Behavioral Health Individual Provider and or Group Practice Application

a. Please fill in the below form. All fields are required and confidential.
b. Note: The Information entered on this page can be saved to allow for completion at a later date. Incomplete requests will be automatically deleted from the system after 30 days of inactivity.

Purpose
Federal regulations set forth in 42 CFR Part 455 Subpart B require Provider Entities who are entering into or renewing a provider agreement to disclose to managed care organizations that contract with a Medicare/Medicaid agency:
a) information on ownership and control,
b) information related to business transactions, and
c) information on persons who have ownership or control interest and have been convicted of crimes related to the person’s involvement in Medicare, Medicaid, or the Title XX services program. Completion and submission of this Disclosure Form is a condition of participation under Rhode Island’s Medicaid Program and is also part of a provider’s contractual obligation with Neighborhood. Failure to submit requested information may result in a refusal by Neighborhood to enter into a provider agreement or contract, or in termination of existing provider agreements and contracts.

I. Disclosure Timeframes:
1. Disclosures of Ownership and Control are due to Neighborhood:
a) Upon the Provider Entity or Provider Person submitting the provider application;
b) Upon the Provider Entity or Provider Person executing the provider agreement;
c) Within 35 days of a request from Rhode Island’s Executive Office of Health and Human Services’ (EOHHS);
d) Upon Neighborhood’s request for information from the Provider Entity or Provider Person for re-credentialing/re-contracting; and
e) When there are significant changes to the information required on this form, for example: an ownership change, the addition of a new managing employee, or the change of your business location.
2. Disclosures of Business Transactions are due to Neighborhood within 35 days of EOHHS’ request or the request of the Secretary.
3. Disclosures of Criminal Convictions are due to Neighborhood:
f) Upon submission of the provider application;
g) Upon execution of renewal of the provider agreement;
h) Upon Neighborhood’s request for information from the Provider Entity or Provider Person for re-credentialing/re-contracting; and
i) At any time upon written request by EOHHS.

II. Definitions:
Group of Practitioners: two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).
Immediate Family Member: a person’s husband or wife; natural or adoptive parent; child or sibling; stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild.
Indirect Ownership Interest: an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Member of a household: with respect to a person, any individual with whom they are sharing a common abode as part of a single family unit, including domestic employees and others who live together as a family unit. A roomer or boarder is not considered a member of a household.
Other Disclosing Entity: 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 following programs:
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 provider 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: the possession of equity in the capital, the stock, or the profits of the disclosing entity.
Person with Ownership or Control Interest: 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.
Significant Business Transaction: any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 or 5 percent of a provider's total operating expenses.
Subcontractor:
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: 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).
Wholly Owned Supplier: a supplier whose total ownership interest is held by a provider or by a person(s) or other entity with an ownership or control interest in a provider.

In order to participate with Neighborhood, disclosure of your ownership information is required as mandated by the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (HHS), the State of Rhode Island Executive Office of Health and Human Services (EOHHS) and 42 CFR Part 455.104-106. If you are already a participating Provider Entity with Neighborhood, completion of this form is required as part of the re-credentialing process to continue your participation with Neighborhood.

Directions: Use this form if you are applying for network participation as a Provider Entity (a Medicare/Medicaid provider-other than an individual practitioner or group of practitioners, or a fiscal agent), if you are re-credentialing or re-contracting the Provider Entity, or if there have been significant changes to the information required on this form, for example: an ownership change, the addition of a new managing employee, or the change of your business location. A Provider Entity is a business entity, i.e. a partnership or corporation that provides covered services to Neighborhood members. Please answer all questions as of the current date. If a question is not applicable, please respond with “N/A” for that question. No question should be left blank.

Identifying Information

II. Ownership and Control Interest*:

Ownership and Control Interest/Criminal Conviction Information:
An Owner is a person or business entity which owns 5% or more of the assets, stock or profits of the Provider Entity (see 42 CFR §455.102 on how to determine ownership or control percentages). This ownership of 5% or more may be Direct or Indirect (see definitions). In addition to ownership of stock, an Owner is also a person who owns a legal obligation like a mortgage or loan that is secured by the assets of the Provider Entity.
A person with Control Interest is someone who directs the Provider Entity and includes Directors, Trustees and Officers of Corporations and Partners in a Partnership.
A Managing Employee is 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 for the Provider Entity.
An Agent is any person who has been delegated the authority to obligate or act on behalf the Provider Entity.

Directions: Please provide the following information for Individuals who are Owners, persons with Control Interests, Managing Employees and Agents of the Provider Entity.

C. Specific Questions

III. Business Transactions

IV. Board of Directors or Governing Board

V. Provider Entity Attestation, Signature, and Date

INDIVIDUAL STATEMENT: I certify that information on this form, and any attached documentation has been reviewed by me, and is true, accurate and complete, to the best of my knowledge. I will notify Neighborhood of any additions or changes to this information immediately. Additionally, I understand that false statements or representations of the required disclosures may be prosecuted under applicable federal or state laws (42 CFR § 455.106).

This application constitutes an agreement between Neighborhood Health Plan of Rhode Island (Neighborhood) and its affiliated professional or institutional provider, as identified below, to accept direct deposit of claim payment to provider’s bank. Direct deposit will be made through Bank of America’s Automated Clearinghouse into the account and bank routing address indicated below. Professional or institutional providers equipped to accept electronic remittance advices are requested to enter their document format preferences in the box provided below. Neighborhood supports remittances in two formats: (1) electronic transmission of standard-format remittance advice file (image of paper RA) via Neighborhood secure e-mail in PDF format OR (2) machine-readable ASCX12 835 (available for retrieval via ftp/sftp). If provider is applying for the standard-format PDF format via Neighborhood secure e-mail), provider warrants that access and retrieval of the .pdf RA using provider’s e-mail address (included below) at their place of business will be in a HIPAA- compliant, secure manner with handling by authorized personnel only. Submission of this completed application to Neighborhood at 910 Douglas Pike, Smithfield, RI 02917 enables participation in Neighborhood’s electronic claim payment and remittance advice transmission processes. Provider will be contacted prior to implementation date for transmission testing if necessary.
Please allow thirty (30) to forty (40) business days for processing.