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Credentialing and Contracting Instructions What’s required? All Dentists who want to enroll with DentaQuest must be credentialed AND contracted before you can begin treating members. To get credentialed you need to submit a completed credentialing application. If the office you will be participating with is not contracted, one contract for the business (i.e. Tax ID), listing all
participating providers and a W-9 is required. If the office you will be participating with is already contracted with DentaQuest please simply supply a letter on
company letterhead requesting the provider to be added to the existing contract. Be sure to include the business name, Tax ID, and applicable office location(s).
Please note some states require additional forms that can be found on our website. All enrollment documents can be found at: www.dentaquest.com Dentists[State]Dentist Page. Send enrollment documents to: Email: [email protected] | Fax: 262.241.7401 How do I get Credentialed and Contracted? There are a couple of ways to submit a credentialing application to DentaQuest. Please select one of the following options to begin the enrollment process. Option 1: Complete DentaQuest’s Initial Provider Credentialing Application along with the applicable Provider Service Agreement, W-9, Disclosure of Ownership, and state required forms. Option 2: Submit your existing CAQH application. You can do this by sending us the applicable Provider Service Agreement, W-9, Disclosure of Ownership, and state required forms along with your full name and CAQH (Council for Affordable Quality Healthcare) ID using the chart
Option 3: Begin an online application with CAQH. To do this complete and send back the information in the below chart along with the applicable Provider Service Agreement, W-9, and Disclosure of Ownership, and state required forms. DentaQuest will then roster you with CAQH. A CAQH Quick Reference Guide is available at https://upd.caqh.org/oas/UPDQuickReferenceGuide20120820.pdf.
Important Tips and Reminders Submit your application as soon as possible. but do not submit without a Medicaid ID (if applying for a Medicaid
program). Credentialing Contact Information – Name, phone number, email address. Required Documents- Check that all the information you provide is current (e.x. mal-practice insurance). Throughout
the process, we will be contacting you. Please respond quickly. Submit application with all applicable sections completed. If something does not pertain, indicate N/A. Do not leave
any fields blank. Questionnaire – please answer each question either yes or no. N/A is not an acceptable answer on the CAQH
application. For any question you answer Yes, a detailed explanation including a summary of the situation and the resolution is required.
Disclosure of Ownership is required, but is not included in the CAQH application. If you are submitting a CAQH application be sure to send us our Disclosure of Ownership.
Certification, Statements and Signature Page – read the statement carefully. Sign and date this page. Signature may not be older than 120 days old.
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CAQH Enrollment Instructions What is CAQH? The CAQH (Council for Affordable Quality Healthcare) offers a single credentialing application and an online data base that contains information necessary for insurance companies to credential a provider. This allows providers to submit and maintain their credentialing information at one location rather than filing with many organizations. There is no cost to file an application with CAQH and it can be completed online. If you already have an active application with CAQH simply fill-out the below chart. DentaQuest will roster you. If you have not selected the option for all insurance companies to have access to your application you will need to give DentaQuest access to your application after we have rostered you. Remember to send the appropriate contract, W-9, and other required documents for your state.
Required Fields Provider 1 Provider 2
Full Provider Name
Individual NPI CAQH ID (if app already on file with CAQH)
If you do not have an application on file with CAQH, but would like to complete an online CAQH application please fill-out the following chart. Once DentaQuest has the information we will roster you on the CAQH website. This will trigger CAQH to send you an invitation to join CAQH with instructions on how to log-in and begin your application. Once you have this you can login to https://upd.caqh.org/oas/ using your CAQH ID
Required Fields Provider 1 Provider 2
Full Provider Name
Degree Type (DDS, DMD)
License Number & Specialty
Individual (Type I) NPI
Date of Birth
Mailing Address
Phone
Fax Email (Dentist’s Personal & Credentialing Contact)
All enrollment documents can be found at: www.dentaquest.com Dentists[State]Dentist Page. Send enrollment documents to: Email: [email protected] | Fax: 262.241.7401 A CAQH Quick Reference Guide is available at https://upd.caqh.org/oas/UPDQuickReferenceGuide20120820.pdf.
