1. Letter Of Interest
Letter of Interest Form must be completed, click here to view the form . Then upload a screenshot of the application number, date, and time stamp below.
Attach Letter of Interest File Here: (Max Upload Size: 5mb | File Type: .pdf, .png, .jpeg, .jpg)
2. First Tier, Downstream, and Related Entities Attestation Form
Complete and submit this attestation form to Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. (Presbyterian) to demonstrate compliance with the First Tier, Downstream, and Related Entities (FDR) training requirement. Incomplete attestations will not be accepted.
Provider Information
Office/Organization Name:
Tax ID Number:
Your Name:
Your Title:
Attestation Questions
1. Is your office Medicare-certified?
A facility, practitioner, provider or healthcare agency is Medicare-certified when it applies for a National Provider Identifier (NPI) number, meets the federal regulations, and is approved to provide care and be reimbursed under Medicare for services rendered.
Yes No N/A If N/A Please give reason:
2. Does your office/organization have a code of conduct?
Yes No N/A If N/A Please give reason:
2a. If yes, does your code of conduct or other relevant policy include language about non-retaliation for good faith reports about suspected conduct violations?
Yes No 2b. If yes, does your office have a reporting and review process to manage conflicts of interest?
Yes No 2c. If you answered "No" to any part of the second question, then do you agree to abide by the Presbyterian Code of Conduct?
Yes No 3. Does your office contract with other organizations or use affiliated entities to provide services to
Presbyterian members?
Yes No 3a. If yes, do you have a system in place to monitor the affiliated entities’ compliance with Medicare’s program requirements?
Yes No 3a. If yes, do you ensure related entities train their employees on Medicare compliance expectations?
Yes No 4. Does your office/organization have a compliance program?
Presbyterian reserves the right to request a description of your program or seek additional information.
Yes (Please answer Questions 4a-e) No (Please proceed to Question 5) N/A If N/A Please give reason:
4a. Does your compliance program include a mechanism(s) for reporting and investigating compliance concerns or violations?
Yes No 4b. Does your office/organization perform compliance training for employees and governing body members upon hire and annually thereafter?
Yes, we provide our own internal compliance training that includes information for employees about how to report compliance concerns and violations Yes, we distribute the compliance training information provided by Presbyterian No 4c. Does your office/organization apply discipline to employees and down-stream contractors, as appropriate, for compliance-related incidents?
Yes No 4d. Does your office/organization implement a corrective action plan for any identified compliance- related deficiencies?
Yes No 4e. Does your compliance program include monitoring and auditing your business practices to ensure compliance with applicable federal and state regulations?
Yes No 5. Does your office contract with other organizations or use affiliated entities to provide services to Presbyterian members? Presbyterian reserves the right to request documentation of these verifications.
Yes No N/A If N/A Please give reason:
6. Do you acknowledge that your office/organization will report any concerns or violations related to compliance or fraud and abuse that impact the contracted services we perform to Presbyterian immediately?
Yes No Attestation
By adding your signature and submitting this attestation form, you are indicating that you have approved authority
to sign for your office/organization. You are also confirming that the information provided on this form is accurate
and complete to the best of your knowledge. In addition, you are attesting that you, and any individuals or entities
that you or your office contracts with for the administration of the Medicare program or the delivery of benefits or
services to Presbyterian Medicare members, are compliant with all applicable laws, rules and regulations regarding
Medicare’s FDR program requirements.
Signature:
Date:
3. Disclosure of Ownership and Control Interest Form
Purpose: In compliance with 42 CFR 457.935, 42 CFR §455.104, §455.105, and §455.106, providers/disclosing entities are required to disclose including, but not limited to, information regarding (1) the identity of all persons with an ownership or control interest in the provider/disclosing entity, or in any subcontractor in which the provider/disclosing entity has a direct or indirect ownership of 5 percent or more including the identity of managing employees, and other disclosing entities; (2) certain business transactions and significant business transactions between the provider/disclosing entity and subcontractors/wholly owned suppliers; and (3) the identity of any person with an ownership or control interest in the provider/disclosing entity or who is an agent, or a managing employee of the provider/disclosing entity that has ever been convicted of any crime related to that person’s involvement in any program under the Medicaid, Medicare, or Title XX program (Social Services Block Grants), or XXI (State Children’s Health Insurance Program) of the Social Security Act since the inception of those programs. Any authorized/designated representative of the provider/disclosing entity may complete and sign this form on behalf of the provider/disclosing entity.
