Report concerns about abuse or neglect to your county or tribal agency. Medically Necessary or Medical Necessity: Terminating Participation or Termination: Rehabilitative and therapeutic service records. 10 states in part: "A provider shall not place restrictions or criteria on the services it will make available, the type of health conditions it will accept, or the persons it will accept for care or treatment, unless the provider applies those restrictions or criteria to all individuals seeking the provider's services. All Rights Reserved. UCare Contract Intake Form Posted 11.23.22. Lead agencies must allow all PCA/CFSS services agreements with edits that require DHS-level review to route to DHS for processing. An MHCP provider who sells or transfers ownership or control of a provider entity enrolled in MHCP must notify MHCP Provider Enrollment no later than 30 days before the effective date of the sale or transfer by submitting a Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF). 2. - Enrollment with Minnesota Health Care Programs (MHCP) 294 0 obj <> endobj Prescribing Privileges for PCP Partners The Minnesota Provider Screening and Enrollment (MPSE) portal is a new web-based application that allows providers to submit and manage their Minnesota Health Care Programs (MHCP) provider enrollment records and related requests online. (Minnesota Statutes 256B.02, 256B.433, 256B.48 subd. PDF DHS-4074A-ENG (Personal Care Assistance (PCA) Technical Change Request) For assistance, refer to the Instructions to Complete the PCA Request (DHS-4292), DHS-4292A. Minnesota Rules 9505.0015 Definitions Provider Notification / Change Request Adult Rehabilitative Mental Health Services (ARMHS) U9863 Page 1 of 2 ARMHS Provider Notification / Change Request FYI Incomplete, illegible or inaccurate forms will be returned to sender. endstream endobj startxref The federal Health and Human ServicesOffice of Inspector General (OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal health care programs. Last Updated: 10/26/2022 Was this page helpful? ! DHS 4159 (CTSS) Children's Therapeutic Services and Supports Authorization Form-Posted 2.23.23. %%EOF HQK0+.y+B")RaO m!n[d]{1|9s}Z2t6BIe)U$}C`u! Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs, Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website. 98 0 obj <> endobj Minnesota Statutes 256B.02 Policy BG[uA;{JFj_.zjqu)Q c%/ui6-U=i.X7(XjC)Rxr .D"NlI0kb`%*@Hnf`bd|r(A0@ '" Program overviews. DHS shall notify the vendor no less than 24 hours before obtaining access to a health service or financial record, unless the vendor waives notice. Stipulated Settlement Agreement Day v. Noot, 2023 Minnesota Department of Human Services, Enrollment with Minnesota Health Care Programs (MHCP), Payment Reversals for Terminated Providers, Surveillance & Integrity Review Section (SIRS), Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF), Disclosure of Ownership and Control Interest Statement for Participating Providers (DHS-5259) (PDF). 4, upon request, the Medical Assistance recipient's health service records related to services under a program. 0qPWp:dW5 ;6V]BpJ#@DE"?Fo=+57]>>=@^{"p5yM~'A}t`)6ts(T^ `p]~@5zPn/VO=RB;#Gkj@!bg~7s}f For example, providers cannot deny treatment for a certain diagnosis (for example, pregnancy) to MHCP recipients unless treatment for that diagnosis is also not available for other clients. Minnesota Rules 9505.2197 Vendors Responsibility for Electronic Records Subp. You must ensure that the electronically stored records meet all of the general record keeping requirements, including the ability for DHS to access and copy the records when required and any other requirement of Minnesota Rule 9505.2197. CountyLink Other manuals Durable Medical Equipment/Supply Prior Authorization Form To learn about what Minnesota is doing to build provider capacity, refer to DHS - Building EIDBI provider capacity. Change of Information TEMPORARY LICENSED AND LICENSED HOME CARE PROVIDERS . Consult with the appropriate professionals before taking any legal action. endstream endobj 299 0 obj <>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 300 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W-9, Manage Your Information - Add/Change/Term DHS retains the right to pursue monetary recovery, or civil or criminal action against the seller or transferor. Minnesota Rules 9505.0440 Medicare Billing Required (Minnesota Statute 256B.48, subd. The notification must include the provider name, the