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Application and Contract Checklist Dear Provider: It is our intention to provide a streamlined credentialing process. To guide you through the process, prior to sending us your application, please use the checklist below to ensure you have sent us all the required items. Incomplete applications cannot be processed.
Email address must be supplied to utilize DentaQuest’s online credentialing and recredentialing – coming soon! Date of birth – required to begin the credentialing process You must supply your state issued Medicaid ID, where applicable. Specialty (i.e. General Dentist, Pediatric Dentist, Oral Surgeon, etc.) State License section must be completed or a copy of the license provided. Providing a copy of the license will speed-
up the credentialing process: CDS (Controlled Drug Substances) and/or BNDD (Bureau of Narcotics and Dangerous Drugs) – enclose a copy. The
state listed on the CDS and/or BNDD, must match the state where you are requested to be credentialed. Complete DEA (Drug Enforcement Administration) section. A DEA is required for each state where you practice. A
disclosure is required if you do not hold a DEA. Individual NPI (National Provider Identifier) number Group NPI if W-9 Type is Corporation, LLC, or Partnership (exception: sole proprietor’s with an LLC) Location Name, address, city, state, zip, phone, fax, email address. Office Type – Federally Qualified Health Center, Local Health Department, Group Practice, etc. Credentialing correspondence contact, email address, phone and address, city, state, zip. American Board Certification – if you hold board certifications, you must list them. Privilege Information – you must identify hospital(s) at which you have admitting privileges. Employment History section of application or curriculum vitae—5 year (10 year if providing CAQH application)
history required in month and year format. An explanation of gaps within the last 5 years that are greater than 6 months is required. Start date at primary location is required.
Education /Training Section – list all institutions and training with the month and year of attendance. Providers treating Florida members must supply two peer reference letters Liability Insurance Binder - must not expire within 60 days and must comply with plan limits Attestation Questions (yes/no section) completed. N/A is not an allowable on the CAQH (Council for Affordable
Quality Healthcare) application. If “Yes” to any attestation questions (1-14) please enclose a separate disclosure explanation page Signed Application - must be hand written, no stamps. Date must be less than 120 days old. Disclosure of Ownership must be completed. State required form(s) in your application packet
Contract and W9 Completeness Checklist
Contract signed and dated All Applicants must be listed on contract W9 signed and dated Contract Street Address, City, state, and Zip Entity Name on the contract must match line 1 of the W-9 and TIN on contract must match W-9.
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12121 North Corporate Parkway, Mequon, WI 53092
(262) 241-7140 or (800) 417-7140 Fax (262) 241-7401
**INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** 1. Please print or type ALL responses. 2. If you need additional space to complete a section, please attach additional sheets. 3. If a question does not apply, please indicate “N/A”. 4. If you answer “yes” to any questions in the Questionnaire Section, you MUST attach a detailed
explanation. 5. Incomplete applications will not be accepted. Every field must be completed. If an item is not
applicable, please indicate “N/A.” 6. Please complete all sections with additional focus on those sections or questions with an *.
PLEASE REMEMBER: PROVIDER CANNOT BEGIN TO TREAT MEMBERS UNTIL A WELCOME LETTER
FROM DENTAQUEST IS RECEIVED
DentaQuest Credentialing Process Credentialing is the process of verifying credentials (i.e. training, licensing, hospital affiliations) of potential providers by primary sources. DentaQuest takes pride in its network of providers and is proud to say that all providers are credentialed following the guidelines of the National Committee for Quality Assurance (NCQA) to ensure our members that they are receiving the best quality care possible. Using NCQA guidelines for credentialing ensures an organization that the providers affiliated with their panel are the best in the dental field.
PLEASE Check One: New Provider, New Location New Provider, Existing Location Adding Additional Location Other
Please add _______________________ to current contract under ______________________________ (Provider Name) (Entity Name) With Tax ID# ______________________________.
