Provider Enrollment Attachment
To be completed by Billing Providers only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as a Billing Provider to be paid by Oregon Medicaid, you must complete
this attachment and return it (along with copies of information requested) with the
following information:
 Completed DHS 3972 (Provider Enrollment Request)
 Signed and dated DHS 3974 (Disclosure Statement of Ownership and Control Interest)
 Signed and dated DHS 3975 (Provider Enrollment Agreement)
Definitions
A Billing Provider is a person, agent, business, corporation, clinic, group, institution, or
other entity who, in connection with the submission of claims to the Oregon Health
Authority (OHA) receives or directs the payment (either in the name of the Performing
Provider or the name of the Billing Provider) from OHA on behalf of a Performing
Provider and has been delegated the authority to obligate or act on behalf of the
Performing Provider.
A Performing Provider is the actual provider of services, items or supplies to or on
behalf of Recipients.
Payment includes but is not limited to electronic fund transfer (directly or indirectly);
cashing, depositing or otherwise negotiating a check; authority to access the Performing
Provider’s bank account; or other financial arrangement such as using a lock box or post
office box.
Purpose
Any business arrangement where the billing entity may receive the Performing Provider’s
payment means that OHA requires the billing entity to enroll as a Billing Provider.
OHA enrolls Billing Providers in order to ensure compliance with Medicaid payment
regulations, federal and state tax laws, HIPAA requirements, and program integrity related
to the proper disposition of provider payments.
The following questions are designed to establish that the Billing Provider’s relationship
with its Performing Providers is correctly documented with OHA. At any time, OHA may
request copies of all agreements/contracts associated with this billing relationship. This
information must be kept current, and changes must be submitted within 30 days as
required by OHA rules.
Provider Enrollment Attachment – Billing Provider
DMAP 3110 (Rev. 07/11)
Identifying Information
1.
List any current or previous OHA Provider Numbers here:
2.
List any names/business names currently or previously used with DMAP or other
Oregon Health Authority (OHA) contracts:
3.
Is the Billing Provider owned by a unit of government when providing these
services? Check any government type that applies to this provider.
County
School district
Transportation district
State
Special purpose district
Tribal
City
Publicly operated teaching hospital
Other governmental unit (specify):
4
List all Performing Providers and their OHA Provider Number, NPI number and the
individual Tax Identification Number for the Performing Provider. This cannot be
the same Tax Identification Number as the Billing Provider.
It must be the Tax Identification Number the Billing Provider uses to report the
Performing Provider’s income to the Internal Revenue Service. Normally this is a
Social Security Number or an Employer Identification Number. You may use a
spreadsheet of your choice to submit this information and attach to this document.
Performing Provider
Name
OHA Provider
Number
Provider Enrollment Attachment – Billing Provider
NPI
Tax Identification Number
(SSN or EIN)
DMAP 3110 (Rev. 07/11)
Billing Agreement Information
Answer the following questions about the Billing Provider’s agreement/contract with
Performing Providers enrolled with the Oregon Health Authority. Check any of the
following conditions that apply:
1.
Is the Billing Provider the employer of the Performing Provider, where the
Performing Provider is required as a condition of employment to turn over his or her
fees to the employer?
Yes
No
2.
Is the Billing Provider a facility in which the service is provided, where the
Performing Provider has a contract under which the facility submits the claim?
Yes
No
3.
Is the Billing Provider a foundation, plan, or similar organization operating an
organized health care delivery system, where the Performing Provider has a contract
under which the organization submits the claim?
Yes
No
4.
Is the Billing Provider providing billing or claims or other services to a Performing
Provider for any reason that is not covered in questions 1-3?
Yes
No
If Yes, answer all of the following questions:
Does the Performing Provider’s Medicaid payment go directly to the
Performing Provider?
Yes
No
Does the Performing Provider’s Medicaid payment go directly to the Billing
Entity?
Yes
No
Does the Performing Provider’s Medicaid payment go directly to a Post
Office Box or Lock Box? If Yes, identify who has access to the Post Office
Box or lock box here:
Yes
No
Does the Billing Provider either give the Medicaid payment directly to this
Performing Provider or deposit the payment into this Performing Provider’s
bank account?
Yes
No
Does the Performing Provider’s Medicaid payment go directly to a bank?
Yes
No
Is the bank account only in the name of the Performing Provider?
