Blank Enrollment Promise Template

What is the Enrollment Promise form used for?

The Enrollment Promise form is used by healthcare providers to enroll in Pennsylvania’s PROMISe™ Medicaid system. This form allows individuals and facilities to request enrollment, revalidation, and reactivation of provider numbers within the state’s Medicaid program. Completing this form is essential for providers who wish to deliver services to Medicaid patients and receive reimbursement for those services.

What are the requirements for completing the form?

The form must be typed or filled out in black ink. Stapling is not permitted, as the applications will be scanned for processing. Additionally, out-of-state providers need to provide proof of their participation in their respective State's Medicaid Program. Copies of relevant documents, such as the National Provider Identifier (NPI) confirmation letter and Social Security documentation, must also accompany the application.

How do I indicate if I'm reactivating a provider number?

If you are reactivating a provider number, you should provide the 13-digit PROMISe™ provider number you wish to reactivate. Additionally, you should complete the form as if you are enrolling for the first time, ensuring all required fields are filled out fully. This includes indicating your primary specialty, taxonomy codes, and providing any necessary documentation related to your practice.

What should I do if I have more than one service location?

When you have multiple service locations, you need to list those on Page 13 of the Enrollment Promise form. Each service location must correspond with a valid physical address, not a P.O. Box. Ensure that all addresses meet the requirements for service location codes, including the proper zip code format and contact information. Facilities must complete a new base application if adding locations to their file.

How do I submit my completed Enrollment Promise form?

Once you have completed the form and gathered all necessary documentation, return your application to the address specified for your provider type's requirements. If no specific address is provided, you may mail your application to the DPW Provider Enrollment at PO Box 8045, Harrisburg, PA 17105-8045. Double-check the Did You Remember… Checklist included with your application to ensure that everything is in order before submission.

1. Inconsistent Completion Method: Failing to complete the Enrollment Promise form either in black ink or by typing is a common mistake. Applications not adhering to this requirement will be rejected, which can lead to unnecessary delays in the enrollment process.

2. Missing Required Documentation: Applicants often forget to include essential documents, such as proof of Medicaid participation for out-of-state providers or copies of Social Security cards and tax identification numbers. Lack of these documents can result in the form being deemed incomplete.

3. Incorrectly Entering Provider Numbers: When reactivating a provider number or adding a new provider to a group, applicants sometimes provide incorrect provider numbers or service location codes. These errors can cause significant processing problems and lead to further complications.

4. Neglecting Signature Requirements: Applicants may overlook the requirement to sign the application. A missing signature, or a signature not made in black ink, can result in automatic disqualification of the application.

5. Ignoring Communication Preferences: Many applicants fail to indicate whether they or their staff can communicate with patients in languages other than English. This information is crucial and omitting it may affect the ability to serve a diverse patient population effectively.

The Enrollment Promise form is a vital document for healthcare providers seeking to enroll in the Pennsylvania Medical Assistance Program. Along with this form, several other documents are typically required or helpful in the enrollment process. Here is a list of these forms and their brief descriptions.

• NPPES Confirmation Letter: This document verifies the National Provider Identifier (NPI) and taxonomy codes assigned to the healthcare provider applying for enrollment. It is often necessary to include this letter with the application.
• W-2 or IRS Documents: A copy of a W-2 form or any IRS-generated document that shows the Social Security Number of the applicant must be submitted. This is necessary for verification of identity and compliance.
• Tax Identification Number (TIN) Document: This includes either a TIN label or an IRS document that verifies the TIN of the entity applying for enrollment. A standard W-9 form is not accepted.
• License Documentation: A current copy of the provider's professional license must accompany the application. This ensures that the provider is legally permitted to operate in their respective field.
• Drug Enforcement Administration (DEA) Certificate: If applicable, this document must be submitted to confirm that the provider is authorized to prescribe controlled substances.
• CLIA Certification: Providers offering laboratory services need to include a copy of their Clinical Laboratory Improvement Amendments (CLIA) certificate, confirming compliance with federal regulations.
• CMS Certification: For certain providers, submitting a copy of the Centers for Medicare & Medicaid Services (CMS) certification is necessary to certify their participation in the Medicare program.
• Fictitious Business Name Statement: If the provider operates under a fictitious business name, a copy of the recorded statement or permit must accompany the Enrollment Promise form.
• Confidential Information Sheet: This sheet must be completed with responses to sensitive questions as part of the application process. If there are affirmative answers, explanations must be provided on a separate sheet.