PROVIDER APPLICATION GENERAL INFORMATION
Last Name
First Name
Middle Initial
Degree
* Provider Social Security Number
*Date of Birth (MM/DD/YY)
*Provider Personal E-mail Address
� Male � Female Provider Gender
� American Indian/Alaska Native � Asian � Black/African American � Hispanic � Native Hawaiian or Other Pacific Islander � White Provider Race/Ethnicity � Other
Medicaid ID
Specialty
Please list Dental, Medical and Anesthesia licenses for all states you currently hold or previously held a license. License Type
License Number
License State
Effective Date
Expiration Date
License Type
License Number
License State
Effective Date
Expiration Date
License Type
License Number
License State
Effective Date
Expiration Date
DEA Number ____________________________ Expiration Date ___________________________ Note: A DEA license is required for each state you practice in. Please Check the Schedules that apply on your DEA certificate: � 2 � 2N � 3 � 3N � 4 �5 � All Schedules If you do not hold a DEA license, please provide an explanation as to why and the name of the provider who will prescribe on your behalf, should a patient require medications. ________________________________________________________________________________________________________________________
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INDIVIDUAL NPI NUMBER NPI Number
NPI Type - Individual
NPI Effective Date
Taxonomy Code
OTHER NPI INFORMATION �Please check box if Sole Proprietor is indicated on your W9. ALL providers MUST complete
NPI information.
GROUP /ORGANIZATION NPI INFORMATION (REQUIRED unless Sole Proprietor is indicated on your W9)
NPI Number
NPI Type - Group
NPI Effective Date
Taxonomy Code
SUB-PART NPI INFORMATION (Not required) NPI Number
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
NPI Number
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
NPI Number
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
PRIMARY SERVICE OFFICE INFORMATION Primary Office Name
Office Contact
Office Phone Number
Office Fax Number
Primary Office Address
Office Email Address
City
State
� Clinic � FQHC � Article 28 (NY) Office Type
Zip Code
County
Secondary Office Name
Office Contact
Office Phone Number
Office Fax Number
Secondary Office Address
Office Email Address
City
State
� Clinic � FQHC � Article 28 (NY) Office Type
Zip Code
County
CREDENTIALING CORRESPONDENCE INFORMATION (address where credentialing information will be sent)
Credentialing Correspondence Office Name
Credentialing Contact Name
Credentialing Telephone Number
Credentialing Fax Number
Correspondence Address
*Credentialing Correspondence E-mail Address
City
State
Zip Code
BILLING INFORMATION
Federal Tax Identification Name (Name as it appears on Line 1 of W9)
Federal Tax Identification Number
Billing Office Address
City
State
Zip Code
Billing Office Contact Name / Title
Telephone Number
Fax Number
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Billing information for secondary location if different from Primary Location
Federal Tax Identification Name (Name as it appears on Line 1 of W9)
Federal Tax Identification Number
CRS-1 Identification Number (NM only) Billing Office Address
City
State
Zip Code
Billing Office Contact Name / Title
Telephone Number
Fax Number
AMERICAN SPECIALTY BOARD CERTIFICATION
Specialty Board(s) by which you are certified Name
Date Certified
Expiration Date
Recertification Date
PATIENT INFORMATION
Patient Type (check one) � Adults Only � Children Only � Adults & Children *Minimum Age ______________________________________ Maximum Age ___________________________
HOSPITAL PRIVILEGES
List all Hospitals at which you have admitting privileges: Hospital Name Address City State Hospital Name Address City State Hospital Name Address City State
OFFICE INFORMATION (Not Provider Specific)
Office Hours Primary Location
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Office Hours Secondary Location
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