Instructions For Completing the Ownership & Control Interest Disclosure Form
1. Read all definitions and instructions outlined throughout the Form and then reference the definitions and instructions while completing the Form. Terms with corresponding regulatory definitions are italicized and underlined throughout this Form. Please review the applicable definition before responding to the question.
2. Definitions for Disclosure of Ownership and Control Interest Form - See Appendix A
3. Completion and submission of this Statement/Disclosure is a condition of participation as a credentialed or enrolled provider in the New Mexico Centennial Medicaid Managed Care Network or the State Children’s Health Insurance Program (CHIP) network for services to members under Medicaid and CHIP benefit plans.
4. Answer all questions as of the current date i.e. request date.
5. If there is no information to include, indicate “None” or “Not applicable” (N/A) in the space provided. Do not leave blank spaces unless advised to do otherwise in the instructions. Incomplete Forms will be reported back to HSD.
6. If more space is needed, please attach additional sheets.
7. In any space requesting ‘Name,’ if it is the name of an individual, include First, Middle and Last.
8. Business & Service Address: The address for corporate/legal entities must include, as applicable, the primary business address, every business location, and P.O. Box address. Individuals must provide their home address.
9. Provide the Employer Identification Number (EIN) or Tax Identification Number (TIN) for legal entities. Provide the
Social Security Number (SSN) for individuals.
10. This Statement/Disclosure should be submitted with your MCO application, or at initial and renewal of a contract or agreement and any time there is a revision to the information. A Statement must also be provided within 35 calendar days of a request for this information.
11. Failure to submit the requested information may result in denial of a claim, a refusal to enter into a provider agreement or contract, or in termination of existing provider agreements and contracts.
How to Determine Ownership or Control Percentages (42 CFR 455.102).
12. Indirect ownership interest. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.
13. Person with an ownership or control interest. In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in the provider’s assets equates to 4 percent and need not be reported.
Section 1 – Disclosure Regarding Managing Employees (42 CFR 455.104(b)(4))
1) Does the provider/disclosing entity have any Managing Employees?
Yes No If Yes, provide the following details for any managing employee of the provider/disclosing entity. See the definition of managing employee in Appendix A.
Name:
SSN:
Birthdate:
Complete Address (street/city/state/zip):
NPI:
Position:
Name:
SSN:
Birthdate:
Complete Address (street/city/state/zip):
NPI:
Position:
Name:
SSN:
Birthdate:
Complete Address (street/city/state/zip):
NPI:
Position:
Section 2 – Criminal Offense Disclosure (42 CFR 455.106)
2) Has the provider, or any person (individual or entity) who has ownership or controlling interest in the provider/disclosing entity, or who is an agent or managing employee of the provider/disclosing entity, ever been convicted of a criminal offense related to that person's involvement in any program established under Titles XVIII (Medicare), XIX (Medicaid), XXI (SCHIP), or Title XX (Social Services Block Grants) since the inception of those programs?
Yes No (verify exclusion through the applicable federal and state specific exclusion databases.) If Yes, provide the following details and a description of offense(s).
Name:
SSN/TIN:
Birthdate:
Description of Offense(s):
Name:
SSN/TIN:
Birthdate:
Description of Offense(s):
Name:
SSN/TIN:
Birthdate:
Description of Offense(s):
Section 3 – Person(s) with Ownership or Control Interest Disclosure (42 CFR 455.104(b)(1))
3) Are there any persons (individual or entity) with an ownership or control interest in the provider/disclosing entity?
Yes No If Yes, provide the following details and include the title (for example, CEO, owner, board member etc). For corporations/entities that have an ownership or control interest in the Disclosing Provider, please separately list its primary business address, every business location and post office box address. See definitions in Appendix A.
