MEDICARE BED CAPACITY: Enter Number of Medicare eligible beds in facility.
37. LONG TERM CARE FISCAL MEDICARE FISCAL INTERMEDIARY: Enter Name of Medicare carrier.
38. LONG TERM CARE BUILDING ID CODE: Enter seven (7) digit code assigned by Department of Public Health.
HFS 2243 (R-10-07)
IL478-1934
DO NOT RETURN THIS PAGE
DO NOT RETURN THIS PAGE
INSTRUCTIONS
ILLINOIS MEDICAL ASSISTANCE PROGRAM
PROVIDER ENROLLMENT APPLICATION
Enrollment in the Illinois Medical Assistance Program requires the completion of an application with an original signature of an
individual or if a business entity, an authorized person. All providers are required to complete, sign and date a Provider Agreement.
Enclose additional pages when more information is available than space allows.
Providers are required by the U.S. Postal Service to use a 9-digit zip code for all address. Mail without the 9 digits may be
returned by the U.S. Postal Service
NOTE: When a Change of Name occurs, a new enrollment application, agreement and attachments must be completed and submitted
to the Department.
NOTE: Transportation requires copy of Vehicle Identification Card for all vehicles approved to transport medical clients.
SECTION A: PROVIDER
1.
Check appropriate box for type of enrollment.
2.
PROVIDER TYPE: Enter allocable three (3) digit code from Attachment A.
3.
PROVIDER NAME: Individual Practitioners must enter name in last name, first name format. All other applicants must
enter the complete business name.
4.
PRIMARY OFFICE ADDRESS STREET: Provider must give a physical location, not a PO Box.
6.
COUNTY: For Transportation providers this must reflect the county where vehicle (s) are located.
11. EMAIL ADDRESS: Enter up to three (3) e-mail addresses.
12. NATIONAL PROVIDER IDENTIFICATION # - NPI: Enter ten (10) digit NPI number assigned by Federal Government
to eligible health care providers and provide a copy of NPI approval letter.
15. LICENSE/CERTIFICATION/ENROLLMENT REQUIREMENTS: See Attachment B for specific provider
requirements.
16. DRUG ENFORCEMENT ACT NUMBER: Enter the DEA number issued to the above identified address and any
additional DEA numbers issued.
17. MEDICARE PART A NUMBER: Enclose documentation of Medicare Certification.
18. ORGANIZATION TYPE: Enter the one (1) digit number to indicate the type of ownership: (1) SOLE PROPRIETARY (2)
PARTNERSHIP (3) CORPORATION.
19. CONTROL OF FACILITY: Enter the one (1) digit number to indicate the type of facility control: (1)
STATE/COUNTY/CITY (2) PARTNERSHIP (3) CORPORATION.
20. FISCAL YEAR: Enter the end date of your Business Fiscal Year (MM/DD/YYYY.
21. CLINICAL LABORATORY IMPROVEMENT ACT NUMBER: Enter appropriate CLIA number documenting the
approval to provide laboratory services.
SECTION B: SERVICE/SPECIALTY
22. CATEGORY OF SERVICE: Enter all applicable three (3) digit codes (s) from Attachment C.
23. PROVIDER SPECIALTY: See Attachment D-1.
24. PHYSICIAN UPIN NO: Unique Physicians Identification Number.
25. OMNIBUS BUDGET RECONCILIATION ACT (OBRA) QUALIFICATION: (Physician only) OBRA’90 mandates
that physicians being reimbursed for services to children under the age of 21 meet certain qualifications. Enter each three
digit alpha code from Attachment D-2 which applies.
27. PHARMACY LOCATION: Enter the one (1) digit number which best describes the location of the pharmacy. (1) Hospital
based (2) Long Term Care based (3) Other.
32. PHARMACY NCPDP #: Enter seven (7) digit National Council for Prescription Drug Program Number.
33. TRANSPORTATION (only): Usual and Customary rates: TAXI: Enter usual and customary base, meter, or flag and
mileage rate. Enclose a copy of documentation approving your municipality rate, if applicable.
36. LONG TERM CARE MEDICARE BED CAPACITY: Enter Number of Medicare eligible beds in facility.
37. LONG TERM CARE FISCAL MEDICARE FISCAL INTERMEDIARY: Enter Name of Medicare carrier.
38. LONG TERM CARE BUILDING ID CODE: Enter seven (7) digit code assigned by Department of Public Health.
HFS 2243 (R-10-07)
IL478-1934
SECTION C: FORMER PARTICIPATION
If you are not currently participating in the Illinois Medical Assistance Program, but have participated in the past, please complete this
section. If not applicable, leave blank.
