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Individual Provider Enrollment (Ownership) Page

You use the Ownership page to add or edit an individual provider's ownership information to the enrollment application.

 

Ownership- Section 7 Fields

Field Description

Ownership Fields

1. Have you ever had ownership in any organization that has billed, or is currently billing Medicare or to Alaska Medical Assistance or Title XIX services?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit your ownership information.
To add new ownership information, click Add Ownership. Existing ownership information, if any, is listed in a table. To edit, in the Ownership table, click the appropriate table row. After changing or adding new ownership information, on the Ownership action bar, click Save.
Business Name Official name under which the individual owner is doing business.
Alaska Medical Assistance # The individual's current Medicaid provider number.
Medicare # The individual's current Medicare number.
NPI # National provider identifier number.
Organization’s Legal Business Name Organization's legal business name as it appears in IRS forms.
Effective Date

Date when ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.
End Date

Date when ownership ends.

Format: MM/DD/YYYY, or click the calendar to select a date.
Address Physical street address of organization.
City City where the organization is located.
State State where the organization is located.
Zip Zip code and extension where the organization is located.
FEIN # Organization's Federal Employer Identification number.
Please enter an AK Medical Assistance, Medicare, NPI and/or other state Title XIX number. Select to indicate whether you have an Alaska Medical Assistance number, Medicare Number, NPI #, and/or a state Title XIX number.
Current AK Medical Assistance Provider # The current Medicaid provider number.
Medicare # The current Medicare number.
NPI # National provider identifier number.
Other State Title XIX # Another state Medicaid number, if applicable.
State Select State for Other State Medicaid number.

Managing/Directing Fields

2. Have you ever managed or directed any organization that has billed or is currently billing Medicare, AK Medical Assistance, or other state Title XIX services?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to complete information for each organization the owner has managed or directed in the last 10 years.

To add new managing/directing information, click Add Managing/Directing Information. Existing managing/directing information, if any, is listed in a table. To edit, in the Managing/Directing Information table, click the appropriate row. After changing or adding information, on the Managing/Directing Information action bar, click Save.
Organization’s Legal Business Name The legal business name of the organization.
Effective Date

Date when ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.
End Date

Date when ownership ends.

Format: MM/DD/YYYY, or click the calendar to select a date.
Address Physical street address of organization.
City

City where the organization is located.
State

State where the organization is located.

Default: AK

Zip Zip code and extension where the organization is located.
FEIN # Organization's Federal Employer Identification Number.
Please enter an AK Medical Assistance, Medicare, NPI and/or other state Title XIX number.

Check to indicate if you have either a current Medicare, Medicaid, NPI and/or Other State Title XIX number.
Current AK Medical Assistance Provider # The current Medicaid provider number.
Medicare # The current Medicare number.
NPI # National provider identifier number.
Other State Title XIX # Another state Medicaid number, if applicable.
State Select State for Other State Title XIX #.

Subcontractor Information Fields

3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients.)

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit subcontractor information.
To add new subcontractor information, click Add Subcontractor. Existing subcontractor information, if any, is listed in a table. To edit, in the Subcontractor table, click the appropriate table row. After changing or adding information, on the Subcontractor Information action bar, click Save.
Subcontractor Name Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients.
Address Physical street address of the subcontractor providing medical care to your patients.
City City where the subcontractor is located.
State State where the subcontractor is located.
Zip Zip code and extension where the subcontractor is located.
FEIN Federal Employer Identification Number of the subcontractor.
Percentage Percentage of ownership of the subcontractor.

Subcontractor Relative Fields

4. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit family information.
To add new family information, click Add Relative. Existing subcontractor information, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding information, on the Relative Information action bar, click Save.
Last Name Last name of the relative who has ownership in the subcontractor business or practice.
First Name First name of the relative who has ownership in the subcontractor business or practice.
MI Middle initial of the relative who has ownership in the subcontractor business or practice.
Relationship Relationship of relative to the owner of the subcontractor business or practice.
Subcontractor Name Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients that is associated with the relative.
Address Physical street address of the subcontractor associated with the relative.
City City where the subcontractor associated with the relative is located.
State State where the subcontractor associated with the relative is located.
Zip Zip code and extension where the subcontractor associated with the relative is located.
FEIN Federal Employer Identification Number of the subcontractor.
Percentage Percentage of ownership of the subcontractor associated with the relative.

 

Version as of 6/30/2015.

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