Name:
TIN or SSN (as applicable):
Birthdate:
Title:
Address (street/city/state/zip):
% Ownership Interest:
Name:
TIN or SSN (as applicable):
Birthdate:
Title:
Address (street/city/state/zip):
% Ownership Interest:
Name:
TIN or SSN (as applicable):
Birthdate:
Title:
Address (street/city/state/zip):
% Ownership Interest:
Section 4A – Direct or Indirect Ownership of 5% or More in a Subcontractor Disclosure (42 CFR 455.104(b)(1))
4A) Does the provider/disclosing entity have a Direct or Indirect Ownership Interest of 5% or more in any Subcontractor?
Yes No If Yes, provide the following details about the subcontractor. See definitions in Appendix A.
Name of Subcontractor:
TIN or SSN (as applicable):
Birthdate:
Address (street/city/state/zip):
% Ownership Interest:
Name of Subcontractor:
TIN or SSN (as applicable):
Birthdate:
Address (street/city/state/zip):
% Ownership Interest:
Name of Subcontractor:
TIN or SSN (as applicable):
Birthdate:
Address (street/city/state/zip):
% Ownership Interest:
Section 4B – Direct or Indirect Ownership of 5% or More in a Subcontractor Disclosure (42 CFR 455.104(b)(1))
4B) Does the provider/disclosing entity have a Direct or Indirect Ownership Interest of 5% or more in any Subcontractor?
Yes No If Yes, provide the information below about any person (individual or entity) with an ownership or control interest, in any subcontractor in which the provider/disclosing entity has a 5 percent or more direct or indirect ownership or control interest. See definitions in Appendix A.
Name of Subcontractor (from section 4A):
Name of Person(s) with an ownership or control interest in the subcontractor:
TIN or SSN (as applicable) of Person(s):
Birthdate of Person(s):
Address (street/city/state/zip) of Person(s):
% Ownership Interest:
Name of Subcontractor (from section 4A):
Name of Person(s) with an ownership or control interest in the subcontractor:
TIN or SSN (as applicable) of Person(s):
Birthdate of Person(s):
Address (street/city/state/zip) of Person(s):
% Ownership Interest:
Name of Subcontractor (from section 4A):
Name of Person(s) with an ownership or control interest in the subcontractor:
TIN or SSN (as applicable) of Person(s):
Birthdate of Person(s):
Address (street/city/state/zip) of Person(s):
% Ownership Interest:
Section 5A – Relationships Disclosure (42 CFR 455.104(b)(2))
5A) Are any of the individuals disclosed in Section 3 above related to each other as a spouse, parent, child, or sibling?
Yes No If Yes, provide the following details:
Name (From Section 3):
Nature of Relationship (e.g., spouse):
Related to Name (From Section 3):
Name (From Section 3):
Nature of Relationship (e.g., spouse):
Related to Name (From Section 3):
Name (From Section 3):
Nature of Relationship (e.g., spouse):
Related to Name (From Section 3):
Section 5B – Relationships Disclosure (42 CFR 455.104(b)(2))
5B) Are any of the individuals disclosed in Section 3 above related to any of the individuals disclosed in Section 4B as a spouse, parent, child, or sibling?
Yes No If Yes, provide the following details:
Name (From Section 3):
Nature of Relationship (e.g., spouse):
Related to Name (From Section 4B):
Section 6 – Other Disclosing Entity Disclosure (42 CFR 455.104(b)(3))
6.1) Does the provider/disclosing entity or any one named in Section 3 have an Ownership or Control Interest in any other Medicaid provider?
Yes No N/A 6.2) Does the provider/disclosing entity or any one named in Section 3 have an Ownership or Control Interest in any other disclosing entity that does not participate in Medicaid but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, XX, or Title XXI of the Social Security Act?
Yes No N/A If Yes to Items 1 or 2 of this Section 6, provide the following details:
Name (From Section 3):
Name of other disclosing entity or other Medicaid Provider:
SSN and/or TIN, as applicable of the other entity/provider:
Section 7A – Business Transactions Disclosure (42 CFR 455.105)
7A) Business Transactions - Subcontractors: Has the provider/disclosing entity had any business transactions with a Subcontractor totaling more than $25,000 in the previous twelve (12) month period?
Yes No If Yes, provide the following details:
Name of Subcontractor:
TIN or SSN, as applicable of subcontractor:
Birthdate:
Address (street/city/state/zip):
Transaction Amount:
Section 7B – Significant Business Transactions Disclosure (42 CFR 455.105)
7B) Significant Business Transactions: Has the provider/disclosing entity had any Significant Business Transactions with a Wholly Owned Supplier or subcontractor during the previous 5-year period?