Completing the Enrollment Promise form along with these supportive documents ensures a smoother enrollment experience. Each document plays a role in confirming the qualifications and compliance of the provider, facilitating access to Pennsylvania's Medical Assistance Program.

The Medicare Enrollment Application, also known as Form CMS-855I, is quite similar to the Enrollment Promise form. Both documents serve as official applications for healthcare providers seeking to enroll in public health programs. The Medicare application requires detailed personal information, such as provider identification numbers, practice locations, and professional credentials. It also mandates the inclusion of supporting documentation, including proof of license and degree. Just as with PROMISe, providers must ensure accuracy and completeness to avoid delays in the enrollment process.

The Medicaid Provider Enrollment Application exhibits a close resemblance to the Enrollment Promise form as well. Both forms are utilized for enrollment in state-funded healthcare programs. The Medicaid application includes information on the provider’s legal structure, practice locations, and service types. It requires that supporting documents, such as tax identification numbers and national provider identifiers, accompany the application, mirroring the requirements outlined in the Enrollment Promise form.

The National Provider Identifier (NPI) Registration form is another document similar to the Enrollment Promise form. Both require the submission of identifying information, such as Social Security numbers and tax identification numbers. The NPI Registration form specifically pertains to obtaining a unique identifier for billing purposes, while the Enrollment Promise focuses on facilitating enrollment in Pennsylvania's Medicaid program. Both necessitate that applicants provide verification of their credentials and professional status.

The Provider Contracting form for managed care organizations shares similarities with the Enrollment Promise form in its purpose of credentialing healthcare providers. Both documents require comprehensive information about the provider’s qualifications, including specialty areas and practice locations. In addition, both require the submission of supporting documentation to verify eligibility. This procedure ensures that only qualified providers can serve patients under respective health programs.

The CLIA Application for Certification is akin to the Enrollment Promise form in that it seeks necessary information from healthcare providers who perform laboratory tests. The CLIA application requires details about the laboratory’s operations and personnel qualifications, while the Enrollment Promise form focuses on the individual's practice and enrollment in Medicaid. Both forms necessitate precise reporting of personal and professional information to maintain compliance with state and federal regulations.

The Drug Enforcement Administration (DEA) Registration form serves a similar function as the Enrollment Promise form. Both documents are essential for healthcare providers who prescribe medications. The DEA form requires applicants to provide personal identifying information, including tax and Social Security numbers. Similar to the Enrollment Promise form, this application also needs corroborating documentation to facilitate the approval process for prescribing controlled substances.

The Essential Health Benefits form bears similarities to the Enrollment Promise form in that both aim to establish provider eligibility within health insurance networks. Each form requests detailed personal information, including provider identifiers and service addresses. Supporting documentation is also a necessary requirement in both instances, ensuring that providers meet requisite standards to deliver healthcare services under public programs.

The Home and Community-Based Services (HCBS) Provider Enrollment Application echoes aspects of the Enrollment Promise form by focusing on applicant eligibility to provide specific services. Both documents require information about qualifications, service locations, and supporting documentation to validate claims of eligibility. Similar procedures reinforce the integrity of the process and safeguard the quality of care for recipients of these services.

The Home Health Agency (HHA) Application for Enrollment resonates with the Enrollment Promise form as it is an essential document for entities seeking to provide home health services. Both require extensive personal and practice details. Supporting materials highlighting professional credentials, financial information, and physical addresses are necessary for both applications, ensuring compliance with governing regulations for Medicaid participation.

Finally, the Ambulance Services Provider Enrollment Application closely aligns with the Enrollment Promise form, given their shared purpose of facilitating enrollment in Medicaid services. Both documents necessitate detailed information on service provision, including types of care offered and geographical locations serviced. Additionally, both applications require thorough documentation to substantiate the applicant's qualifications, enabling a streamlined process for enrollment in healthcare programs.