*In the event of an emergency, do you have coverage after normal business hours or provide emergency contact information on your office phone or have any other protocol? � Yes � No If yes, Please list your contact information: ___________________________________________________________ __________________________________________________________________________________________________________________________ *Languages spoken at office (check all that apply) � English � Spanish � Arabic � Chinese � French � German � Hmong � Hindi � Laotian � Philippine � Vietnamese �Other __________ *Does your office provide access to a skilled medical interpreter? � Yes � No *Are translation services available? � Yes � No *Is your office handicapped/wheelchair accessible? � Yes � No *Is your entry way handicapped/wheelchair accessible? � Yes � No *Is your waiting room handicapped/wheelchair accessible? � Yes � No *Are your bathrooms handicapped/wheelchair accessible? � Yes � No *Are your treatment room’s handicapped/wheelchair accessible? � Yes � No **Do you provide sedation services for members with complex medical or behavioral conditions? � Yes � No *Does your office accept patient with Special Needs? � Yes � No If yes check all that apply: �Adult � Child �ADHD �Physically Disabled �Learning Disabled �HIV �AIDS �Paraplegic �Quadriplegic �Seizure Disorders �Cognitive Disability �Mobility Limitations �Autism �Communication Disorders �Behavioral Disorders �Hearing Impaired �Visually Impaired *Is the office accessible by public transportation? � Yes � No Number of treatment chairs: __________ Does your office have a computer with internet access? � Yes � No
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PROFESSIONAL EMPLOYMENT HISTORY (READ CAREFULLY)
Chronologically list all present and previous work history related to your professional employment within the past five (5) years (if you graduated less than five (5) years ago work history should be provided starting with your graduation date). All dates must be in Month and year format. Please provide a written explanation of any gaps greater than 6 Months. *What was your start date at your primary location? __________ / __________ / __________ (month/day / year) Hire Date (MM/YY)
Termination Date (MM/YY)
Employer
Location Address
Reason for Leaving
EDUCATION / TRAINING Professional School Name
City/State
Degree(s)
Date Received
Post Graduate Education- Name
City / State
Type (Residency, Internship, etc)
Specialty
Beginning / Ending Dates
Post Graduate Education- Name
City / State
Type (Residency, Internship, etc)
Specialty
Beginning / Ending Dates
ASSOCIATES If applicable, please list the name(s) of Associates at practice(s) Name
Name
Name
Name
Name
Name
PROFESSIONAL REFERENCES – REQUIRED for New Mexico and Florida Providers
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
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PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE
I am currently covered by the Federal Tort Claims Act? � Yes � No If No complete the section below with current malpractice carrier information. If Yes please complete the section below with Qualifying Entity information. Name of current Carrier
Mailing Address
Phone #
Fax #
Policy #
Effective Date
Expiration Date
Amounts of Coverage: Occurrence/Claim $____________________
Aggregate $_____________________
Name of Qualifying Entity (Please attach a copy of the Notice of Deeming Action)
Effective Date
Expiration Date
Coverage Limits
Virginia Providers only: For Mobile Dental Clinics or Portable Dental Operations Only: Is your mobile dental clinic or portable dental operation operated by a federal, state or local governmental agency? ___Yes ____ No Does your mobile dental clinic or portable dental operation provide dental treatment without charge to patients or to any third party payer and which is not provided on a regular basis (recurring at fixed or uniform intervals)? ___Yes ____ No If the answer to either of the questions above is no, is your mobile dental clinic or portable dental operation registered to legally operate in Virginia? ____Yes ____ No (Note: Proof of registration must be included with this application)
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QUESTIONNAIRE YES N/A ____ ____ Have you verified through the System for Award Management (SAM.gov) that none of the employees and none of
your Board of Directors or Governing Board and Managing Employees (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) working in you practice(s) are excluded from participating in Medicaid or Medicare programs?
For this response, Not Applicable indicates the following: I am not the owner of the Dental Practice as identified on the attached disclosure of
ownership form. Please mark with an X under the yes/no columns for each question. If you answer YES to any of the following questions with the exception of 15 & 16, please provide us with a detailed explanation and attach to the application. YES NO ____ ____ 1. Has your Dental License been limited, suspended, denied, revoked, restricted, subject to probationary conditions, or
have proceedings been instituted against you? ____ ____ 2. Have you voluntarily relinquished, reduced, restricted, or otherwise limited your dental license in any jurisdiction?
