Maintenance User Guide Facility/Agency/Organization (FAO .
Maintenance User Guide –Facility/Agency/Organization (FAO)forState of Idaho MMISNote: If you are a Mental Health Clinic, Rehabilitative Mental Health Service, or MentalHealth Case Management, you must enroll and maintain your records with Optum Idaho(see Section 1 Introduction).Date of Publication: 02/24/2021Document Number: TRN152Version: 3.0 2020-2021 Gainwell Technologies Company. All rights reserved.
Idaho MMISMaintenance User Guide - FAOTable of Contents1.2.3.4.Introduction . 3System Requirements . 3Start Enrollment . 3Business Info Tab . 54.1. Name and Tax ID Tab . 54.2. Contacts Tab . 54.3. Billing Provider Info Tab . 64.4. Address Tab . 75. Ownership Info Tab . 85.2. Relationship Tab . 125.3. Control Interest Tab . 126. Service Locations . 136.1. Address Tab . 136.2. Office Hours Tab . 156.3. Services Tab. 166.4. Provider Type/Specialty Tab . 176.5. Programs Tab . 226.6. Healthy Connections Tab . 236.7. Facility or Group Information Tab . 247. Rendering Providers . 257.1. Rendering Provider Tab . 257.2. Provider Type/Specialty Tab . 277.3. Affiliation Tab . 308. Documents . 308.1. Financial Agreement Tab . 308.2. Supporting Docs . 329. Signature . 329.1. Signature . 3310.Resuming an Existing Maintenance . 34Last Updated: 02/24/2021Page ii
Idaho MMIS1.Maintenance User Guide - FAOIntroductionThank you for your participation in the Idaho Medicaid program. Enrolled Medicaid providersare required to keep their records current, per the Idaho Medicaid Agreement. Allmaintenance is performed electronically through the Provider Enrollment Application locatedon the Gainwell Technologies Provider Portal. Only an enrolled and approved provider canperform maintenance.To learn more about the Idaho Behavioral Health Plan, or to maintain your provider record,please contact the Optum Idaho Regional Network Manager in your area. Regional NetworkManagers are listed on the Regional Representation Flyer found at www.optumidaho.com Contact Us tab.The Maintenance User Guide- FAO describes the maintenance process for a Facility, Agencyor Organization.If you are not an FAO, refer to the appropriate maintenance user guide for instructions,which can be found here on the Gainwell Technologies Provider Portal.Maintenance may be performed to update or change items such as, but not limited to, thefollowing: Add or remove:o an owner/board membero a service location Provide updated licensure, certification, and insurance information, such asexpiration dates. Update contact and address information Update EFT informationNote: The Pay-to NPI number cannot be changed when performing a maintenance. A newenrollment application is required if the Billing or Pay-To NPI number is changed.For a complete explanation of the fields presented on the application or the informationrequired in the fields, please see the Provider Enrollment FAO User Guide.2.System RequirementsTo utilize all features of the provider enrollment application, ensure that your computersystem meets the following minimum requirements: Internet browser 11 Microsoft Edge 85.x Google Chrome 85.x Safari 5.1.7 Mozilla Firefox 33 and 34 Acrobat Reader DC Screen Resolution of 1024 x 768 or higher3.Start EnrollmentTo access the Provider Enrollment Application portal, sign into your secure Trading PartnerAccount. Hover over the Account Maintenance tab and select the Provider Enrollment Link.Last Updated: 02/24/2021Page 3 of 35
Idaho MMISMaintenance User Guide - FAOTo start a maintenance case, select the arrow icon associated to the record in the MyEnrollment Applications table, and select the Maintenance link.Note: If a maintenance case is in process, it must be completed and approved before a newmaintenance case can be initiated.After beginning the maintenance case, all details that were provided during the enrollmentwill be auto-populated. To add or update information on the record, navigate to theappropriate tab or sub-tab within the application, and save the data. The maintenanceapplication will not be submitted, unless the Submit button is selected on the final page ofthe application.The Enrollment Case Number field on the application banner will shows the case numberfollowed by a hyphen, which indicates the number of times maintenance has beenperformed on the record. An email with the case number is sent to the contact emailaddress on file.Last Updated: 02/24/2021Page 4 of 35
Idaho MMIS4.Maintenance User Guide - FAOBusiness Info TabThe Business Info tab will include details related to the Billing Provider including thebusiness name, office contact information, W9 details and address information.4.1. Name and Tax ID TabThe Name and Tax ID tab, located in the sub-menu on the Business Info tab. The followingcan be updated through a maintenance case:4.1.1. Business Info SectionFEIN*4.1.2.Organization Section Legal Name (must match W9) * Email and Re-Type Email *Note: The email provided in this portion of the application will used for any futurecorrespondence related to this provider record, and any other necessary emailcommunications. Doing Business As Billing Provider Name *4.2. Contacts TabThe Contacts tab is located in the sub-menu on the Business Info tab, the following can beupdated through a maintenance case:Last Updated: 02/24/2021Page 5 of 35
