Fill and Sign the Unitedhealthcare Community Plan Provider Disclosure Form Provider Entity 7 2015docx

Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement UnitedHealthcare Community Plan (“UnitedHealthcare”) is required to collect disclosure of ownership, controlling interest and management information from providers that participate in the Medicaid and/or the Children’s Health Insurance Program (CHIP) managed care network pursuant to a Medicaid and/or CHIP State Contract with the State Agency and the federal regulations set forth in 42 CFR Part §455. Required information includes: 1) the identity of all owners and others with a controlling interest; 2) certain business transactions as described in 42 CFR §455.105; 3) the identity of managing employees, agents and others in a position of influence or authority; and 4) criminal conviction information for the provider, owners, officers, directors, agents and managing employees. The information required includes, but it is not limited to, name, address, date of birth, social security number (SSN) and tax identification (TIN). Completion and submission of this Statement is a condition of participation in the Medicaid and/or CHIP managed care network and is a contractual obligation with UnitedHealthcare for services to members under Medicaid and CHIP benefit plans. Failure to submit the requested information may result in denial of a claim, a refusal to enter into a provider contract, or termination of existing provider contracts. This Statement should be submitted with the initial contract and updated every three (3) years or at the renewal of the contract and at any time there is a revision to the information or upon a request for updated information. A Statement must be provided within 35 days of a request for this information. Physician and health care professional members of a group practice that are credentialed or enrolled into the Medicaid or CHIP managed care program by UnitedHealthcare or by a delegate of UnitedHealthcare must submit a signed Individual Provider Statement attesting to the requirements under these regulations at the time of credentialing, enrollment, or contracting, if requested by UnitedHealthcare or by a delegate of UnitedHealthcare. Any members of a group practice that have an ownership or controlling interest in the Provider Entity identified below, or is related to another owner of the Provider Entity, must submit a signed Individual Provider Statement. Detailed instructions and a glossary for capitalized terms can be found at the end of this form. If attachments are included, please indicate to which section those attachments refer. Contracted Provider Entity Information Please fill out the entire section. Every field must be complete. If fields are left blank, the form will not be processed and will be returned for corrections/completeness. If the form is unreadable due to illegible handwriting, the form will not be processed. As applicable, if Provider Entity is a medical group or facility, attach a roster of individual providers covered under this Statement. Please include provider name, address, date of birth, and social security number. Do you have a roster to attach? ____Yes ____No Type of disclosing entity. Please choose appropriate category: ___ Partnership ___ Non-Profit ___ Corporation ___ Limited Liability Corporation (LLC) ___ Government/Public Entity ___ HCBS Provider ___Other:_________________________________ Name of Person Completing the Form Title Phone Number Fax Email In which state do you -select oneparticipate in Medicaid? _________________ Legal Name (“Provider Entity”): DBA Name (if different from Provider Entity Legal Name): Complete Address (must include at least one street address; corporations must include the primary business and every business location and P.O. Box address; hospital systems must include address of the corporate headquarters): STREET CITY STATE ZIP Additional Addresses (list all Practice locations – attach a separate sheet if necessary): Do you have a list to attach? ___Yes ___No **Federal Tax ID/SSN #: *Medicaid ID #: *National Provider ID (NPI) #: *CAQH #: ___Applied for NPI ___Applied for Medicaid ID ___Applied for CAQH ____Not Applicable ____Not Applicable ____Not Applicable *These fields cannot be left blank; “N/A” non-applicable and “applied for” are acceptable responses. **Individual providers please use social security number; field cannot be left blank: “N/A” non-applicable and “applied for” are acceptable responses UnitedHealthcare Provider Entity Disclosure Form 01/2016 Section I: Identification of All Owners Are there any individuals or organizations with a Direct or Indirect Ownership of 5% or more in the Provider Entity? ___Yes___No Do you have a list to attach? ___Yes____No If yes, list the name, primary address, date of birth (DOB) and Social Security Number (SSN) for each person having a Direct or Indirect Ownership Interest in the Provider Entity of 5% or greater. List the name, Tax Identification Number (TIN), primary business address, every business location and P.O. Box address of each organization, corporation, or entity having a Direct or Indirect Ownership Interest of 