Note: this includes allowing a license to expire because you no longer practice in a state. ____ ____ 3. Have you been reprimanded or disciplined by any State or Commonwealth Department of Regulation and Licensure of
the Dental Examining Board? ____ ____ 4. Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been
suspended or limited or have you voluntarily terminated your participation? ____ ____ 5. Have you been convicted of any criminal offenses, pending or otherwise, other than a minor traffic violation? ____ ____ 6. Have you had a judgment made against you for alleged malpractice, negligence, or related matters? Are any cases
pending? ____ ____ 7. Have you had any judgments made against you in a professional liability case or has your liability insurer placed any
conditions or restrictions on your coverage or ability to attain coverage? ____ ____ 8. Have any litigation settlements been made on your behalf? ____ ____ 9. Are you, or have you been, under the treatment for the use of narcotics, barbiturates, alcohol, or other drugs? ____ ____ 10. Do you presently have any physical or mental conditions that would adversely affect your ability to provide high
quality professional services? Are there any accommodations that need to be considered? Please list accommodations below.
____ ____ 11. Has your participation with a managed care organization, other health care organization, or hospital privileges been
suspended, limited, or terminated? ____ ____ 12. Has your Drug Enforcement Agency (DEA) registration been denied, revoked, suspended, or not renewed? ____ ____ 13. Are you currently using illegal drugs? ____ ____ 14. Do you use any form of protective stabilization without having completed a residency program, a graduate program, or
a Continuing Medical Education (CME) certified course in protective stabilization? ____ ____ 15. (NJ provider only are required to complete this question) Are accommodations made for the patient’s cultural and
linguistic needs and are they noted in the patient’s dental record? ____ ____ 16. (Florida Medicaid Providers only) I attest and affirm that this office maintains a ratio of one FTE per 1,500 active
patients and 500 additional active patients for each FTE licensed dental hygienist up to a maximum of two hygienists per FTE dentist. The active patient load is a complete count of all the office’s active patients for all lines of business and plans
(including Medicaid, Medicare and commercial) An active patient is defines by AHCA as any patient who has been seen by the office two times in the last year
For example, if a patient was seen only one time in the last year they would not be considered and active patient. FTE stands for full time equivalent.
Dentist Name: (Please Print) ________________________________________________
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CERTIFICATION, STATEMENTS, AND SIGNATURE
I hereby acknowledge that the information provided in this application is material to the determination by DentaQuest whether or not to execute an agreement with me. I hereby represent and warrant that all information provided herein is true, correct and complete to the best of my knowledge, and I agree to notify DentaQuest in the event an error is discovered or when new events occur which alter the validity of any response herein. I hereby authorize DentaQuest to consult with individuals or institutions with which I have been associated and with others, including but not limited to past and present malpractice carriers, educational institutions, and state licensing boards, who may have information bearing on my professional competence, character and ethical qualifications and authorize the release of any such written or oral verification as needed by DentaQuest. I hereby release from liability for any such entity, institution, or organization that provides information as part of the application process. I certify that: * All parties of material interest have been identified and include no persons or entities with a potential for profit from self-
referral, * All services are provided by and under the “on Premise” supervision of a licensed dentist, * The above information is complete, correct and true to the best of my knowledge,
* My malpractice information is current at the time of application and the limits are at or exceed the minimum amounts required by the Plan and DentaQuest.
