Form FA-31B "Provider Revalidation Application (Groups/Facilities)" - Nevada

What Is Form FA-31B?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 12, 2013;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FA-31B by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form FA-31B "Provider Revalidation Application (Groups/Facilities)" - Nevada

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Nevada Medicaid and Nevada Check Up
Provider Revalidation Instructions
(Groups/Facilities)
This document provides instructions for completing the Provider Revalidation Application for
Group/Facility providers who have received a revalidation letter. Please answer all questions as of the
current date. Attach additional sheets if necessary to answer each question completely. Each additional sheet
must display the relevant question number from the application. These instructions are designed to clarify certain
questions on the application. Instructions are listed in question order for easy reference. No instructions have
been given for questions considered self-explanatory.
Section 1: General Information
Question 2 (Provider Type)
Nevada Medicaid has defined approximately 60 different medical service types, also referred to as “provider
types.” Enter the appropriate 2-digit provider type number from the left column of Table E-2 found in the
Provider Enrollment Information Booklet.
Some providers provide more than one type of service. You must submit one complete set of documents for
each provider type you are revalidating (i.e., Provider Revalidation Packet and documents listed on the
relevant enrollment checklist for that provider type). For example, if you supply Durable Medical Equipment
(provider type 33) as well as pharmaceutical drugs (provider type 28), complete two sets of revalidation
documents. The same National Provider Identifier (NPI) would be noted on each application. The difference
between the two applications would be the provider type number and the attachments required per the
enrollment checklists.
Question 3 (Specialties)
Some provider types require you to identify a 3-digit specialty code in Question 3 on the Application.
The 3-digit specialty code is shown next to each bulleted item in Table E-2 found in the Provider
Enrollment Information Booklet.
A specialty is required for provider types 14, 17, 19, 20, 34, 38, 48, 57, 58 and 82. For provider
types 14, 17 and 82 only, enter one specialty code per Application. A Provider Revalidation Packet
must be submitted for each specialty being enrolled.
To assist in Medicaid tracking, we recommend that provider types 22, 26, 54 and 76 identify a
specialty when applicable.
All other provider types may leave Question 3 blank.
Section 2: Tax and Business Information
Questions 8-10 (Legal Name, DBA, TIN/SSN) Must match the IRS records
The legal name and Tax Identification Number or Social Security Number listed must match the information
registered with the Internal Revenue Service (IRS), what is listed on your IRS Employer ID Number (EIN)
___________________________________________________________________________________________________
FA-31B-I: Provider Revalidation Instructions (Groups/Facilities)
Page 1 of 3
04/12/2013
Nevada Medicaid and Nevada Check Up
Provider Revalidation Instructions
(Groups/Facilities)
This document provides instructions for completing the Provider Revalidation Application for
Group/Facility providers who have received a revalidation letter. Please answer all questions as of the
current date. Attach additional sheets if necessary to answer each question completely. Each additional sheet
must display the relevant question number from the application. These instructions are designed to clarify certain
questions on the application. Instructions are listed in question order for easy reference. No instructions have
been given for questions considered self-explanatory.
Section 1: General Information
Question 2 (Provider Type)
Nevada Medicaid has defined approximately 60 different medical service types, also referred to as “provider
types.” Enter the appropriate 2-digit provider type number from the left column of Table E-2 found in the
Provider Enrollment Information Booklet.
Some providers provide more than one type of service. You must submit one complete set of documents for
each provider type you are revalidating (i.e., Provider Revalidation Packet and documents listed on the
relevant enrollment checklist for that provider type). For example, if you supply Durable Medical Equipment
(provider type 33) as well as pharmaceutical drugs (provider type 28), complete two sets of revalidation
documents. The same National Provider Identifier (NPI) would be noted on each application. The difference
between the two applications would be the provider type number and the attachments required per the
enrollment checklists.
Question 3 (Specialties)
Some provider types require you to identify a 3-digit specialty code in Question 3 on the Application.
The 3-digit specialty code is shown next to each bulleted item in Table E-2 found in the Provider
Enrollment Information Booklet.
A specialty is required for provider types 14, 17, 19, 20, 34, 38, 48, 57, 58 and 82. For provider
types 14, 17 and 82 only, enter one specialty code per Application. A Provider Revalidation Packet
must be submitted for each specialty being enrolled.
To assist in Medicaid tracking, we recommend that provider types 22, 26, 54 and 76 identify a
specialty when applicable.
All other provider types may leave Question 3 blank.