5% or greater. (42 CFR §455.104(b)(1)) Attach additional sheet as necessary Name of Owner DOB Complete Address (Street/City/State/Zip) ** SSN (individual) and/or % (mm/dd/yyyy) TIN (entity) Interest List both as applicable Street City Street State -select one- Zip City Street State City State -select one- Zip -select oneZip Section II: Identification of All Individuals & Entities with a Controlling Interest Board of Directors: Does the Provider Entity have a Board of Directors or other governing body? ___Yes __No Do you have a list to attach? ___Yes____No If yes, list each member of the Board of Directors or Governing Board for corporations, including the name, date of birth (DOB), address, and Social Security Number (SSN) (42 CFR §455.104(b)(1)) Attach additional sheets as necessary Name DOB Complete Address (Street/City/State/Zip) ** SSN (mm/dd/yyyy) Street City Street State -select oneZip -select one- City State Zip Officers and Directors: Does the Provider Entity have any officers or directors (e.g., CEO, VP of Finance, etc.)? ___Yes __No Do you have a list to attach? ___Yes____No If yes, list all corporate officers and directors, including the name, date of birth (DOB), address, and Social Security Number (SSN) and applicable title or position (42 CFR §455.104(b)(1)) Attach additional sheets as necessary DOB Complete Address(Street/City/State/Zip) Name ** SSN Title (mm/dd/yyyy) Street City State-select one- Zip Street City State -select one- Zip Are there any other individuals or entities with a Controlling Interest in the Provider Entity (e.g., business partners, etc.)? ___Yes___No If yes, list the name, address, date of birth (DOB) and Social Security Number (SSN) for each person having a Controlling Interest in the Provider Entity. List the name, Tax Identification Number (TIN), primary business address, every business location and P.O. Box address of each organization, corporation, or entity having a Controlling Interest. (42 CFR §455.104(b)(1)) Attach additional sheets as necessary Do you have a list to attach? ___Yes____No Name of Individual or Entity Complete Address (Street/City/State/Zip) ** SSN (individual) DOB and/or TIN (entity) (mm/dd/yyyy) Title (as applicable) Street City Street State -select one- City State -select one- Zip Zip ** SSN and TIN required under §455.104; see Sect 4313 of Balanced Budget Act of 1997 amended Sec. 1124 and Federal Register Vol. 76 No. 22 UnitedHealthcare Provider Entity Disclosure Form 01/2016 Section III: Ownership & Controlling Interest in Other Disclosing Entities Do any of the individuals or entities identified in Section I have an Ownership or Controlling Interest in any Other Disclosing Entity? ___Yes ___No Do you have a list to attach? ___Yes____No If yes, list the name and the SSN or TIN of the Other Disclosing Entity in which the Owner identified in Section I also has an Ownership or Controlling Interest. (42 CFR §455.104(b)(3)) Attach additional sheet as necessary Name of Owner from Section I Name of Other Disclosing Entity Other Disclosing Entity’s SSN (individual) or TIN (entity) Section IV: Ownership & Controlling Interest in Subcontractors Does the Provider Entity have a Direct or Indirect Ownership Interest of 5% or more in any Subcontractor? ___Yes ___No If yes, does another individual or organization also have an Ownership or Controlling Interest in the same Subcontractor? ___Yes ___No If yes, list the following information for each person or entity with an Ownership or Controlling Interest in any Subcontractor in which the Provider Entity also has Direct or Indirect Ownership Interest of 5% or more. (42 CFR §455.104(b)(1)&(2)) Attach additional sheets as necessary. Do you have a list to attach? ___Yes____No Subcontractor TIN/SSN Legal Name of Subcontractor Name of Other Individual/Entity with Ownership or Controlling Interest Other Individual/Entity’s Complete Street Address Street/City/State/Zip) Other Entity’s TIN City Other Individual’s SSN Other Individual’s DOB State Zip % Interest in Subcontractor (mm/dd/yyyy) Subcontractor TIN/SSN Legal Name of Subcontractor Name of Other Individual/Entity with Ownership or Controlling Interest Other Individual/Entity’s Complete Street Address Street/City/State/Zip) Other Entity’s TIN City Other Individual’s SSN Other Individual’s DOB State Zip % Interest in Subcontractor (mm/dd/yyyy) Section V: Familial Relationships Are any of the individuals identified in Sections I, II, III or IV related to each other? ____Yes If yes, list the individuals identified and the relationship to each other (e.g., spouse, sibling, parent, child) ____No (42 CFR §455.104(b)(2)) Attach additional sheets as necessary Do you have a list to attach? ___Yes____No Name of Individual #1: Name of Individual #2: Relationship Medical Groups Only: Are any provider members of the group related to the listed owners or those with a controlling interest? ___Yes ___No Do you have a list to attach? ___Yes____No If yes, list the following information for each group provider member related to the listed owners and those with a controlling interest. Attach additional sheets as necessary. Note: each provider member listed must submit a signed Individual