Enrollment and revalidation requirements Medicaid participation

To bill for services rendered or to order, prescribe, and refer services to Nevada Medicaid recipients, you must enroll as a Nevada Medicaid provider and revalidate enrollment timely. This is also true to bill for services rendered or to order, prescribe, and refer services to Nevada Medicaid recipients enrolled through a managed care organization (MCO), such as Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).

As per the instructions found in the Provider Enrollment Information Booklet, which can be located at https://www.medicaid.nv.gov/Downloads/provider/NV_Provider_Enrollment_Information_Booklet.pdf, and also restated below, all individual (servicing) providers and all group (billing) providers must enroll and revalidate enrollment timely.

If an individual (servicing) provider and/or group (billing) provider is not enrolled as a Nevada Medicaid provider Anthem will reject any initial application requesting a contract and any add to existing group application. Once the individual (servicing) provider and/or group (billing) provider have received confirmation of their enrollment with Nevada Medicaid, they can reapply to participate with Anthem.

If an individual (servicing) provider and/or group (billing) provider does not revalidate their enrollment with Nevada Medicaid, Anthem will immediately terminate the individual (servicing) provider and/or the group (billing) provider. If an individual (servicing) provider and/or group (billing) provider was terminated by Anthem for failure to revalidate and they are later reinstated by Nevada Medicaid, the individual (servicing) provider and/or group (billing) provider will need to reapply with Anthem and, upon successful completion of the applicable processes, will only be made effective on a forward going basis.

Enrollment information and the Online Provider Enrollment Portal link are at www.medicaid.nv.gov (select Provider Enrollment from the Providers menu).

The following information can be found in the Provider Enrollment Information Booklet:

https://www.medicaid.nv.gov/Downloads/provider/NV_Provider_Enrollment_Information_Booklet.pdf.

Required for enrollment or revalidation

The following are required for your enrollment and revalidation in the Nevada Medicaid program:

• Provider Initial Enrollment Application or Revalidation Application submitted through the Online Provider Enrollment Portal and electronically signed contract.

• Valid NPI issued by NPPES.

• All documentation listed on the Enrollment Checklist for your provider type.

The Nevada Medicaid Provider Revalidation Report on the Provider Enrollment webpage lists each provider and the date their next revalidation is due. To avoid contract termination, your revalidation application must be processed and approved prior to the revalidation due date. Providers may revalidate up to a year in advance of their revalidation due date.

Billing type

Billing type is a required field on the provider enrollment application for all applicants and providers or will be automatically defaulted. Select Biller, Performer, or Both, depending on the appropriate billing structure.

Biller

Submits claims and receives payments. If Biller is selected, provider may not be listed as Performer:

• A group or organization which submits claims and receives payments for services rendered by qualified enrolled providers linked to the Biller as of the date the services are rendered.

Performer

Performs services:

• An enrolled provider linked to a Biller. The Biller submits claims and receives payment for services rendered by the Performer within scope of practice. A Performer may not submit claims and/or receive payments directly.

Both

Receives payments as both Biller and Performer of services rendered:

• A provider may enroll as Both (Biller and Performer) based on provider type and specialty, as well as scope of practice.

The Billing Type selected will not override existing restrictions and criteria necessary to submit claims and receive payments for providers.

Provider groups

Nevada Medicaid can pay a group entity billing under one NPI. To request this, each individual provider in the group must be enrolled in the Nevada Medicaid program (in other words, submit their own, individual enrollment application). The group then submits its own set of enrollment documents (in addition to the documents submitted by the individual providers). In order for the individuals to be linked to the group that will be paid, the individual names and NPIs of all providers who will be paid under the group must be listed on the group’s Enrollment Application. Each provider must sign the list on the application to acknowledge participation in the group.

Provider groups may be formed for the following provider types:

• Applied behavior analysis (ABA) – provider type 85

• Audiologist group – provider type 76

• Behavioral health outpatient treatment group – provider type 14

• Behavioral health rehabilitative treatment group – provider type 82

• Chiropractic group – provider type 36

• Dentist group – provider type 22

• Optometrist group – provider type 25

• Physician 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

Claims for a provider group are submitted using the Professional Health Care Claim: Fee-for-Service (837P) with the group’s NPI and the servicing provider’s NPI in the appropriate fields. Use Direct Data Entry (DDE) or a Trading Partner to submit claims. See Electronic Verification System (EVS) User Manual Chapter 3 Claims or the 837P Companion Guide for billing instructions.

You may add or remove a group member by completing a change/update via the secure web portal (EVS). Any changes to group membership must be reported within five business days.

If you submit claims to Medicare as a Provider Group and you wish for the claims to automatically cross over to Nevada Medicaid, then you must also enroll that same Provider Group with Medicaid.

Reporting business information

Individual (servicing) provider

Individuals must enroll with their individual information instead of reporting the group’s information. The individual will enroll with their own information then be linked to the group or billing provider for claims processing, payment, and reporting purposes. If you are an individual linking to a group, the tax liability of income received from Nevada Medicaid will be on the billing provider. You would only receive tax documents if you were receiving payment directly from Nevada Medicaid.

As an individual provider you will need to answer the following questions related to how you report doing business as:

• If you would like to be linked to a group, please enter the group provider’s NPI.

• Only enter your personal Social Security number and/or personal tax ID if you have one in the provider information section under Tax and Business Information.

• Your legal name and Doing Business As will be your own name as recognized by the IRS for tax purposes.

• Only report Secretary of State name and business ID if you personally have a business license under your name. It is not required for an individual enrollment linking to a group.

• For the electronic funds transfer (EFT) Information section: If you will be receiving direct payments from Nevada Medicaid, you must provide your individual EFT information. If you will only be receiving payments through a group, indicate that in the EFT section and do not enter any EFT information.

• You would not need to report owners as you are not enrolling as a business. Note, you will need to still report a managing individual. This could be yourself or anyone that can report changes on your behalf.

Group (billing) provider

Group enrollments are for businesses that will be billing for services provided by the servicing provider.

As a group/billing provider you will need to answer the following as a group applicant:

• Enter the Federal Tax ID recognized by the IRS for the business.

• Enter the provider legal name as recognized by the IRS.

• Select individual/servicing provider(s) by NPI(s) to be linked to the group applicant.

• Enter EFT information and include the EFT authorization form and proof of account information in the attachments panel.

• Enter owners (individuals or parent corporations) of 5% or more direct or indirect interest, board members, managing individuals, and/or agents in the entity information. Note if a parent corporation is listed, then Nevada Medicaid will need the owners, managing individuals, or agents of that parent corporation. Please see the Ownership and Disclosure section of the Medicaid Provider Enrollment Compendium (MPEC) for additional instructions via:

https://www.medicaid.gov/affordable-care-act/program-integrity/index.html

Managed care organization (MCO) network providers:

• All MCO network providers must be enrolled in Fee-for-Service (FFS) prior to enrolling with any of the MCOs.

• MCO Network providers must use the same NPI type (Type 1 for individual enrollment or type 2 for group enrollment) and NPI they want to use to credential with the MCOs.

• Please note: MCO Network providers enrolled in Nevada Medicaid FFS are not required to accept Medicaid FFS recipients.