National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI), office address, and billing agent's name and address. Legacy Provider Claim Reconsideration Request Form B) (DHS) Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) . endstream endobj 1119 0 obj <>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 1120 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Within DHS, the SIRS section is responsible for identifying and investigating suspected fraud, theft, and abuse. See additional requirements in Home Care Services and HCBS Waiver Programs and AC Program. They are also useful for those who are not proficient in graphic design, as they eliminate the need to start from scratch or hire a professional designer. MHCP also excludes individuals and entities from participation in MHCP if they are on either the federal or state excluded provider list. The Department of Human Services (DHS) licenses certain Home and Community-Based Services (HCBS) provided to people with disabilities and those over age 65. A vendor shall grant DHS access during the vendor's regular business hours to examine health service and financial records related to a health service billed to a program. Minnesota Statutes 270C.40 Interest Payable to Commissioner NovusMED IP Address- Add, Remove Record retention under change of ownership. A new owner of an entity enrolled in MHCP must complete and comply with all provider screening and enrollment requirements and conditions. Renewing MA eligibility. Portico data set-up Minnesota Rules 9505.2175 Health Care Records Combined Six-Month Report (CSR) (DHS-5576) (PDF). Factor: An individual or organization that advances money to a provider for their accounts receivable for an added fee or a deduction of the accounts receivable worth. endstream endobj 301 0 obj <>/Subtype/Form/Type/XObject>>stream Send the notice to: DHS MHCP Provider Enrollment Minnesota Health Care Programs (MHCP) requires all enrolled providers to follow applicable state and federal regulations. Printable templates offer a convenient and cost-effective solution for individuals and businesses who need to produce a high volume of similar documents. Hn0} Document in the patient's medical record whether the patient has executed an advance directive. W-9, Initial Credentialing Application MHCP funds paid for health care not documented in the health service record are subject to monetary recovery. Federal law does not affect a provider's obligation to obtain informed consent to treatment. 416 0 obj <>stream Send the notice to: DHS - MHCP Provider Enrollment PO Box 64987 St. Paul, MN 55164-0987 Fax 651-431-7425 Payment to Provider or Billing Agent The Medical Assistance recipient's authorization of the release and review of health service records for services provided while the person is a Medical Assistance recipient shall be presumed competent if given in conjunction with the person's application for Medical Assistance. They are customizable, allowing users to make modifications to the text, colors, and layout, and they can be saved and reused for future use. hbbd```b``A$>dz0[LI30)gbEa%dX q .bLFv ~sT5a"H y8 gb3@$ Provider Change Request. The SASD Support Team provides the following technical assistance: Lead agencies must send screening document deletion requests by online form only using Screening Deletion Request, DHS-4689A. 42 CFR 431.53 Assurance of transportation Printable templates are pre-designed documents or forms that can be easily printed and filled out by hand. If you are a provider eligible for an NPI, you must obtain your NPI number (s) from the National Plan and Provider Enumeration System (NPPES) before you enroll with MHCP. Hn0} 42 CFR 447.10 Prohibition against reassignment of provider claims endstream endobj 1117 0 obj <>stream See 0007 (Reporting), 0007.12 (Agency Responsibilities for Client Reporting), 0007.15 (Unscheduled . Form DHS 3535 ENG Download Fillable PDF Or Fill Online Individual Practitioner Mhcp Provider Profile Change Form Minnesota Templateroller. Abuse: In the case of a vendor, a pattern of practice inconsistent with sound fiscal, business, or health service practices, and that results in unnecessary costs to MHCP or in reimbursement for services not medically necessary, or that fail to meet professionally recognized standards for health services. MN-ITS - Minnesota %PDF-1.6 % 156 0 obj <> endobj Many application forms are published in languages other than English and can be found through eDocs. Refer to these statutes for additional details of these provisions. In addition, a nursing facility participating in the demonstration project may charge private pay residents up to the Medicare rate for the first 100 days after admission only if the private pay resident's stay is less than 101 days. Uniform Re-Credentialing Application, Join Our Network They are typically utilized for things like requesting passports, visas, or social security numbers. 