Yes
No
Does the Performing Provider have unrestricted access to the bank account
and statements?
Yes
No
Does the bank answer only to the Performing Provider regarding what the
Performing Provider wants from the bank?
Yes
No
Is the Billing Provider responsible for cashing, depositing or otherwise
negotiating the performance of the Performing Provider’s check?
Yes
No
Is the Billing Provider’s compensation related on a percentage basis to the
dollar amounts billed or collected?
Yes
No
Is the Billing Provider’s compensation related in any way to the dollar
amounts billed or collected?
Yes
No
Provider Enrollment Attachment – Billing Provider
DMAP 3110 (Rev. 07/11)
Is the Billing Provider’s compensation dependent on the actual collection of
the payment?
Yes
No
Is the Billing Provider an individual or organization, such as a collection
agency or service bureau, that advances money to the Performing Provider
for accounts receivable that the Performing Provider has assigned, sold or
transferred to the individual or organization for an added fee or a deduction
of a portion of the accounts receivable?
Yes
No
Electronic Billing Information
1.
Does the Billing Entity submit or receive claims electronically to DHS on behalf of
the Provider?
Yes
No
2.
Is the Billing Provider authorized to act as the Performing Provider’s EDI
Submitter?1
Yes
No
If Yes, provide the EDI Submitter registration number used by the Billing Provider
on behalf of the Performing Provider/Trading Partner:
3.
Will the Billing Provider be submitting claims on behalf of the Performing Provider
using the Performing Provider’s Web Portal Access?
Yes
No
Billing Provider Certification
Billing Provider agrees to and certifies as follows:
1.
All data I submit to OHA on behalf of the Performing Provider is a true and correct
representation of the data I received from the Performing Provider.
2.
I understand that I may be prosecuted under applicable federal and state criminal
and civil laws for submitting false claims, concealing material facts,
misrepresentation, falsifying data, or other acts of misrepresentation.
3.
I will maintain all records for seven years from the date of service and be able to
reproduce claims for resubmission or audit upon request of OHA or other authorized
entity.
4.
I will allow, upon request and at a reasonable time and place, authorized federal or
state government agents to inspect and copy any records that I maintain on the
services provided and billed on behalf of the Provider, or otherwise related to a
claim for service.
1
An EDI submitter is an entity that establishes an electronic connection with OHA to submit or receive an
electronic data transaction on behalf of a Provider. In order to qualify as an EDI Submitter, the entity must
be authorized by a Performing Provider under a Trading Partner Agreement with OHA. Registration of an
EDI Submitter is governed by the forms and rules available at
www.oregon.gov/OHA/admin/hipaa/testing_reg.shtml.
Provider Enrollment Attachment – Billing Provider
DMAP 3110 (Rev. 07/11)
5.
I understand that if my activities relate to payment for Medicaid services or supplies
by OHA to the Provider, the following rule applies to any claim for payment – 42
CFR 447.10:
(d) Who may receive payment? Payment may be made only –
(1) To the Provider; … or
(3) In accordance with paragraphs (f) and (g) of this section.
(f) Business agents. Payment may be made to a business agent, such as a billing
service or an accounting firm that furnishes statements and receives payments in the
name of the provider, if the agent’s compensation for this service is –
(1) Related to the cost of processing the billing;
(2) Not related on a percentage or other basis to the amount that is billed or
collected; and
(3) Not dependent upon the collection of the payment.
(g) Individual practitioners. Payment may be made to –
(1) The employer of the practitioner, if the practitioner is required as a condition
of employment to turn over his fees to the employer;
(2) The facility in which the service is provided, if the practitioner has a contract
under which the facility submits the claim; or
(3) A foundation, plan, or similar organization operating an organized health care
delivery system, if the practitioner has a contract under which the organization
submits the claim.
6.
I certify that I am not an individual or an organization, such as a collection agency,
that advances money to a Provider for accounts receivable that the Performing
Provider has assigned, sold or transferred to the individual or organization for an
added fee or a deduction of a portion of the accounts receivable.
Provider Signature
My signature signifies agreement to these Billing Provider registration and certification
conditions.
Billing Provider Name
Date
Name of Authorized Representative (print or type)
Title of Authorized Representative
Signature of Authorized Representative
Provider Enrollment Attachment – Billing Provider
DMAP 3110 (Rev. 07/11)