Idaho MMISMaintenance User Guide - FAO Contact Title*Note: If Other is selected, the Other Title* box is populated to allow the user to providean explanation of the individuals’ title. Contact Name* Primary Phone* Secondary Phone Mobile Phone Emergency Phone Fax Number4.3. Billing Provider Info TabThe Billing Provider Info tab, located in the sub-menu on the Business Info tab, includesinformation related to the legal name, tax reporting details and the physical address of theBilling Provider, the following can be updated through a maintenance case:4.3.1.Billing Provider Info Section Billing Provider Name*Note: The Billing Provider Name field is auto-populated from the details provided on theName and Tax ID tab. If changes need to be made, return to the Name and Tax ID tab. Doing Business AsNote: The Doing Business As field is auto-populated from the details provided on the Nameand Tax ID tab. If changes need to be made, return to the Name and Tax ID screen. Billing Provider Tax Entity*Note: If Other is selected, the W9 Please Explain* box is populated to allow the user toprovide an explanation of the Groups’ tax entity type chosen. W9 Exempt Payee* Provider Profit Status* Corporation Type*Note: Gainwell Technologies cannot provide guidance on tax-related selections for theprovider. Please consult with a tax professional to determine selections, if necessary or referto IRS site. Fiscal Year End Date (MM)* Fiscal Year End Date (DD)*Last Updated: 02/24/2021Page 6 of 35
Idaho MMISMaintenance User Guide - FAO4.3.2. Physical Address Section Services are performed at the billing provider locationNote: This field cannot be unchecked. If services are no longer performed at the billingprovider location, the service location must be terminated. Address Line 1*Note: If the address for the Billing Provider is updated, and the Services are performedat the billing provider location box is checked, the service location address on theService Locations screen will automatically be updated. Address Line 2 Zip Code* Zip Code Extn*Note: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. City, County, State, and Country*4.4. Address TabThe Address tab, located in the sub-menu on the Business Info tab, includes informationrelated to the W9 and mailing address of the Billing Provider, the following can be updatedthrough a maintenance case:4.4.1.W9 Address Section W9 Address Line 1*Note: If the Same as Physical Address box is checked, and the auto-populated informationin the W9 address fields is incorrect, the information will need to be corrected on the BillingProvider Info tab. Navigate back to this tab, located in the sub-menu to make the necessarycorrection(s). W9 Address Line 2 W9 Zip Code* W9 Zip Code Extension*Last Updated: 02/24/2021Page 7 of 35
Idaho MMISMaintenance User Guide - FAONote: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. W9 City*, County*, State*, and Country*4.4.2. Mailing Address Section Address Line 1*Note: If the Same as Physical Address box is checked, and the auto-populated informationin the W9 address fields is incorrect, the information will need to be corrected on the BillingProvider Info tab. Navigate back to this tab, located in the sub-menu to make the necessarycorrection(s). Address Line 2 Zip Code* Zip Code Extension*Note: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. City*, County*, State*, and Country*5.Ownership Info TabThe Ownership Info section will contain questions related to the ownership of the entity,including demographics, legal information, relationships, and controlling interest details forall owners, board members/directors, and managing employees. All individuals who meetthe criteria, per 42 CFR 455.100-106, should be reported in this section. Once the individualis reported, they will display in the Ownership/Board Member table.If an existing owner/board member’s information is being updated, select the individual ororganization from the table and choose EDIT to update information or DELETE to removethem as an owner/board member. To add a new owner/board member, choose ADD.Last Updated: 02/24/2021Page 8 of 35
Idaho MMISMaintenance User Guide - FAONote: A board member should be reported as a managing employee.5.1.1.Ownership Board SectionThe Ownership/Board member section displays the following questions, related to theperson or entity that meets the criteria to be reported. The following can be added orupdated through a maintenance case:If the Tax ID Type of SSN was selected, the following fields are displayed ():Tax ID Type*Type*First Name*Middle NameLast Name*SuffixSSN*Date of Birth*PositionBirth CityBirth StateBirth CountryBegin Date*Term DateLast Updated: 02/24/2021Page 9 of 35
Idaho MMISIf the Maintenance User Guide - FAOTax ID Type of FEIN was selected, the following fields are displayed ():Organization Name*FEIN*Begin Date*Term DateFor each individual or entity reported in this section, the following screen and questionsmust be answered by selecting the Yes or No radio buttons. If Yes is chosen, two fields willpopulate; Date and Description. The date associated to the incident and details about theinstance are required. Neglect, Abuse, or Fraud. Any individual or entity with a finding by agovernmental agency of endangering the health or safety of the patient, orof patient abuse, neglect or exploitation involved in neglect or abuse of apatient, fraud, theft, embezzlement, breach of fiduciary responsibility, orother financial misconduct, unlawful manufacture, distribution, prescriptionor dispensing of a controlled substance*Select Yes or No. If Yes is chosen, provide the Date and Description associated tothe incident. A Felony or Criminal offense. Any individual or entity convicted of a felonyor criminal offense under federal or state law related to Medicare, Medicaid,or any federal agency or program*Select Yes or No. If Yes is chosen, provide the Date and Description associated tothe incident.Last Updated: 02/24/2021Page 10 of 35