Yes No If Yes, provide the following details:
Type of Entity:
Wholly Owned Supplier Subcontractor
Name:
TIN or SSN, as applicable:
Birthdate:
Address (street/city/state/zip):
Transaction Amount:
Section 8 – Attestation
Through signature below, I hereby certify that persons with ownership and control interest in the provider/disclosing entity or in a subcontractor, agents, subcontractors, managing employees, and any employees providing healthcare services as part of this application are screened with the applicable background check including, but is not limited to, verification against the applicable state and federal exclusion databases. I hereby represent and warrant that all information contained in this form is true, correct, and complete in all aspects. I understand that misleading, inaccurate, or incomplete data may result in a denial of participation or termination of an existing contract. I further understand completion of this form does not guarantee participation with the Managed Care Organization.
Name:
Title:
Signature:
Date:
APPENDIX A
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Term/Words
Definition
1
Agent
Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. It also means any person who has express or implied authority to obligate or act on behalf of an entity (42 CFR 1001.1001).
2
Disclosing entity
Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent.
For purposes of completing the Medicaid Disclosure Form, solo practitioners and the group contracting entity are also treated as a “disclosing entity.”
Group Providers: The contracting group entity should complete the Form on behalf of the group.
3
Fiscal agent
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.
4
Group of practitioners
Group of practitioners means 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).
5
Health Insuring Organization (HIO)
Health insuring organization (HIO) has the meaning specified in § 438.2.
6
Indirect ownership interest
Indirect ownership interest means 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. It also means an ownership interest through any other entities that ultimately have an ownership interest in the entity in issue (42 CFR 1001.1001). (For example, an individual has a 10 percent ownership interest in the entity at issue if he or she has a 20 percent ownership interest in a corporation that wholly owns a subsidiary that is a 50 percent owner of the entity in issue.)
7
Managed care entity
Managed care entity (MCE) means managed care organizations (MCOs), PIHPs, PAHPs, PCCMs, and HIOs. These terms are defined in 42 CFR § 438.2.
8
Managing employee
Managing employee means 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 of, an institution, organization, or agency.
9
Other disclosing entity
Other disclosing entity means 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 programs established under title V, XVIII, or XX of the Act. This includes:
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);
Any Medicare intermediary or carrier; and
Any entity (other than an individual practitioner 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.
10
Ownership interest
Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. It also means an interest in:
The capital, the stock or the profits of the entity, or
Any mortgage, deed, trust or note, or other obligation secured in whole or in part by the property or assets of the entity.
11
Person with an ownership or control interest
Person with an ownership or control interest means a person or corporation that:
Has an ownership interest totaling 5 percent or more in a disclosing entity;
Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;
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;
Is an officer or director of a disclosing entity that is organized as a corporation; or
Is a partner in a disclosing entity that is organized as a partnership.
12
Prepaid ambulatory health plan (PAHP)
Prepaid ambulatory health plan (PAHP) has the meaning specified in § 438.2.
13
Prepaid inpatient health plan (PIHP)
Prepaid inpatient health plan (PIHP) has the meaning specified in § 438.2.
14
Primary care case manager (PCCM)
Primary care case manager (PCCM) has the meaning specified in § 438.2.
15
Significant business transaction
Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $ 25,000 and 5 percent of a provider’s total operating expenses.
16
Subcontractor
Subcontractor means:
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
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.
17
Supplier
Supplier means 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).
18
Termination
Termination means –
For a--
Medicaid or CHIP provider, a State Medicaid program or CHIP has taken an action to revoke the provider's billing privileges, and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired; and
Medicare provider, supplier or eligible professional, the Medicare program has revoked the provider or supplier's billing privileges, and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired.
In all three programs, there is no expectation on the part of the provider or supplier or the State or Medicare program that the revocation is temporary.
The provider, supplier, or eligible professional will be required to reenroll with the applicable program if they wish billing privileges to be reinstated.
The requirement for termination applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing privileges revoked for cause which may include, but is not limited to--
Fraud;
Integrity; or
Quality.
19
Wholly owned supplier
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.