4+t?1zxn nmZn5&xUAX5N(;a,r}=YUUA?z r[ $ Legal Disclaimer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. &7Z`. If Provider Enrollment denies an initial provider enrollment application, the provider may not appeal the decision. Page 3 of 6 DHS-7196-ENG 11-16 *Note: You must submit a Direct Deposit for the Minnesota Child Care Assistance Program Form (DHS-3552) Change to Tax Information *CCAP agency must submit DHS form 5243 to have Provider Tax Information changed in MEC Minnesota Rules 9505.2160 to 9505.2245 Surveillance and Integrity Review Program %%EOF Counties, tribes, and enrollees use the following contact information to return SNBC Choice forms to DHS: Fax Number: 651-431-7464 Mail to: Managed Care - Department of Human Services PO Box 64838 St. Paul, MN 55164-0838 . Personal care provider records must comply with additional documentation requirements in the PCA section of this Manual. Minnesota Rules 9505.2185 Access to Records General Prior Authorization Request Form Review the Housing Stabilization Services Enrollment Criteria and Forms section of the DHS Provider Manual for enrollment criteria and instructions on how to enroll with DHS. The United States Government Forms are not just for the federal government. Changes to services / Minnesota Department of Human Services Housing Stabilization Services. Enrollees get health care services through a health plan. The following practices are deemed to be abuse by a provider: Electronically Stored Data: Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape, or computer disk. This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions, Care Coordination Referral Form Uniform Re-Credentialing Application, NOMNC - Notice of Medicare Non-Coverage (Advance Notice) The SASD Support Team will only accept change requests and corrections when there is an existing service agreement in MMIS. Subp. As a professional or professionals delegate engaged in social services and the care of vulnerable adults, MHCP enrolled providers are mandated reporters under Minnesota Statute 626.557. Prior Authorization Form for Out-of-Network Providers Medical Injectable Drug Authorization form The provider shortage particularly affects rural areas. Minnesota Rules 9505.0210 Covered Services; General Requirements Remove an organization or close a location UCare is a registered service mark of UCare Minnesota | 2023 UCare Minnesota. Providers must be able to document their community education efforts. NOMNC Valid Delivery Documentation Form Information about the monitoring of recipient use of health services is found in Health Care Programs and Services. National Provider Identifiers (NPIs) are the standard unique identifiers to use in submitting and processing health care claims and other transactions. 7. Housing Stabilization Services is a new Minnesota Medical Assistance benefit to help people with disabilities, including mental illness and substance use disorder, and seniors find and keep housing. @yun-wQPX,TZ'V-x!oa K83\$b(4l 5m8hph~>D!x7YI!0whs&/(! Whether for personal or business use, they provide a cost-effective and convenient option for those who need to create and print multiple copies of similar documents. Interpreter Mileage Request Form MN Uniform Facility Credentialing Application You can choose your health plan from those serving MinnesotaCare enrollees in your county. TemplateRoller.com will not be liable for loss or damage of any kind incurred as a result of using the information provided on the site. Provider: An individual, organization, or entity that has entered into an agreement with DHS for the provision of health services, including a personal care assistant. Inpatient hospitals, nursing facilities, providers of home health and personal care services, hospice programs and managed care plans must maintain written policies and procedures as well as the following: Providers are encouraged to work with associations and advocacy groups to further educate the community on these issues. MinnesotaCare is funded by a state tax on Minnesota hospitals and health care providers, Basic Health Program funding