Section 2: Tax and Business Information
Questions 8-10 (Legal Name, DBA, TIN/SSN) Must match the IRS records
The legal name and Tax Identification Number or Social Security Number listed must match the information
registered with the Internal Revenue Service (IRS), what is listed on your IRS Employer ID Number (EIN)
___________________________________________________________________________________________________
FA-31B-I: Provider Revalidation Instructions (Groups/Facilities)
Page 1 of 3
04/12/2013
confirmation letter and the W-9 form. Include with your Revalidation Packet a copy of the Internal Revenue
Service (IRS) acceptance letter.
Questions 11 and 12 (Secretary of State)
Questions 11 and 12 are required for in-state providers only.
#11: Enter the entity name listed on your business license or registered with the Secretary of State office.
#12: Enter the Secretary of State issued NV Business ID number.
Question 21 (Electronic Funds Transfer)
It is required that all providers must accept Nevada Medicaid and Nevada Check Up payments via Electronic
Funds Transfer (EFT). Enter the business or personal bank account number along with the authorized signature.
An original voided check or letter from your bank that contains your bank’s routing number must accompany the
application. Photocopied checks and bank deposit slips are not accepted.
Section 3: Background, Ownership and Disclosure of Disclosing Entity
Completion of this section is a condition of participation in the Nevada Medicaid program and is mandated by
42CFR §455.100 – 106.
Click here
to view the full regulation.
List the names of all individuals and organizations having direct or indirect ownership interests, or controlling
interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing
entity.
Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of
the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that
furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program,
or health-related services under the social services program.
Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership
interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other
entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership
interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity.
Example: If A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing
entity, A’s interest equates to an 8 percent indirect ownership and must be reported.
Controlling interest is 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 (i.e., joint venture agreement, unincorporated business status) of the disclosing
entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the
disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or
other operating or management direction of the disclosing entity; the right to control any or all of the assets or
other property of the disclosing entity upon the sale or dissolution of that entity; 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 ownership
or control.
Other definitions:
Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.
Disclosing entity means a Medicaid provider or a fiscal agent.
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.
Managing employee means 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.
___________________________________________________________________________________________________
FA-31B-I: Provider Revalidation Instructions (Groups/Facilities)
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04/12/2013
Other disclosing entity means 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, XVIII 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 XVIII);
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.
Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.
Person with an ownership or control interest means a person 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.
Subcontractor means:
a) An individual, agency or organization to which a disclosing 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 (or leases of real property) to obtain space, supplies, equipment, or services
provided under the Medicaid agreement.
Supplier means an individual, agency or organization from which a provider purchases goods and services used in
carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds or a
pharmaceutical firm).
Section 4: Group and Facility Information
Question 38 (Group Information)
Nevada Medicaid can pay a group of providers under one NPI. To request this, each individual provider in the
group must be enrolled in the Nevada Medicaid program (i.e., submit their own, individual enrollment or
revalidation documents). The group then submits its own set of revalidation documents (in addition to the
documents submitted by the individual providers). The group enrollment/revalidation must attach a list of the
individual names and NPIs of all providers that will be paid under the group.
Provider groups may be formed for the following provider types:
Audiologist Group – provider type 76
Dentist Group – provider type 22
Chiropractic Group – provider type 36
Optometrist Group – provider type 25
Physicians Group – includes any combination of provider types 20, 24, 72, 74 and 77
Podiatrist Group – provider type 21
Psychologist Group – provider type 26
Therapist Group – provider type 34
___________________________________________________________________________________________________
FA-31B-I: Provider Revalidation Instructions (Groups/Facilities)
Page 3 of 3
04/12/2013
Nevada Medicaid and Nevada Check Up
Provider Revalidation Application (Groups/Facilities)
This Provider Revalidation Application is to be used only by active group/facility providers who have received
a revalidation letter. All questions must be completed by all providers unless otherwise marked. Attach additional
sheets if necessary to answer each question completely. Each additional sheet must display the relevant question
number from the Application. Changes to enrollment information presented herein (except changes in business
ownership) must be updated via form FA-33 within five business days of the change. Business ownership changes
must be reported within five business days by resubmitting a complete, new set of enrollment documents and a copy
of the purchase agreement.
Section 1: General Information
1. Provider name: _______________________________________________________________________________
2. Enter the 2-digit number for the provider type you are revalidating: ________
See the Provider Enrollment Information Booklet for the list of provider types and corresponding 2-digit numbers.
3. Name your board certified specialties that pertain to the provider type you are revalidating. This is required for
provider types 14, 17, 19, 20, 34, 38, 48, 57, 58 and 82. It is recommended for provider types 22, 26, 54 and 76
when applicable. All other provider types may leave this question blank. For provider types 14, 17 and 82 only,
enter one specialty code per Application. A Provider Revalidation Packet must be submitted for each
specialty being revalidated. See the Provider Enrollment Information Booklet for the list of Specialty Codes.