SECTION D: ADDITIONAL NPI – NATIONAL PROVIDER IDENTIFICATION #
If you have been issued more than one (1) National Provider Identification – NPI, please complete this section
and provide a copy of all NPI approval letters. If not applicable, leave blank.
41. NATIONAL PROVIDER IDENTIFICATION: Enter additional ten (10) digit NPI numbers assigned by the Federal
Government to eligible health care providers.
SECTION E: PAYEE INFORMATION
One or more payee section (s) must be completed.
Individual Practitioners are to complete a payee section for each address to which payments are to be sent. If payments are to be sent
to more than two addresses, enclose a sheet of paper with payee information for each.
The enclosed Alternate Payee Form and Power of Attorney must be completed if the payee name is different than
the provider name.
42. PAYEE NAME: Individual Practitioners must enter name in last name, first name format. All other applicants must enter
the complete business name.
44. DOING BUSINESS AS (D/B/A): If a Sole Proprietorship using a d/b/a name, enter the d/b/a name.
49. TAXPAYER IDENTIFICATION NUMBER (TIN) TYPE CODE: Enter the one (1) digit type code below which
identifies the tax structure of the SSN/FEIN entered:
TYPE CODE
1
Federal Employer Identification Number (Corporation/Partnership)
2
Social Security Number (Individual)
3
Governmental Unit
51. BILLING PROVIDER/PAY TO NPI: Enter ten (10) digit NPI number assigned by the Federal Government to eligible
Billing Providers or Payees.
52. MEDICARE PART B NUMBER: Enter the six (6) digit number assigned by your Medicare Part B Carrier.
53. PHYSICIAN ID NUMBER (PIN): Enter the six (6) digit number assigned by your Medicare Part B Carrier.
54. DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC): Enter the ten (10) digit number assigned by
DME Regional Carrier.
SECTION F: ENROLLMENT DATA/CERTIFICATION/SIGNATURE/HANDBOOK
THIS SECTION MUST BE COMPLETED IN ITS ENTIRETY.
Questions regarding completion of the Provider Enrollment Application should be directed to the Provider Participation Unit, (217)
782-0538. Please mail the completed application, signed agreement, and all other required documentation to:
Illinois Department of Healthcare and Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, Illinois 62794-9114
Provider Participation Unit email address
aidppu@illinois.gov
Additional information regarding Illinois Healthcare and Family Services can be obtained at:
http://www.hfs.illinois.gov/
Illinois HFS Laws and Rule Regulations available for viewing at:
http://www.hfs.illinois.gov/lawsrules/
Illinois HFS enrollment Forms are available at:
http://www.hfs.illinois.gov/enrollment/
DO NOT RETURN THIS PAGE
HFS 2243 (R-10-07)
IL478-1934
DO NOT RETURN THIS PAGE
ATTACHMENT A
PROVIDER TYPE
Provider Type Code
Eligible Provider Type
010
Physician
011
Dentist
012
Optometrist
013
Podiatrist
014
Chiropractor
016
Advanced Practical Nurses
022
Physical Therapists
023
Occupational Therapists
024
Speech Therapists
025
Audiologists
030
General Hospital
031
Psychiatric Hospital
032
Rehabilitation Hospital
036
Mental Health Services Providers
039
Hospice
040
Federally Qualified Health Center (FQHC)
043
Encountered Rate Clinic (ERC)
044
Healthy Kids Clinic
046
Ambulatory Surgical Treatment Center (ASTC)
047
Local Education Agency (LEA)
048
Rural Health Clinic
050
Home Health Agency
052
County Health Department
054
Certified Hospital Organized Satellite Clinics (CHOSC)
055
Early Intervention
056
School Based Clinic
060
Pharmacy
061
Independent Laboratory
062
Opticians/Optical Company
063
Durable Medical Equipment/Supply
064
Imaging Centers
070
Transportation (Ambulance)
071
Transportation (Medicar)
072
Taxicab/Livery Companies
073
Other Transportation (non registered)
074
Hospital based Transportation
075
Alcohol and Substance Abuse
080
Prepaid Health (HMO)
083
Prepaid Health Plans
086*
Clinical Social Worker
087*
Psychologist
088*
Other Behavioral Health Providers
*These provider types are enrolled with the Department for the purpose of collecting Medicaid Managed Care encounter
data. The Department does not currently reimburse these provider types for services rendered to Medicaid participants.