and enrollee premiums and cost sharing. Refer to the MNITShome page for more information, system availability or to sign up to get email notices of changes. . A pertinent provision of these statutes is: Whoever knowingly and willfully offers; pays or solicits; or receives any compensation (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind: Offering or transferring remuneration to any individual eligible for benefits under this program, that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner or supplier any item or service for which payment may be made in whole or in part by this program. H\V=z[1}wT)Srvn!N @ FacilityAdd - UCare If you suspect either a treating or rendering provider, or a provider group or agency, of fraud, abuse or improper billing, contact SIRS. Disclosure of Ownership Form All program application forms can be found in eDocs. MN Uniform Facility Credentialing Application FORMS/HANDOUTS FOR APPLICANTS - dhs.state.mn.us Advance Directive: A written instruction such as a living will or durable power of attorney for health care, recognized under state law and relating to the provision of care when the patient is incapacitated. PCA UMPI Change Form Fraud: Acts which constitute a crime against any program, or attempts or conspiracies to commit those crimes including the following: Health Plan: A managed care organization that contracts with DHS to provide health services to recipients under a prepaid contract. Requirements regarding the need for a referral, or which days are available for treatment, etc., are legitimate requirements for MHCP recipients only if they are also applied to other clients. ![T*JXc]` o H;? Record retention after vendor withdrawal or termination. Non-participating Provider Claim Adjustment Form. Form Details: Released on January 1, 2012; Minnesota Rules 9505.0315 Medical Transportation Examples of benefits include, but are not limited to such items as coupons providing discounts, cash, merchandise or other goods or services of value in exchange for utilizing services or obtaining goods from a particular provider. Theft: The act defined in Minnesota Statutes 609.52, subd. Payment rates and special services for nursing homes and its private pay residents: A nursing home is not eligible to receive MA payments unless it refrains from requiring its residents to pay more than its MA rate for similar services. Minnesota Statutes 256B.0625 Covered Services Minnesota Rules 9505.0225 Request to Recipient to Pay 1; 256B.434). Yes No Section 504 of the Rehabilitation Act of 1973 Medical Injectable Drug Authorization form The Department of Revenue establishes the rate under Minnesota Statute 270.75. Nursing Facility Communication Form, Credentialing and Recredentialing Fax 651-431-7425. Title XVIII, section 1877(b) of the Social Security Act According to federal law, the following providers must give written information on state laws regarding the patient's right to make decisions and the provider's policies concerning implementation of those rights at the following times: If a patient is incapacitated at one of the above times, and if the provider issues materials about policies and procedures to families, surrogates, or other concerned persons, the provider must include in those materials the information about advance directives. Notice of Admission Form for Withdrawal Management Vendor: The meaning given to "vendor of medical care" in Minnesota Statute 256B.02, subd. Housing Stabilization Services is a Minnesota Medical Assistance benefit to help people with disabilities, including mental illness and substance use disorder, and seniors find and keep housing. Clients must report changes to the designated provider 30 days before the change. Licensing and child care / Minnesota Department of Human Services A provider shall render to recipients services of the same scope and quality as would be provided to the general public. If specific enrollment information is not listed for a provider type, see the enrollment webpage. Minnesota Rules 9505.2190 Retention of Records Legal Disclaimer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. X&=@8 LBJv")Hs3pmS&M09&:*>.6)1!5%9#=-;+3/7 7/8(0,4$2"HWO_K[G]CSEUMQIYN^AZFVBRJTL\HX_@@ mN,Tp%N- \1* Unless otherwise provided by law, no provider of health care services will be declared ineligible without prior notice and an opportunity for a hearing under Minnesota Statute 14. The notification must include the provider name, the National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI), office