Free ForwardHealth Provider Change of Address or Status Completion Instructions, F01181A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1181A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

PROVIDER CHANGE OF ADDRESS OR STATUS COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to certify providers and to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Non-submission of changes in address or status may result in incorrect reimbursement, misdirected payment, claim denial, or suspension of payments. Provision of the information requested on this form is mandatory; however, the use of this version of the form is voluntary. Providers may develop their own version of this form as long as it includes all the information on this form. INSTRUCTIONS If a request is made to change an individual provider's file, ForwardHealth requires the individual provider's signature on the Provider Change of Address or Status form, F-1181. Signature stamps are not allowed. Complete all areas of the form affected by change. A change in ownership, group affiliation, federal tax identification number (Internal Revenue Service [IRS] number), etc., must be reported to ForwardHealth before the change. A change in address must be reported immediately after moving. Section I is required to be filled out in addition to the sections where the change to the provider file is indicated. It is imperative that the information in Section I is provided in order for ForwardHealth to update the correct provider file. SECTION I -- IDENTIFYING INFORMATION The information in this section pertains to the provider who performs ForwardHealth services and the location where the provider office is physically located and where the records are normally kept. Element 1 -- Name -- Provider This is a required field. Enter the individual provider's first name, middle initial, and last name, or the name of the clinic or facility. Element 2 -- Provider ID This is a required field. Enter the provider's National Provider Identifier (NPI). Non-healthcare providers are required to enter the provider number assigned by ForwardHealth at the time of certification. Element 3 -- Taxonomy Code This is a required field for health care providers and not applicable to specialized medical vehicle and personal care-only agencies. Enter the provider's taxonomy code assigned by ForwardHealth to be used to identify the provider file to be updated. Element 4 -- ZIP+4 Code This is a required field. Enter the complete ZIP+4 code for the practice location on file with ForwardHealth. Element 5 -- Updates on this form are applicable to the following programs. This is a required field. Check all programs to which the provider file changes apply. Only choose programs for which the provider is certified. SECTION II -- PRACTICE LOCATION INFORMATION Practice location is the street address where a provider office is physically located and where the records are normally kept. Elements 6 and 7 -- Name and Telephone Number -- Contact Person Enter the name and telephone number for the contact person. The contact person's telephone number is required when a contact person's name is entered. The contact person's information is used for ForwardHealth administrative purposes only. Element 8 -- Telephone Number -- For Member Use Enter the telephone number that members should use to contact the provider. This telephone number will be listed in a provider directory that is available to the public. Elements 9-13 -- Practice Location Address Enter the provider's complete practice location address (street, city, state, ZIP+4 code). This address is where the provider's office is physically located and where records are normally kept. It is not acceptable to indicate a drop box or P.O. Box for the practice location address.

PROVIDER CHANGE OF ADDRESS OR STATUS COMPLETION INSTRUCTIONS F-1181A (10/08)

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Element 14 -- County Enter the county of the provider's practice location. SECTION III -- PROVIDER FINANCIAL INFORMATION ForwardHealth will generate payments to the provider and report income to the IRS using this information. This information must be the current taxpayer information on file with the IRS. Taxpayer Information Element 15 -- Taxpayer Identification Number (TIN) This is a required field. Enter the TIN that should be used to report income to the IRS. Element 16 -- Name -- Taxpayer This is a required field. Enter the taxpayer's name for the TIN indicated in Element 15. The name entered must be the same name that is on file with the IRS. Element 17 -- TIN Type This is a required field. Indicate whether the TIN indicated in Element 15 is an Employer Identification Number (EIN) or a Social Security number (SSN). Element 18 -- TIN Effective Date Enter the effective date of the TIN. Element 19 -- TIN End Date Enter the end date of the TIN. Checks and Remittance Advice Address Elements 20-24 -- Address These are required fields. Enter the complete address to which checks and remittance advices should be mailed. Elements 25-26 -- Name and Telephone Number -- Contact Person Enter the financial contact person's name and telephone number. SECTION IV -- IRS FORM 1099 MAILING ADDRESS ForwardHealth will mail the IRS Form 1099 to this address. IMPORTANT: Only one 1099 will be sent per TIN. If the provider completing this form is not responsible for receiving the 1099, the provider should not complete this section. Elements 27-31 -- IRS Form 1099 Mailing Address Enter the complete address to which the IRS Form 1099 should be sent. (Enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code). SECTION V -- MAILING INFORMATION Indicate the address where ForwardHealth should send general information and correspondence. Element 32 -- Name ­ Mail To Enter the first name, middle initial, last name, or the name of the office, clinic, facility, or place of business for the mailing address. Element 33 -- Name -- Attention Line Enter attention line information ForwardHealth should use for mailing general information and correspondence. Elements 34-38 -- Mailing Address Enter the provider's complete mailing address (enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code).

PROVIDER CHANGE OF ADDRESS OR STATUS COMPLETION INSTRUCTIONS F-1181A (10/08)

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SECTION Vl -- PRIOR AUTHORIZATION INFORMATION Indicate the address where ForwardHealth should send prior authorization (PA) information. This section is not applicable for Wisconsin Well Woman Program providers. Element 39 -- Name -- Provider Enter the first name, middle initial, last name, and title or the name of the office, clinic, facility, or place of business for the PA address. Element 40 -- Name -- Attention Line Enter the attention line information that ForwardHealth should use for mailing PA information. Elements 41-45 -- Address Enter the provider's complete PA address. (Enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code). Elements 46 -- Fax Number Enter the fax number. Elements 47 -- Telephone Number -- Contact Person Enter the telephone number for the contact person. SECTION Vll -- SUPERVISING PROVIDER INFORMATION For non-billing providers only. Indicate the following information for the non-billing provider's supervisor. Element 48 -- Name -- Supervisor Enter the supervisor's first name, middle initial, and last name. Element 49 -- Telephone Number -- Supervisor Enter the supervisor's telephone number, including the area code. Elements 50-54 -- Address Enter the supervisor's complete address. (Enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code). Elements 55 -- Effective Date of Supervision Enter the date the supervisor began supervising the non-billing provider. SECTION VIII -- GENERAL INFORMATION Enter other miscellaneous information regarding the provider. Elements 56 -- Language(s) Indicate the language(s) spoken by the organization's staff who are available to interpret for members. This information will be used in a provider directory that will be made available to the public. Check all that apply. Element 57a-d -- Drug Enforcement Agency (DEA) Information Enter the DEA number(s) for the provider. Additional space is provided to allow for multiple DEA numbers. Elements 58-63 Indicate the provider's Medicare enrollment(s) and the effective date(s). If an organization has identified subparts for the purpose of submitting claims to Medicare, and the NPIs will only appear on automatic crossover claims to ForwardHealth, enter the Secondary NPIs. SECTION IX -- AUTHORIZED SIGNATURE INFORMATION Element 64 -- Signature -- Provider The signature of the individual provider or authorized representative of a clinic or facility provider is required. Signature stamps and electronic signatures are not acceptable. Element 65-- Date Signed This is a required field. Enter the month, day, and year (in MM/DD/CCYY format) this form was completed and signed.