Individual Provider Participation Attestation Attestation to confirm that you have agreed to become a Participation Provider/ Provider Dentist in the DentaQuest provider network, by means of your or your office’s Provider Agreement with DentaQuest to render services to Members pursuant to the Agreement with DentaQuest. Signed by: __________________________________________ Date: ________________________________ Principal Please print name: ______________________________________
All applications are subject to review and approval by DENTAQUEST. All information contained in a credentialing file will be held in strict confidence, and available for review by only duly authorized employees of DentaQuest Dental USA, Inc., the Plan, and/or third party review organizations (i.e. NCQA, etc.). Practitioner has the right to obtain a copy of their credentialing file, by submitting a written, signed request to the Supervisor of Credentialing at the corporate headquarters for. Any corrections, additions, or clarifications to these files must be submitted in writing to the Supervisor of Credentialing within 30 days of the original submission. This information will be added to the provider application and considered in the credentialing decision. The practitioner has the right, upon request, to be informed of the status of their credentialing or recredentialing application via phone, fax, or mail. If the Credentialing Committee recommends the acceptance of an application with restrictions, denial of an application, or discipline or termination of a practitioner, written notification will be issued within 30 days of that decision. The practitioner then has 30 days from the date of the notice to submit a written appeal of that decision. Appeals should be addressed to the Credentialing Committee, sent to DentaQuest’s corporate address. In the event that a dentist’s application for participation is rejected or limited for reasons pertaining to the applicant’s professional conduct or competence, DentaQuest is required to submit a report to the Plan. The Plan will submit a report to the National Practitioner Data Bank and the state licensing board as required by law.
03012014 Page10
Disclosure of Ownership and Control Interest Statement
The federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a provider agreement to disclose to the U.S. Department of Health and Human Services, the State Medicaid Agency, and to managed care organizations that contract with the State Medicaid Agency: 1) the identity of all owners with a control interest of 5% percent or greater, 2) certain business transactions as described in 42 CFR 455.105 and 3) the identity of any excluded individual or entity with an ownership or control interest in the provider, the provider group, or disclosing entity or who is an agent or managing employee of the provider group or entity. Please attach a separate sheet if necessary.
Practice Information (REQUIRED for all provider applications)
Check one that most closely describes you: Individual Group Practice Disclosing Entity Name of Individual, Group Practice or Disclosing Entity: DBA Name: Address: Federal Tax Identification Number:
Are you _______________________ a 5% or greater owner in the entity associated with the Social Print Name
Security number or Tax Identification Number (s) referenced in this application? � Yes � No If yes, complete sections I through VI and a signature and date are required. If No, a signature and date is all that is required.
Section I
List the name, title, address, date of birth (DOB) and Social Security Number (SSN) for each individual having an ownership or control interest of 5 percent or greater in this provider entity.
List the name, Tax Identification Number (TIN) and business address of each organization, corporation or entity having an ownership or control interest of 5 percent or greater. Please attach a separate sheet if necessary. (42 CFR 455.104)
Name of individual or entity DOB Address
SSN (if listing an individual)
TIN (if listing an entity)
Section II
Are any of the individuals listed above related to each other? Yes No
If yes, list the individuals named above who are related to each other (spouse, sibling, parent, child). (42 CFR 455.104)
Names Relationship
Section III
Are there any subcontractors that the Disclosing Entity has direct or indirect ownership of 5% percent or more? Yes No
If yes, list the name and address of each person with an ownership or controlling interest in any subcontractor used in which the disclosing entity has direct or indirect ownership of 5% percent or more. (42 CFR 455.104)
Name of individual or entity DOB Address
SSN (if listing an individual)
TIN (if listing an entity)
03012014 Page11
Section IV
Has any person who has an ownership or control interest in the provider, or is an agent or managing employee of the provider ever been convicted of a crime related to that person’s involvement in any program under Medicaid, Medicare or Title XX program? Yes No (verify through HHS-OIG Web site)
If yes, please list those persons below. (42 CFR 455.106)
Name/Title DOB Address SSN
Section V
Business Transactions: Has the disclosing entity had any financial transaction with any subcontractors totaling more than $25,000 or any significant business transactions with any subcontractors? Yes NoIf yes, list the ownership of any subcontractor with whom this provider has had business transactions totaling more than $25,000 during the previous twelve 12-month period; and any significant business transactions between this provider and any wholly owned supplier, or between the provider and any subcontractor, during the past five-year period. (42 CFR 455.105). Attach a separate sheet if necessary.
