Residential Care Facility or Assisted Living Facility Enrollment Packet
A provider of Personal Care services must have a valid participation agreement with the Missouri Department of Social Services (DSS), Missouri Medicaid Audit & Compliance Unit (MMAC).
Disclosures for Medicaid Providers Federal & State
Please submit the following documents to: Missouri Medicaid Audit & Compliance (MMAC), Provider Contracts Section, P.O. Box 6500, Jefferson City, MO 65102. The physical address for mailing is MMAC Provider Contracts Section, 205 Jefferson Street, 2nd Floor, Jefferson City, MO 65102.
RCF or ALF Enrollment Application Package
|1.||RCF/ALF Provider Profile Form|
|2.||Business Organizational Structure Form (BOS) and all documents as indicated by the section of the form completed.|
|3.||Notification from the Internal Revenue Service of the applying provider’s Federal Employer Identification Number. Submit a copy of one of the following preprinted federal documents to verify the legal payment name registered with the IRS: CP-575 or 147C letter; 941 Employer’s Quarterly Federal Tax Return, Form 8109 Tax Coupon, or a letter from the IRS with the assigned tax ID number and legal name|
|4.||Notification from the Missouri Department of Revenue of the business entity’s Missouri Employer Identification Number.|
|5.||Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf|
|6.||National Provider Identification Number (NPI) – This needs to be a Type 2 Organizational NPI
You can print out your NPI from the following website:https://nppes.cms.hhs.gov/ If you have not applied for an NPI you can do so at this same site
|7.||A copy of the RCF/ALF license issued by the Section for Long Term Care Regulation.|
|8.||Personal Care Questionnaire for RCF & ALF|
|9.||MO HealthNet Provider Enrollment Application|
|10.||Title XIX Personal Care Participation Agreement|
|11.||DSS-MMAC Electronic Funds Transfer Authorization form. Attach a pre-printed voided check OR a letter from your bank with the legal name of the account holder, routing number and account number.|
|12.||On a separate sheet of paper, provide the full names (including maiden name), DOB and SSN for each owner, member, officer, director, managing employee and/or nurse supervisor.|
|13.||Provide the Family Care Safety Registration documentation for each person listed in #12 that will have contact with Medicaid participants.
Go to https://webapp02.dhss.mo.gov/bsees/Main to register
|14.||Copy of confirmation of Application Fee Payment – App Fee Vendor Site|
Lease agreement or deed for the facility location.
Upon receipt of this enrollment packet, your application will be reviewed. MMAC staff will contact you if additional information is required.
If you have questions or need assistance completing the enrollment packet, please contact the MMAC Contracts Section at email@example.com