Idaho MMISMaintenance User Guide - FAO Failed to Repay. Any individual or entity that has failed to repay theDepartment monies which had been previously determined to have beenowed to the Department*Select Yes or No. If Yes is chosen, provide the Date and Description associated tothe incident. Civil Monetary Penalties. Any individual or entity that has had civil moneypenalties or assessments imposed*Select Yes or No. If Yes is chosen, provide the Date and Description associated tothe incident. Sanctioned, Terminated, or Excluded as a Medicaid Provider. Any individualor entity that was the managing employee, officer, or owner of an entity,whose provider agreement was sanctioned, terminated or excluded as aMedicaid Provider*Select Yes or No. If Yes is chosen, provide the Date and Description associated tothe incident.5.1.2.Ownership Physical Address SectionThe Ownership Physical Address section is related to the individual or entity, who wasreported in the section above. The following can be added or updated through amaintenance case: Address Line 1* Address Line 2 Zip Code* Zip Code Extension*Note: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. City*, County*, State*, and Country*5.1.3.Ownership Mailing Address SectionThe Ownership Mailing Address section is related to the individual or entity, who wasreported in the section above. The following can be added or updated through amaintenance case: Address Line 1* Address Line 2 Zip Code* Zip Code Extension*Note: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. City*, County*, State*, and Country*Last Updated: 02/24/2021Page 11 of 35
Idaho MMISMaintenance User Guide - FAO5.2. Relationship TabThe Relationship tab and section will contain questions to define the relationship betweentwo or more individuals reported. This section will only apply if there is more than oneindividual reported with an SSN. Are any Owners/Board Members of this entity related to any otherOwners/Board Members of this entity?Select the radio button, Yes or No. If Yes, the following will populate: Owner/Board Member 1* Relationship* Owner/Board Member 2*Once all individuals have been appropriately reported or updated, select SAVE ANDCONTINUE to save and advance to the next tab.5.3. Control Interest TabIf the entity or any individual reported in the Ownership section of the enrollmentapplication holds any ownership or controlling interest in another organization that bills forMedicaid services, it is required to be reported.If an existing information is being updated, select the individual or organization from thetable and choose EDIT to update information or DELETE to remove them as anowner/board member. To add a new owner/board member, choose ADD. Does any owner or board member have ownership or control interest inother organizations that bill Medicaid for services? If so, please specify*Select the radio button, Yes or No.Last Updated: 02/24/2021Page 12 of 35
Idaho MMIS6.Maintenance User Guide - FAOService LocationsThe Service Location tab will allow the provider to maintain all service locations, includingprovider demographics and provider type-specialty information for each of the locations.The following fields will display for the Service Location and can be provided or updatedthrough a maintenance:6.1. Address TabProvide or update the following information for each service location, as needed.It is important to note that the information reported in this section will be used in the OnlineHealthPAS Provider Directory, for Referrals, to complete accurate billing, and for PriorAuthorization submissions.If an existing service location is being updated or terminated, select the service locationfrom the table and choose EDIT to update.To add a service location, choose ADD.Last Updated: 02/24/2021Page 13 of 35
Idaho MMIS6.1.1. Service Location Details SectionService Location Name*Primary Phone*FaxTerm DateReason for Disenrollment* (required only when a term date has been entered)Email*Provider Profit Status*6.1.2. Maintenance User Guide - FAOPhysical Address SectionAddress Line 1*Address Line 2Zip Code*Zip Code Extension*City*, County*, State*, and Country*6.1.3.Mailing Address Section Address Line 1* Address Line 2 Zip Code* Zip Code Extension*Note: The zip code extension will automatically populate as “0000”. If the zip code is in twoor more counties the zip code extension must be provided in order for the City and Countyto auto-populate correctly. City*, County*, State*, and Country*Once all service locations have been appropriately reported or updated, select SAVE ANDCONTINUE to save and advance to the next tab.Last Updated: 02/24/2021Page 14 of 35
Idaho MMISMaintenance User Guide - FAONote: If the service location that a termination date was entered for is a HealthyConnections service location, additional action is required on the Provider Type andSpecialty screen.6.2. Office Hours TabThe Office Hours tab is provided for each service location, and this will allow the entity toprovide the hours of operations for the location, including periods of closure.24 Hours or Selected Hours*To populate Office Hours, select the clock icon and choose the time from theavailable selection*Select the clock next to the day of the wee
The Maintenance User Guide- FAO describes the maintenance process for a Facility, Agency or Organization. If you are not an FAO, refer to the appropriate maintenance user guide for instructions, which can be found here on the Gainwell Technologies Provider Portal. Maintenance may be perform
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