Provider Statement. Name of group provider UnitedHealthcare Provider Entity Disclosure Form 01/2016 Relationship DOB (mm/dd/yyyy) SSN Section VI: Criminal Convictions, Sanctions, Exclusions, Debarment and Terminations* 1. Has the Provider Entity, or any person who has an Ownership or Controlling Interest in the Provider Entity, or who is an Agent or Managing Employee of the Provider Entity ever been convicted of a crime related to that person’s involvement in any program under Medicaid, Medicare, CHIP or a Title XX program since the inception of those programs? ___Yes ___No If yes, list those persons and the required information below. (42 CFR §455.106) Attach documentation and additional sheets as necessary Do you have documents to attach? ___Yes____No Name DOB (mm/dd/yyyy)  SSN (individual) or TIN (entity) State of Conviction -select one- Complete Address (Street/City/State/Zip) Street State -select one- City Zip Matter of the Offense Date of Conviction(mm/dd/yyyy)  Date of Reinstatement(mm/dd/yyyy) 2. Has the Provider Entity, or any person who has an Ownership or Controlling Interest in the Provider Entity, or who is an Agent or Managing Employee of the Provider Entity ever been sanctioned, excluded or debarred from Medicaid, Medicare, CHIP or a Title XX program?___Yes ___No If yes, list those persons and the required information below. (42 CFR §455.436) Attach documentation and additional sheets as necessary Do you have documents to attach? ___Yes____No Name DOB (mm/dd/yyyy) SSN (individual) or TIN (entity) Complete Address (Street/City/State/Zip) Street City State -select one- Zip Reason for Sanction, Exclusion or Debarment Date(s) of Sanctions, Exclusions or Debarments (mm/dd/yyyy) Date of Reinstatement List all States where currently excluded: (mm/dd/yyyy)  3. Has the Provider Entity, or any person who has an Ownership or Controlling Interest in the Provider Entity, or who is an Agent or Managing Employee of the Provider Entity ever been terminated from participation in Medicaid, Medicare, CHIP or a Title XX program? ___Yes ___No If yes, list those persons and the required information below. Attach documentation and additional sheets as necessary Do you have documents to attach? ___Yes____No Name DOB (mm/dd/yyyy) SSN(individual) or TIN (entity) Complete Address (Street/City/State/Zip) Street City State -select one- Zip Reason for Termination Date of Termination (mm/dd/yyyy) State that originated Termination -select one- Date of Reinstatement (mm/dd/yyyy) Medicare billing privileges revoked? Yes_____ No______ *At any time during the Contract period, it is the responsibility of the Provider Entity to promptly provide notice upon learning of convictions, sanctions, exclusions, debarments and terminations (See Fed. Register, Vol. 44, No. 138) UnitedHealthcare Provider Entity Disclosure Form 01/2016 Section VII: Business Transaction Information Business Transactions - Subcontractors: Has the Provider Entity had any business transactions with a Subcontractor totaling more than $25,000 in the previous twelve (12) month period? ____Yes ____No Do you have a list to attach? ___Yes____No If yes, list the information for Subcontractors with whom the Provider Entity has had business transactions totaling more than $25,000 during the previous 12 month period ending on the date of this request (42 CFR §455.105(b)(1)) Attach additional sheets as necessary Name of Subcontractor: Subcontractor’s SSN (individual) or TIN (entity): Subcontractor’s Street Address City: State: Name of Subcontractor’s Owner: Subcontractor’s Owner’s SSN/TIN: Subcontractor’s Owner’s Street Address City: State: -select one- -select one- ZIP ZIP Significant Business Transactions – Wholly Owned Suppliers: Has the Provider Entity had any Significant Business Transactions with a Wholly Owned Supplier exceeding the lesser of $25,000 or 5% of operating expenses during any one fiscal year in the past Do you have a list to attach? ___Yes____No five (5) year period? ____Yes ____No If yes, list the information for any Wholly Owned Supplier with whom the Provider Entity has had any Significant Business Transactions exceeding the lesser of $25,000 or 5% of operating expenses during any one fiscal year in the past 5-year period (42 CFR §455.105(b)(2)) Attach additional sheets as necessary. See Glossary for definition. Name of Supplier: Supplier’s Street Address Supplier’s SSN (individual) or TIN (entity): City: State: -select one- ZIP Significant Business Transactions – Subcontractors: Has the Provider Entity had any Significant Business Transactions with a Subcontractor exceeding the lesser of $25,000 or 5% of operating expenses during any one fiscal year in the past five (5) year period? ____Yes ____No Do you have a list to attach? ___Yes____No If yes, list the information for Subcontractor with whom the Provider Entity has had any Significant Business Transactions exceeding the lesser of $25,000 or 5% of operating expenses during any one fiscal year in the past 5-year period (42 CFR §455.105(b)(2)) Attach additional sheets as necessary. See Glossary for definition. Name of Subcontractor: Subcontractor’s Street Address Subcontractor’s SSN (individual) or TIN (entity): City: State: ZIP -select one- Name of Subcontractor’s Owner: Subcontractor’s Owner’s SSN/TIN: Subcontractor’s Owner’s Street Address City: State: -select one- ZIP This information must be provided and/or updated within 35 days of a request. Medicaid payments may be denied for services furnished during the period beginning on the day following the date the information was due until it is received. (42 CFR §455.105) UnitedHealthcare Provider Entity Disclosure Form 01/2016 Section VIII: Management & Control Managing Employees: Does the Provider Entity have any Managing Employees? _____Yes ____No see Glossary for definition Do you have a list to attach? ___Yes____No If yes, list all Managing Employees that exercise operational or managerial control over, or who directly or indirectly conduct the dayto-day operations of Provider Entity (e.g., general manager, business manager, administrator or dept. manager, etc.), including the name, date of birth (DOB), address, Social Security Number (SSN), and title (42 CFR §455.104(b)(4)) Attach additional sheets as necessary Name DOB Complete Address (Street/City/State/Zip) SSN Title (mm/dd/yyyy) Street City Street State -select one- Zip City Street State -select one- Zip City Street State -select one- Zip City State -select one- Zip Agents: Does the Provider Entity have any Agents? ____Yes ___No Do you have a list to attach? ___Yes____No If yes, list all Agents that have been delegated the authority to obligate or act on behalf of Provider Entity (e.g., purchasing agent, broker, etc.), including the name, date of birth (DOB), address, and Social Security Number (SSN) (42 CFR §455.104) see Glossary for definition. Attach additional sheets as necessary Name DOB Complete Address (Street/City/State/Zip) SSN (mm/dd/yyyy) Street City Street State City State -select one- -select one- Zip Zip Through signature below, I hereby certify that any employees or contractors providing services pursuant to a contract with UnitedHealthcare Community Plan are screened with the applicable background check including, but not limited to, verification against the OIG's List of Excluded Individuals & Entities and any applicable state, federal or other governmental exclusion or sanction databases and that the information provided herein is true, accurate and complete. Additions or revisions to the information above will be submitted immediately upon revision. Additionally, I understand that misleading, inaccurate, or incomplete data may result in a denial of a claim and/or termination of the contract. Signature Title (indicate if authorized Agent) Full Name (please print) ____________________________ Phone Number Date ____________________________ Fax Number UnitedHealthcare Provider Entity Disclosure Form 01/2016 ___________________________________ Email Address Instructions for Disclosure of Ownership/Controlling Interest and Management Statement If additional space is needed, please note on the form that the answer is being continued, and attach a sheet referencing the section number that is being continued. (For example: Section I Ownership Information, continued). Please see Glossary for definitions of capitalized terms. Section I: Identification of All Owners: Please list the required information for each individual or organization that has a Direct or Indirect Ownership of 5% or more in your entity. If the Owner is a corporation: the primary business address must be listed and every business location and P.O. Box address. Provider members of a group practice who have ownership or a controlling interest in the Provider Entity must submit a separate Statement. Section II: Identification of All Individuals & Entities with a Controlling Interest: Please list the required information for each individual or organization that has a Controlling Interest in your entity. Individuals with a Controlling Interest include officers and directors of a corporation, as well as the governing board (see Glossary for definition). Providing the SSN and TIN (as applicable) is required under 42 CFR 455.104; please see Section 4313 of the Balanced Budget Act of 1997, amended Section 1124, and the Federal Register Vol. 76 No. 22. Any form without the required SSN and TIN (as applicable) is incomplete and will not be processed. Section III: Ownership & Controlling Interest in Other Disclosing Entities: Please identify the other providers or entities that are owned or controlled at least 5% by the same individual or organization identified in Sections I & II that have an Ownership or Controlling Interest in your entity. This information is to identify shared and interconnected ownership and controlling interests. Section IV: Ownership & Controlling Interest in Subcontractors: If your entity has a Direct or Indirect Ownership of 5% or more in a Subcontractor and other individuals or entities also have a Direct or Indirect Ownership or a Controlling Interest in that same Subcontractor, please identify the Subcontractor and provide the required information for the additional individuals and entities. Section V: Familial Relationships: Report whether any of the persons listed in Sections I, II, III or IV are related to each other