Name Supplier/Subcontractor
Address Transaction Amount
Section VI
Have you identified your status (under Practice Information1) as a Disclosing Entity? Yes No If yes, for Disclosing Entities, list each member of the Board of Directors or Governing Board and Managing Employees (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), including the name, date of birth (DOB), Address, Social Security Number (SSN) and percent of interest.
Name/Title DOB Address SSN %
Interest
I certify that the information provided herein is true and accurate. Additions or revisions to the information above will be submitted immediately upon revision. Additionally, I understand that misleading, inaccurate or incomplete data may result in a denial of participation.
Signature Title (or indicate if authorized Agent
Name (please print) Date
Revised 6.22.12
Commonwealth of Virginia Department of Medical Assistance Services
Smiles for Children Program Participation Agreement
If re-enrolling, enter NPI here→ This is to certify: PAYMENT/CORRESPONDENCE ADDRESS PHYSICAL ADDRESS
(REQUIRED IF DIFFERENT FROM PAYMENT ADDRESS)
INDIVIDUAL NAME
ATTENTION
ADDR LINE 1
ADDR LINE 2
CITY, STATE, ZIP
on this _______ day of _____________________________, ____________ agrees to participate in the Smiles for Children Program, the Department of Medical Assistance Services (DMAS), the legally designated State Agency for the administration of Medicaid, FAMIS and FAMIS Plus. 1. The provider is authorized to practice under the laws of the state in which he is licensed and practicing and is not as a matter of state or
federal law disqualified from participating in the Program. 2. Services will be provided without regard to age, sex, race, color, religion, national origin, or type of illness or condition. No handicapped
individual shall, solely by reason of his handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination in (Section 504 of the Rehabilitation Act of l973 29 USC.794) DMAS.
3. The provider agrees to keep such records as DMAS determines necessary. The provider will furnish DMAS on request information regarding payments claimed for providing services under the State Plan. Access to records and facilities by authorized DMAS representatives and the Attorney General of Virginia or his authorized representatives, and federal personnel will be permitted upon reasonable request.
4. The provider agrees that charges submitted for services rendered will be based on the usual, customary, and reasonable concept and agrees that all requests for payment will comply in all respects with the policies of DMAS for the submission of claims.
5. Payment made by DMAS constitutes full payment except for patient pay amounts determined by DMAS, and the provider agrees not to submit additional charges to the recipient for services covered under DMAS. The collection or receipt of any money, gift, donation or other consideration from or on behalf of a medical assistance recipient for any service provided under medical assistance is expressly prohibited.
6. The provider agrees to pursue all other available third party payment sources prior to submitting a claim to DMAS. 7. Payment by DMAS at its established rates for the services involved shall constitute full payment for the services rendered. Should an
audit by authorized state or federal officials result in disallowance of amounts previously paid to the provider by DMAS, the provider will reimburse DMAS upon demand.
8. The provider agrees to comply with all applicable state and federal laws, as well as administrative policies and procedures of DMAS as from time to time amended.
9. This agreement may be terminated at will on thirty days' written notice by either party or by DMAS when the provider is no longer eligible to participate in the Smiles for Children Program.
10. All disputes regarding provider reimbursement and/or termination of this agreement by DMAS for any reason shall be resolved through administrative proceedings conducted at the office of DMAS in Richmond, Virginia. These administrative proceedings and judicial review of such administrative proceedings shall be pursuant to the Virginia Administrative Process Act.
11. This agreement shall commence on ________________________. Your continued participation in the Smiles for Children Program is contingent upon the timely renewal of your license. Failure to renew your license through your licensing authority shall result in the termination of your Smiles for Children Participation Agreement.
For Provider of Services:
Original Signature of Provider Date
Provider Specialty
_____City OR _____County of
Board License Number (Area Code) Telephone Number
IRS Identification Number (Required) UPIN
Medicare Carrier and Vendor Number