address, and billing agent's name and address. %Qr& endstream endobj 1121 0 obj <>stream This page provides quick links for providers looking for information, including how to enroll with MHCP and what services are covered. Restriction: In the case of a vendor, excluding or limiting the scope of the health services for which a vendor may receive a payment through a program for a reasonable time. UCare Individual & Family Plans Medical Referral for UCare Restricted Member Enrollee This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. Department access to records. PCA UMPI Term Form Mental Health Outpatient Providers will see reversed claims as adjustments on their remittance advices. Minnesota Rules 9505.0185 1251 0 obj <>stream Minnesota Provider Screening and Enrollment Manual (MPSE), Certified Community Behavioral Health Clinic (CCBHC), Community Emergency Medical Technician (CEMT) Services, Allied Oral Health Professional (Overview), Early Intensive Developmental and Behavioral Intervention (EIDBI), Inpatient Hospitalization for Detoxification Guidelines, Lab/Pathology, Radiology & Diagnostic Services, Adult and Children's Crisis Response Services, Adult Residential Crisis Stabilization Services (RCS), Health Behavioral Assessment/Intervention, Physician Consultation, Evaluation and Management, Psychiatric Consultations to Primary Care Providers, Psychiatric Residential Treatment Facility (PRTF), Telehealth Delivery of Mental Health Services, Moving Home Minnesota (MHM) Provider Enrollment, Officer-Involved Community-Based Care Coordination Services, Breast and Cervical Cancer (BRCA) Genetic Testing and Presumptive Elegibility Services, Screening, Brief Intervention, and Referral to Treatment (SBIRT), Telehealth Delivery of Substance Use Disorder Services, Access Services Ancillary to Transportation, Local County or Tribal Agency NEMT Services, Local County or Tribal Agency Nonemergency Medical Transportation (NEMT) Services Claim, Service, and Rate Information, State-Administered Transportation Procedure Codes, Modifiers and Payment Rates, Tribal and Federal Indian Health Services. Minnesota Statutes 609.52, subd. Withholding Payments: Reducing or adjusting the amounts paid to a provider to offset overpayments previously made to the provider. Pattern: An identifiable series of more than one event or activity. Minnesota Rules 9505.0215 Covered Services; Out-of-State Providers Home health or personal care services providers. Provider Enrollment will notify the provider and ask for additional information if it is unable to make a determination. Microfilm records satisfy the recordkeeping requirements of this subpart and Minnesota Rules 9505.2175, subp. Minnesota Statutes 256B.064 Sanctions; Monetary Recovery EIDBI - Overview of EIDBI providers - dhs.state.mn.us %PDF-1.6 % HS]O0}_qd_TILXv]@O.K{=p> X1R)MD*u 7p\y D2a\&bh1hq{.uNj`)9T@*pU&T!Bz $2ToWIGtfN.[4y7n1MDP0j=g*E^ X2SYJsOJ=I!J]D]KRihmOS-f&nR#wa{:f$f? In conclusion, printable templates offer a quick and easy solution for producing high-quality documents and forms. hbbd``b`q F= "d0R"b}\@ If a provider uses a billing agent or organization (person or entity that submits a claim or receives MHCP payment on behalf of a provider), the provider must also list the name and address of the billing agent on the enrollment application. 5 Issuance of Certificate of Authority 0qPWp:dW5 ;6V]BpJ#@DE"?Fo=+57]>>=@^{"p5yM~'A}t`)6ts(T^ `p]~@5zPn/VO=RB;#Gkj@!bg~7s}f Retention required, general. Minnesota Health Care Programs providers / Minnesota Department of Suspending Participation or Suspension: Making a vendor ineligible for reimbursement through MHCP funds for a stated period. Common application forms / Minnesota Department of Human Services Out-of-state providers must comply with all terms of this section and follow laws of the state in which the provider is located. Top of Page. es6R~QQJTPWw_-ebtvwNXz)Ut\Haa5I|*$d9sbhV1&M):>=kimCI 1H|TTj#Jd;bojy{g.,V!_qISaV1F| }9{(HKnatLaO5 VQTr$VS!fCx{0LF 1!Scc|]yP~IqE)cMf$@l( 4aaCUr&vy/M'%a&5Lb3M/j~OB7#$gruy^$y0]XD3j^BC7c{ 7wzk? Minnesota Rules 9505.0170 to 9505.0475 Medical Assistance Payments 1. Subp. Health Service Records: In addition to those listed here, there may be other record obligations located throughout this manual specific to vendors of a particular service. O#E0=n\}G/]{* STS Ride Notification Template. Medical Services Recipient's consent to access. Download a fillable version of Form DHS-3535A-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services. For assistance, refer to the Instructions to Complete the MA Home Care Technical Change Request (DHS-4074), DHS-4074B. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to DHS so DHS can determine whether the provider complies with the requirements of this subpart.". Minnesota Rules 9505.0195, subp. Health Connect 360 Referral Form (Minnesota Statutes 256B.48, subd. Minnesota Statutes 62D.04, subd. The following are some commonly used forms for providers who work with UCare. Housing Stabilization is a Home and Community Based Service (HCBS), and providers of Housing Stabilization must abide by the HCBS requirements. H\t. 'u s1 ^ Enroll with MHCP. Records may be maintained electronically in an Electronic Health Records (EHR) system for all or part of the five-year record keeping period. Investigative Costs: Investigative costs are subject to the provisions of Minnesota Statutes 256B.064, subd. Form DHS-3535-ENG Individual Practitioner - Mhcp Provider Profile Change Form - Minnesota. Renewing MA and MinnesotaCare eligibility / Minnesota Department of 2 Acts constituting theft ~S3(DD`@* UP=%w:T=2U3! Once the federal public health emergency ends on May 11, enrolled Housing Stabilization Services providers must come . hb```f``z] ,@Q= + 2Ljy>400{tt00ht40dt@'S -"`P,LRKX:Y83Le|UxJ\K4#0 d9w$?SW:Da ^ A Minnesota Statutes 256B.0644 Vendor Request for Contested Case Proceeding Form DHS-3535-ENG Individual Practitioner - TemplateRoller 1d, and means the sum of the following expenses incurred by a DHS investigator on a particular case: Medically Necessary or Medical Necessity: A health service that is consistent with the recipient's diagnosis and condition and: Ownership or Control Interest: Has the meaning given in Code of Federal Regulations, title 42, part 455, sections 101 and 102. Documentation required for every child in family child care Documentation family child care license holders must maintain Additional family child care license holder forms and information Minnesota Statutes 256B.27 MA; Cost Reports 24.10.05.10 Designated Provider Option - hcopub.dhs.state.mn.us j7v@i\yU-hB{n/x"ji7v2[Xf*Z&l>n+x^_?Fa.&& DHS Change Of Provider Form Mn - DHS Forms 2023 Frequently asked questions (FAQ) 4. Acupuncture Prior Authorization Request Form, Birth Notification Form for Prepaid Medical Assistance Plan and MinnesotaCare member, Durable Medical Equipment/Supply Prior Authorization Form, Universal Health Plan/Home Health Agency Prior Authorization Request Form, Concurrent Review Form for Withdrawal Management, Notice of Admission Form for Mental Health Inpatient or Residential, Notice of Admission Form for Substance Use Disorder Inpatient or Residential, Notice of Admission Form for Withdrawal Management, Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI), Prior Authorization Form for Out-of-Network Providers, Prior Authorization Form for Psychiatric Residential Treatment Facilities (PRTF), Substance Use Disorder Treatment Outpatient, Medical Injectable Drug Authorization form, Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions, Complex Case Management Referral Form - PDF, Complex Case Management Referral Form - Word, Mental Health & Substance Use Disorder Case Management Referral Form, Intensive Community Based Services (ICBS) Referral Form, Add or update a facility or location form, Advance Recipient Notice of Non-covered Service/Item (DHS), Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA), Legacy Provider Claim Reconsideration Request Form, Online Provider Claim Reconsideration Form, MN Uniform Facility Credentialing Application, NOMNC - Notice of Medicare Non-Coverage (Advance Notice), DENC - Detailed Explanation of Non-Coverage Form, NDMCP - Notice of Denial of Medical Coverage/Payment Form, Nursing Home Swing Bed Admission/Update Form, Provider Directory & Subdirectory Questionnaire, Change or update your facility profile(tax ID, legal name, ownership, address, phone, NPI), Remove an organization or close a location, Provider Notification/Change/Update/Termination Third-Party Agreement, Non-participating Provider Claim Adjustment Form, Restricted Recipient/Restricted Member Program, UCare Individual & Family Plans Medical Referral for UCare Restricted Member Enrollee, UCare Individual & Family Plans Prescribing Privileges for PCP Partners, UCare Individual & Family Plans Restricted Member Program Intake Form, Special Transportation Services - Certificate of Need.
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