"Registration of Locum Tenens Physician" - Kentucky

Registration of Locum Tenens Physician is a legal document that was released by the Kentucky Department of Medicaid Services - a government authority operating within Kentucky.

Form Details:

  • Released on May 1, 2017;
  • The latest edition currently provided by the Kentucky Department of Medicaid Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Department of Medicaid Services.

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Rev (05/17)
REGISTRATION OF LOCUM TENENS PHYSICIAN
RETURN TO: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602
42 CFR § 411.351 allows a physician to temporarily stand in the shoes of another.
Medicaid pays crossover claims from Medicare, and thus the Medicaid time limit for the locum tenens is the same as Medicare.
The maximum time may not exceed sixty (60) continuous days.
This Physician is the TEMPORARY REPLACEMENT who applies and
This Physician will be ABSENT during the billing and will not
will actually perform the services temporarily:
perform the services:
1) ______________________________________________________
1)
________________________________________________
Applicant LOCUM TENENS PHYSICIAN - Full Name
Regular Physician - Full Name
(____)_______________________________
2)
(____)____________________________
2)
Area Code
Phone Number
Extension
Area Code
Phone Number
Extension
3) ______________________________________________________
3)
_________________________________________________
PERMANENT ADDRESS (You may NOT use a PO BOX)
OFFICE ADDRESS (You may NOT use a PO BOX)
_____________________________________________________
__________________________________________________
CITY, STATE, ZIP
CITY, STATE, ZIP
SSN:
4)
_________________________________________________
_______________________________
Email:
4)
Email:
5)
________________________________________________
National Provider Identifier (NPI) for Individual
5)
(Required)
; must be registered with KY DMS
6) Is a CONTRACT AGENCY involved in this placement?
YES – SUPPLY NAME & ADDRESS OF AGENCY.
_____________________________________________________
You may attach a sheet, if necessary.
NPI for Group (Optional);
6)
must be registered with KY DMS
__________________________________________________________
____________________________________________________
__________________________________________________________
Specific Duration –
7)
Not to exceed sixty (60) consecutive
NO
days. Terms like ‘ongoing’ and ‘current’ will not be accepted
_____________ to _____________
MM/DD/YY
MM/DD/YY
To my knowledge, I attest that I am not subject to any of the
Credentialing Agent:
8)
following:
Name:
___________________________________________
 A pending criminal or civil investigation regarding the
Email:
___________________________________________
provision of health care services;
 Formal disciplinary sanction from any such board or
professional association pursuant to KRS 311.565; and
__________________________________________
 A federal or state sanction or penalty that would otherwise
Original Signature/Date required
bar me from participation in Medicare or Medicaid.
CHECK OFF FOR REQUIRED ATTACHMENTS
 I certify and attest, by my signature below, under penalty
of perjury, that the information contained herein is true
COPY of valid PHYSICIAN LICENSE and copy of any
and faithful.
applicable board certification for the locum tenens
physician.
PROOF of malpractice insurance coverage for the locum
tenens physician for period of physician substitution.
_________________________________________
THE Q-6 MODIFIER MUST BE USED FOR BILLING SEVICES
Original Signature/Date required of Locum Tenens
PERFORMED BY A LOCUM TENENS PHYSICIAN.
The holder of the valid provider number is required to bill the services
of any locum tenens physician by utilizing the Health Care Procedure
Coding System (HCPCS) with the procedure modifier code “Q-6” in
item 24d of Form HCFA-1500, for every procedure performed by the
Call 1-800-807-1232 for provider billing assistance.
locum tenens physician. Failure to bill correctly may be considered a
violation of the terms of the Provider Agreement.
Rev (05/17)
REGISTRATION OF LOCUM TENENS PHYSICIAN
RETURN TO: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602
42 CFR § 411.351 allows a physician to temporarily stand in the shoes of another.
Medicaid pays crossover claims from Medicare, and thus the Medicaid time limit for the locum tenens is the same as Medicare.
The maximum time may not exceed sixty (60) continuous days.
This Physician is the TEMPORARY REPLACEMENT who applies and
This Physician will be ABSENT during the billing and will not
will actually perform the services temporarily:
perform the services:
1) ______________________________________________________
1)
________________________________________________
Applicant LOCUM TENENS PHYSICIAN - Full Name
Regular Physician - Full Name
(____)_______________________________
2)
(____)____________________________
2)
Area Code
Phone Number
Extension
Area Code
Phone Number
Extension
3) ______________________________________________________
3)
_________________________________________________
PERMANENT ADDRESS (You may NOT use a PO BOX)
OFFICE ADDRESS (You may NOT use a PO BOX)
_____________________________________________________
__________________________________________________
CITY, STATE, ZIP
CITY, STATE, ZIP
SSN:
4)
_________________________________________________
_______________________________
Email:
4)
Email:
5)
________________________________________________
National Provider Identifier (NPI) for Individual
5)
(Required)
; must be registered with KY DMS
6) Is a CONTRACT AGENCY involved in this placement?
YES – SUPPLY NAME & ADDRESS OF AGENCY.
_____________________________________________________
You may attach a sheet, if necessary.