HFS 2243 (R-10-07)
IL478-1934
DO NOT RETURN THIS PAGE
ATTACHEMENT B
LICENSE/CERTIFICATION/ENROLLMENT REQUIREMENTS
MEDICAL LICENSE/PUBLIC HEALTH ASSOCIATION CERTIFICATION NUMBER: Individual practitioners
licensed by the Illinois Department of Financial and Professional Regulation are to enter their own professional license
number. All other provider types are to enter their Public Health or applicable association certification number.
NOTE: All OUT-OF-STATE applicants must enclose a copy of a currently valid licensure/certification form including
expiration date.
APPLICANTS LISTED BELOW MUST ENCLOSE THE DOCUMENTATION DESCRIBED WHEN THE
APPLICATION IS SUBMITTTED.
AMBULANCE: 1) Copy of certification issued by appropriate regulatory agency (I.e., for Illinois the regulatory agency
is the Department of Public Health), and 2) enclose a copy of Medicare letter with approved Method of Payment. (OUT-
OF-STATE Ambulance enclose ALS certification if applicable).
AMBULATORY SURGICAL TREATMENT CENTER: 1)Copy of license issued by appropriate regulatory agency
(I.e., for Illinois the regulatory agency is the Department of Public Health), and 2) copy of Medicare Certification. An
ASTC must submit a copy of CLIA Certification issued by HHS to enroll for laboratory services.
CERTIFIED REGISTERED NURSE ANESTHETISTS: 1) Copy of RN license, and 2) CRNA Certification.
HOME HEALTH AGENCY: 1) Copy of license, 2) copy of letter of Health and Human Services (HHS) certification
with approved rate of reimbursement.
HOSPICE: 1) Copy of license and Medicare Letter of Certification with Medicare approved rate of reimbursement.
HOSPITAL: 1) Copy of license issued by State Licensing Board, 2) Copy of Medicare Letter of Certification.
IMAGING CENTERS: 1) Copy of Medicare certification as a Portable X-Ray provider.
LABORATORY: 1) Copy of Clinical Laboratory Improvement Act (CLIA) certification.
MIDWIFE: 1) Copy of RN license, 2) copy of letter of Certification by the College Nurse Midwife Association, and 3)
copy of Delivery Privilege Form with delivering physician identified.
ADVANCED PRACTICAL NURSES: 1) Copy of RN license, 2) copy of Certification from American Nurse
Association or National Certification Board of Pediatrics, and 3) copy of Medical Practice Agreement between Physician
and Nurse Practitioner, and 4) Copy of Clia Certification if applicable, and 5) Copy of DEA certificate if applicable.
PHARMACY: 1) Copy of Pharmacy license, 2) Copy of Pharmacist-In-Charge license, 3) Copy of DEA certificate.
PHYSICIANS: 1) Copy of Physician license, 2) Copy of DEA certificate if applicable.
RURAL HEALTH: Copy of HHS letter of certification with rate or reimbursement.
TRANSPORTATION: Copy of Vehicle Identification Card for all vehicles approved to transport medical clients.
HFS 2243 (R-10-07)
IL478-1934
DO NOT RETURN THIS PAGE
ATTACHMENT C
PROVIDER TYPE/CATEGORY OF SERVICE TABLE
PROVIDER TYPE
ALLOWABLE CATEGORY OF SERVICE
Code
Description
Code
Description
010
Physicians
001
Physician Services
006
Physicians Psychiatric Services
017
Anesthesia Services
030
Healthy Kids Services
045
Optical Supplies
011
Dentists
001
Physician Services
002
Dental Services
012
Optometrists
001
Physician Services
003
Optometric Services
045
Optical Services
013
Podiatrists
004
Podiatry Services
014
Chiropractors
005
Chiropractic Services
016
Advanced Practical Nurses
017
Anesthesia Services
018
Midwife Services
030
Healthy Kids Services
057
Nurse Practitioner Services
022
Physical Therapists
011
Physical Therapy Services
023
Occupational therapists
012
Occupational Therapy Services
024
Speech Therapists
013
Speech Therapy/Pathology Services
025
Audiologists
014
Audiology Services
041
Medical Equipment/Prosthetic Devices
048
Medical Supplies
HFS 2243 (R-10-07)
IL478-1934
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