When filling out the Enrollment Promise form, it is crucial to ensure accuracy and compliance with the guidelines provided. The following list includes 10 essential dos and don'ts to help streamline the application process.

• Do complete the application using black ink or type it to ensure legibility.
• Do provide your National Provider Identifier (NPI) number and all relevant taxonomy codes.
• Do enter the effective date for your action request accurately.
• Do include any necessary supporting documents, such as Social Security cards and IRS documents.
• Do sign the application before submission and include your name, title, and date.
• Don't staple any documents to the application before submitting, as they will be scanned.
• Don't use a P.O. Box as a service location; it must be a valid physical address.
• Don't skip providing your legal name as it appears on IRS documents.
• Don't forget to check if you need to provide additional information for any answered “yes” questions on the confidential information section.
• Don't neglect to review the “Did You Remember…” checklist to confirm that all requirements have been met.

• Form Submission Will Be Rejected Without Black Ink: Contrary to popular belief, applications submitted in blue ink are not automatically rejected. However, using black ink is strongly encouraged to ensure legibility during scanning.
• Proof of Participation is Only Required for Out-of-State Providers: Some assume that only out-of-state providers need to prove Medicaid participation. In fact, all providers should ensure they meet any applicable requirements based on their practice location.
• Tax Identification Number (TIN) is Optional: Many believe that the TIN can be omitted if not immediately available. However, including your TIN is mandatory for the application to be considered complete.
• Stapling is Permissible: A common misconception is that stapling the application enhances its organization. In reality, any staples will hinder the scanning process and could lead to rejection.
• Only Newly Established Providers Need to Fill Out the Entire Form: This is inaccurate; even existing providers revalidating or reactivating their enrollment must submit the entire form.
• Providing Social Security Number Affects Eligibility: Some fear that disclosing their Social Security Number could lead to issues. However, this information is necessary to accurately verify identity and eligibility without impacting applicants negatively.
• Multiple Applications Can Be Submitted for Different Locations: It's believed that multiple applications for the same provider can be processed. Each provider must submit a single application per service location to avoid confusion.
• Document Copies Aren't Necessary: Many providers think that they can submit only the application and forgo any supporting documents. This is a misconception; copies of required documentation must always accompany the application.
• Handwritten Applications are Acceptable: While it's tempting to handwrite the application, this can lead to rejection. Typed applications are preferred to enhance clarity and facilitate processing.
• Contact Information is Optional: There’s a belief that contact details can be skipped if the applicant is not easily reachable. However, accurate contact information is vital for communication regarding the application status or required follow-up.

When filling out the Enrollment Promise form for Pennsylvania's PROMISe™ program, it’s crucial to ensure accuracy and compliance with all requirements. Here are several key takeaways to guide you through the process:

• Format Matters: Ensure your application is typed or completed in black ink. Submissions not following this requirement will be rejected.
• Proof of Participation: Out-of-state providers must provide evidence of their participation in their own state's Medicaid program. This documentation is essential for processing your application.
• Correct Provider Information: Fill in your complete name as either an individual or as a representative of a facility. Double-check all entries for correctness.
• Revalidation Process: If you are revalidating, complete the entire application. Any changes in service locations or updates must be clearly documented.
• National Provider Identifier: Enter your NPI number and taxonomy codes accurately. If you have more than four taxonomy codes, attach an additional sheet for clarity.
• Address Requirements: The service location must be a valid physical address. P.O. Boxes are not acceptable for service locations, which could delay your application.
• Documentation is Essential: Attach all required documents, such as Social Security cards, licenses, and any relevant certification. Missing documentation can result in rejection.
• Review Before Submission: Once completed, use the provided checklist to ensure all sections are filled out correctly. This final review helps avoid unnecessary delays in processing your application.

By following these guidelines closely, you enhance your chances of a successful enrollment process with PROMISe™. Timely and accurate submissions can have significant implications for your eligibility and service provision moving forward.