Who Uses This Packet You should use this packet when: Updating Healthy Connections service location information such as demographic information, panel limits, and office hours. Note: If the service location is not part of the Healthy Connections program, then please complete packet Healthy Connections Turn Existing Service Location into a HC Service Location. General Instructions The following information is important. If you have questions, contact DXC Technology Provider Enrollment at 1 (866) 686-4272 or e-mail idproviderenrollment@molinahealthcare.com. All information is required. Be sure to fill out all fields. If there is a field that does not pertain, please enter NA. Any required addenda or supporting documentation (such as a copy of a certification) must be submitted with the packet. Incomplete packets, including packets that are missing the required addenda or supporting documentation, will result in an email from Provider enrollment asking for the missing information. The effective date of an applicant s affiliation to an existing provider agreement is deemed to be the date the application has been fully reviewed and approved by IDHW and DXC Technology Provider Enrollment. Providers are required to report any changes to their provider file within 30 days of the date of the change (per section 2.2 of the Provider Agreement and section 2.1.3 of the Provider Handbook General Provider and Participant Information). All packet documents are interactive PDF files, allowing users to enter information into the fields directly from the computer screen. This information can then be saved to a file and printed for mailing. Using these interactive features facilitates both the packet s completion and review processes. Next Steps 1) Print the completed packet. 2) Make a copy of the packet for your records. 3) Mail, fax, or e-mail the packet, including all required addenda and supporting documentation, to the following address: DXC Technology PO Box 70082 Boise, ID 83707 Fax: 1 (877) 517-2041 E-mail: idproviderenrollment@molinahealthcare.com Last Updated December 2015 PE0050 Page 1 of 6
Current Provider and Contact Information Current Pay-To Provider Information Pay-To Name of Group, Organization, or Individual: National Provider Identifier (NPI): Tax ID (FEIN or SSN): Contact Information The contact name and email relate to the person who can answer questions about the information provided in this packet. Email addresses are used for IDHW business only and will not be sold or shared for other purposes. Contact Name (first name, last name): Phone (with area code): Contact Email Address: Billing Contact Name: Billing Contact Phone (with area code): Updating Information for a Healthy Connections Service Location Indicate on the following table any updates to the Healthy Connections service location information, such as demographic information, panel limits, and office hours. Complete the sections in the table below where the information for the service location has changed; if the information in a section has not changed, leave it blank. Note: This information will be used for the Provider Directory that will be available to members on the OnLine portal. Last Updated December 2015 PE0050 Page 2 of 6
Pay-To NPI or # Healthy Connections Service Location Current Service Location Name: Effective Date for Changes: If name of service location is changing, enter new name: Mailing Address 1: New Mailing Address of Service Location Mailing Address 2: City: State / Province: ZIP / Postal Code: Phone Number: Fax Number: E-Mail Address: Last Updated December 2015 PE0050 Page 3 of 6
Pay-To NPI or # Service Location Panel Information Please list all languages (other than English) spoken by the staff of the service location. Office Hours for this service location: For days when services are unavailable or the office is closed, please check the closed checkbox. For locations that are available 24 hours (for example, Certified Family Home), please check the 24-hour box. Noon is 12:00 P.M. and midnight is 12:00 A.M. Monday A.M. P.M. To A.M. P.M. Closed 24 Hour Tuesday A.M. P.M. To A.M. P.M. Closed 24 Hour Wednesday A.M. P.M. To A.M. P.M. Closed 24 Hour Thursday A.M. P.M. To A.M. P.M. Closed 24 Hour Friday A.M. P.M. To A.M. P.M. Closed 24 Hour Saturday A.M. P.M. To A.M. P.M. Closed 24 Hour Sunday A.M. P.M. To A.M. P.M. Closed 24 Hour Does this service location offer extended hours (46 hours or more per week)? Is this service location accessible to persons with disabilities? Is this service location accepting new patients? Is there an age restriction for patients seen at this service location? If yes: Minimum age in years Maximum age in years (For infants, use 0 years. Maximum age allowed is 110 years.) Is there a gender restriction for patients seen at this service location? No Restriction Female only Male only Last Updated December 2015 PE0050 Page 4 of 6
Pay-To NPI or # Healthy Connections Panel Limits for Service Location Will this service location accept auto-assignment of patients? If yes: Unlimited Limited If limited, indicate number of patients accepted Number allowed per month Total maximum number accepted Other Restrictions / Limits for Service Location: Pregnant Females Only Accept family members of existing patients only Accept existing clinic patients only Clinic must be contacted prior to enrollment of patients Other: Last Updated December 2015 PE0050 Page 5 of 6
Pay-To NPI or # Provider Statement I certify that I am the provider, or I am authorized on behalf of the provider to sign this documentation. I certify this is true, correct, and complete. If I become aware that any information in this document is not true, correct, and complete, I will notify DXC Technology Provider Enrollment of this fact immediately. I authorize the Medicaid provider enrollment unit to verify the information contained herein. I understand that a change in the ownership of my organization or my status as an individual or group biller may require a new application. Provider Name (print): Provider Authorized Signature: Title: Date: Last Updated December 2015 PE0050 Page 6 of 6