Primary Specialty: _________________ Specialty Code: ______ Board Name: ____________________________
4. Enter the following information for the licenses that pertain to the provider type you are revalidating.
License Number: _____________________________________________________________________________
Name of Issuing Licensing Board, State or Entity: ___________________________________________________
5. Are you in enrolled in Medicare?
Yes
No
6. Applicant’s National Provider Identifier (NPI) as issued by NPPES: _____________________________________
Section 2: Tax and Business Information
7. Check the box that most closely describes the entity you are revalidating:
Hospital-Based Physician
Limited Liability Company
Sole Proprietorship
Corporation
Partnership
Limited Liability Partner
Provider Group
Indian Health Program (IHP)
Indian Health Services (IHS)
Non-Profit
Nevada Medicaid uses information in questions 8-10 to generate the annual 1099 form for tax reporting purposes.
8. Legal Name as registered with the Internal Revenue Service (IRS): ______________________________________
9. Doing Business As: ____________________________________________________________________________
10. Tax Identifier (Federal Tax ID Number): _______________________________
11. Nevada Secretary of State Registered Name (in-state providers only): ___________________________________
12. Nevada Secretary of State Issued Business ID (in-state providers only): __________________________________
13. Days and Hours of operation:___________________________________________________________________
14. Do you currently or will you provide service to recipients in the Fee For Service program, the Managed Care
program or both?
Fee For Service Only
Managed Care Only
Both Fee For Service and Managed Care
FA-31B: Provider Revalidation Application (Groups/Facilities)
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02/18/2014 (pv04/12/2013)
15. Are you currently accepting new patients?
Yes
No
16. Can you accommodate recipients with special needs?
Yes
No
17. Service Address: Enter the physical location of the practice/business/facility where services will be rendered. This
must be a street address and NOT a post office box.
Address (Line 1):_____________________________________________________________________________
Address (City, State, Zip and COUNTY):__________________________________________________________
Office phone: ___________________ Extension: __________ E-mail address: ____________________________
Fax: ___________________________________ TDD phone: ________________________________________
Contact name: ____________________________________ Contact phone: _____________________________
18. Mail-To Address: Nevada Medicaid will mail written correspondence, excluding remittance advices, to this
address. If you do not supply a mail-to address, written correspondence will be mailed to the service address.
Address (Line 1):_____________________________________________________________________________
Address (City, State, Zip and COUNTY):_________________________________________________________
Office phone: _____________________ Extension: __________ E-mail address:__________________________
Fax: ____________________________________ TDD phone: ________________________________________
Contact Name: __________________________________________ Contact phone: ______________________
19. Pay-To address: Paper checks will be mailed here while Electronic Funds Transfer (EFT) testing is performed.
Address (Line 1): ____________________________________________________________________________
Address (City, State, Zip and COUNTY): _________________________________________________________
Office Phone: ___________________ Extension: ___________ E-mail address: __________________________
Fax: ___________________________________
TDD phone: _______________________________________
Contact name: ________________________________________ Contact phone: _________________________
20. Remittance Advice Address: Nevada Medicaid recommends using electronic instead of paper Remittance
Advices (RAs) for faster account reconciliation. However, if you wish to receive paper RAs and have them mailed
to an address different from the addresses listed above, please complete the fields below.
Address (Line1): _____________________________________________________________________________
Address (City, State, Zip and COUNTY): _________________________________________________________
Office phone: ___________________ Extension: ____________ E-mail address: _________________________
Fax: __________________________________ TDD phone: __________________________________________
Contact name: ________________________________________ Contact phone: __________________________
21. If the provider is already enrolled in EFT, skip this question. All providers must accept Nevada Medicaid and
Nevada Check Up payments via Electronic Funds Transfer (EFT). If a provider does not have an active EFT
account enrolled with Nevada Medicaid, that provider’s Nevada Medicaid enrollment may be terminated or
denied.
Electronic Funds Transfer (EFT) Authorization: I hereby authorize Nevada Medicaid (Nevada Medicaid
refers to the fiscal agent for Nevada Medicaid) and its subsidiaries to transfer my Nevada Medicaid and Nevada
Check Up payments to the personal or business bank account shown below. I also authorize any necessary debit
entries to correct payment errors. I understand the payments made through electronic funds transfers will be from
federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal
and state laws. This agreement will remain in effect until I notify Nevada Medicaid or the banking institution
otherwise. I understand that Nevada Medicaid and/or my banking institution may also cancel this agreement at any
time. All such cancellation notices must be made in writing and acted upon in a reasonable and timely manner.
Business or personal bank account number: ________________________________________________________
Authorized signature: _______________________________________________ Date: _____________________
FA-31B: Provider Revalidation Application (Groups/Facilities)
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