NPI for Group (Optional);
6)
must be registered with KY DMS
__________________________________________________________
____________________________________________________
__________________________________________________________
Specific Duration –
7)
Not to exceed sixty (60) consecutive
NO
days. Terms like ‘ongoing’ and ‘current’ will not be accepted
_____________ to _____________
MM/DD/YY
MM/DD/YY
To my knowledge, I attest that I am not subject to any of the
Credentialing Agent:
8)
following:
Name:
___________________________________________
 A pending criminal or civil investigation regarding the
Email:
___________________________________________
provision of health care services;
 Formal disciplinary sanction from any such board or
professional association pursuant to KRS 311.565; and
__________________________________________
 A federal or state sanction or penalty that would otherwise
Original Signature/Date required
bar me from participation in Medicare or Medicaid.
CHECK OFF FOR REQUIRED ATTACHMENTS
 I certify and attest, by my signature below, under penalty
of perjury, that the information contained herein is true
COPY of valid PHYSICIAN LICENSE and copy of any
and faithful.
applicable board certification for the locum tenens
physician.
PROOF of malpractice insurance coverage for the locum
tenens physician for period of physician substitution.
_________________________________________
THE Q-6 MODIFIER MUST BE USED FOR BILLING SEVICES
Original Signature/Date required of Locum Tenens
PERFORMED BY A LOCUM TENENS PHYSICIAN.
The holder of the valid provider number is required to bill the services
of any locum tenens physician by utilizing the Health Care Procedure
Coding System (HCPCS) with the procedure modifier code “Q-6” in
item 24d of Form HCFA-1500, for every procedure performed by the
Call 1-800-807-1232 for provider billing assistance.
locum tenens physician. Failure to bill correctly may be considered a
violation of the terms of the Provider Agreement.
Rev (05/17)
COMPLETING THE REGISTRATION OF LOCUM TENENS PHYSICIANS
In emergencies, the completed and signed form can be faxed to: (502)564-3232
:
Kentucky Medicaid PO Box 2110 Frankfort, KY 40602-2110
Otherwise mail two weeks in advance to
Note: for this process the “regular, but absent” physician hires the “locum tenens” physician. The temporary physician who
is going to stand-in and actually perform the services for a short duration for the absent physician is the locum tenens physician.
The locum tenens physician or his/her agent may fill out the form. An ORIGINAL SIGNATURE of the locum tenens physician
is required, a signature stamp may not be used, nor can others sign for this physician. Failure to complete and have a valid
original signature on the form in its entirety may result in Medicaid claims not processing timely and completely.
All required documents that are to be attached are for the locum tenens physician. A locum tenens physician shall be otherwise
be required to be in good standing with all applicable regulatory boards and maintain malpractice insurance to ensure the
protection of the Medicaid recipients they treat pursuant to 42 USC §1396a(a)(19).
The locum tenens physician on the left-side box shall enter:
The locum tenens physician’s full name;
The phone number of the locum tenens doctor where they can be reached during normal office hours if
clarification or additional information is needed; (please include area code and extensions)
As post office boxes are transitory, they may not be used. Please indicate a permanent address for the
locum tenens physician;
The SSN for the locum tenens physician;
Indicate if the placement is based upon an outside contract agency; if YES, provide the full name and
mailing address of the contract agency. A sheet may be attached to complete this process.
Credentialing Agent contact information, if applicable.
- AND -
A copy of a valid current physician license for the locum tenens is attached; and
Proof of the malpractice insurance coverage maintained for the locum tenens physician for the anticipated
period of the services are to be performed is also attached; and
Signature of the Locum Tenens
The physician who is going to be absent for a short period and will not actually perform the service is the regular, but absent,
physician. A locum tenens billing arrangement is intended to promote the continuation of the billing process for regular, but
absent, physicians and their cooperation in helping the locum tenens to complete of this form may be necessary.
Information regarding the regular, but absent, physician appears on the right-side box, and is completed by the
applicant by supplying:
The regular, but absent, physician’s full name and their individual Medicaid Provider Number. Show the
group number also, if any billings for the substitute will utilize a group number;
The signature of the absent Physician;
The phone number of the physician/billing office that can answer most routine questions;
As post office boxes are transitory, they may not be used. Please indicate a permanent address for the regular
physician, a physical address where the services will be performed is also allowable; and
The specific dates the services. They may not to exceed sixty (60) consecutive days. Terms like ongoing or
current will not be accepted. If the services are anticipated to exceed sixty (60) days, then a regular provider
number application must be made concurrent with the locum tenens. A regular provider application may be
secured by calling Medicaid’s fiscal agent toll-free at 877-838-5085. Billing under locum tenens for periods
in excess of sixty (60) consecutive days are specifically not authorized by the Kentucky Medicaid Program.
Questions on proper billing for locum tenens – 1-800-807-1232 Provider Assistance.
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