and identify the parties and their relationship. Provider members of a group practice who are related to the Provider Entity’s owners or those with a controlling interest must submit a separate Statement. Section VI: Criminal Convictions, Sanctions, Exclusions, Debarment and Terminations: List your own criminal convictions, exclusions, sanctions, debarments and terminations, and for any person who has an ownership or controlling interest, or is an agent or managing employee of your entity. List all offenses related to each person’s or entity’s involvement in any program under Medicare, Medicaid, CHIP or the Title XX services since the inception of these programs. Review all of the databases necessary to verify this information. Section VII: Business Transaction Information: 1. List the Ownership of any Subcontractors that you have had business transactions totaling more than $25,000 within the last twelve (12) month period ending on the date of the request. 2. List any Significant Business Transaction between your entity and any Wholly Owned Supplier during the past 5 years. 3. List any Significant Business Transaction between your entity and any Subcontractor during the past 5 years. Remember that a Significant Business Transaction is defined as any transaction or series of related transactions that exceeds the lesser of $25,000 or 5% of a provider’s operating expenses during any one fiscal year. This information must be available within 35 days of a request by the U.S. Department of Health and Human Services (HHS), the State Medicaid Agency, and the Medicaid Managed Care Organization responding to an HHS or State request. Section VIII: Management & Control: 1. List the required information for all employees that hold a position of Managing Employee within your entity. 2. List the required information for all Agents that have the authority to obligate or act on behalf of your entity. CMS requires the identification of officers and directors of a Provider Entity that is organized as a corporation, without regard to the for-profit or not-for-profit status of that corporation. UnitedHealthcare Provider Entity Disclosure Form 01/2016 GLOSSARY Provider Entity: an individual or entity who operates as a Medicaid provider and is engaged in the delivery of health care services and is legally authorized to do so by the state in which it delivers the services. For purposes of this Statement, the Provider Entity is the individual or entity identified on this form as the disclosing entity. HCBS Provider: a provider of Home and Community Based Services for Medicaid beneficiaries. Ownership or Control Interest: an individual or corporation that— (a) Has an ownership interest totaling 5 percent or more in a disclosing entity; (b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; (c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity; (d) 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; (e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership. Direct Ownership Interest: the possession of equity in the capital, the stock, or the profits of the disclosing entity. Indirect Ownership Interest: 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. Controlling Interest: defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity; the ability or authority to nominate or name members of the Board of Directors or Trustees; the ability or authority, expressed or reserved to amend or change the by-laws, constitution, or other operating or management direction; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership control. Determination of ownership or control percentages :(a) 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. (b) 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. Other Disclosing Entity: 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, XV III, or XX of the Act. This includes: (a) 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 XV III); (b) Any Medicare intermediary or carrier; and (c) 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. Significant Business Transaction: any business transaction or series of related that, during any one fiscal year, exceeds the lesser of twenty-five thousand ($25,000) or five percent (5 %) of a Provider Entity’s total operating expenses. Subcontractor: (a) an individual, agency, or organization to which a Provider Entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (b) an individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease to obtain space, supplies, equipment, or services provided under the Medicaid agreement. Supplier: an individual, agency, or organization from which a provider purchases goods or services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, manufacturer of hospital beds, or pharmaceutical firm). Wholly Owned Supplier: a Supplier whose total ownership interest is held by the Provider Entity or by a person(s) or other entity with an ownership or control interest in the Provider Entity. Agent: any person who has been delegated the authority to obligate or act on behalf of a Provider Entity. Managing Employee: 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. UnitedHealthcare Provider Entity Disclosure Form 01/2016