Individual Providers
Disclosure of Ownership, Controlling Interest & Management Statement and
Attestation of Criminal Convictions, Sanctions, Exclusions, Debarment or Termination
Frequently Asked Questions
Q1.
A1.
What is the purpose of the Individual Provider form?
Centers for Medicare and Medicaid (CMS) is responsible for ensuring that all individuals and entities
that receive government funds have not been excluded (directly or indirectly) from the Medicaid,
Medicare, CHIP or Title XX program. This Individual Provider form supports the collection of
information necessary to make such determinations.
Q2.
A2.
Can I submit a state-specific Disclosure form?
Yes; however, Optum prefers that you complete the form provided by Optum as it has been approved
by the state Medicaid agencies for our use.
Q3.
A3.
What happens if the Individual Provider form is not completed as requested?
Failure to submit the requested information may result in a refusal of participation in the Medicaid or
CHIP managed care network or denial of a claim.
Questions/Answer #4 - #7 apply to the Categories listed on the Individual Provider form
Q4.
A4.
If my practice is organized as a Sole Proprietor or Individual Contracted Practitioner, at a
minimum, what information is required in Sections I-VII on the Individual Provider form?
At a minimum, Sections I must be answered as “yes” and you must be listed as the owner in Section I
and as the managing employee in Section VII on the Individual Provider form.
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Q5.
A5.
Legal name of individual (“Individual Provider”) should the same as reported on your
W-9 form
If you have an EIN, the business, trade, or “doing business as (DBA)” name should be listed in
the field for “Name of Group” as reported on your W-9 form
If my practice is organized as an LLC, PLLC or PC, at a minimum, what information is
required in Sections I-VII on the Individual Provider form?
If >1 practitioner shares the same tax identification number, one Entity Provider form must be
completed for the organization and one Individual Provider form must be completed for each
practitioner that shares the same tax identification number.
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On the Individual Provider form, each practitioner should select Individual Member of a Group
and then complete the form for his/her self. If a practitioner owns >5% of the business, he/she
would list his/her owner information in Section I
On the Entity Provider form, at a minimum, Sections I and VII must be answered as “yes” and
the owner/s must be listed in Section I and the information for the managing employees must be
listed in Section VII on the Entity Provider form.
If there is only 1 practitioner that bills under the tax identification number, then the practitioner would
complete the Individual Provider form. At a minimum, Sections I and VII must be answered as “yes” and
the practitioner must be listed as the owner in Section I and as the managing employee in Section VII
on the Individual Provider form.
United Behavioral Health operating under the brand Optum
Individual Provider Form FAQs
01/20/2015
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Q6.
A6.
Legal name of individual (“Individual Provider”) should the same as reported on your
W-9 form
If you have an EIN, the business, trade, or “doing business as (DBA)” name should be listed in
the field for “Name of Group” as reported on your W-9 form
If I’m a member of a group practice that is organized as a corporation, LLC, nonprofit,
partnership, government/public entity or HCBS provider which category should I select?
If you are a member of any type of a group, it would be appropriate to select Individual Member of a
Group. You would then complete the Individual Provider form for yourself. If you own >5% of the
business, you would list yourself as an owner in Section I.
Please note: A separate Entity Provider form must be submitted for the entity as well.
Q7.
A7.
Are individual providers required to sign his/her Individual Provider form?
Yes. The individual provider must sign and date his/her own Individual Provider form. Electronic
signatures are acceptable; however, signature stamps are not acceptable.
Q8.
A8.
Is the 9-digit Social Security Number (SSN) required?
Yes. The 9-digit SSN is required as set-forth by the federal regulations (see Sect. 4313 of
the Balanced Budget Act of 1997, amended Sect. 1124 and Federal Register Vol. 76 No. 22
for further information).
The 9-digit SSN will be used for the purposes of complying with regulatory requirements to
conduct:
° exclusion, sanction, criminal and other background checks
° audits and investigation for the Department of Health and Human Services, Office of
Inspector General
Optum adheres to all applicable federal and state laws including HIPAA privacy and security
rules. Social security numbers are handled by a limited number of staff in compliance with
these rules.
Q9.
A9.
May I include an attachment if I have additional information to share?
Yes. You can submit an attachment or an addendum to the Individual Provider
form if needed. Attachments will be accepted in the form of a Word document,
Excel spreadsheet, and PDF document.
Q11. If I received the Entity Provider Form via email, fax or mail, I should I return the form?
A11. You should return the form via:
Fax: 1-877-847-6398 (preferred method)
Email: bns_disclsosure@optum.com
Mail: Optum
Attn: BNS – Disclosure Summary Unit
2000 West Loop South, Ste. #900 Houston, Texas 77027
If you have any questions, please send an email to bns_disclsosure@optum.com
or call Network Management at (877) 614-0484.
United Behavioral Health operating under the brand Optum
Individual Provider Form FAQs
01/20/2015