Revalidation Requirements

State and federal regulations require all currently enrolled Medicaid providers to revalidate their enrollment at least every five (5) years.

*****IMPORTANT*****

YOU MUST SUBMIT ALL REQUIRED DOCUMENTATION FOR YOUR PROVIDER TYPE BELOW, OR YOUR REVALIDATION WILL BE REJECTED. THIS COULD CAUSE YOUR MO HEALTHNET ENROLLMENT TO ALSO BE DEACTIVATED.

You will be notified and given an explanation via eMOMED if your revalidation application is rejected. You will be given an opportunity to submit any missing documentation prior to deactivation of your MO HealthNet enrollment. If we do not receive the requested documentation within 30 days of notice, your MO HealthNet enrollment will be deactivated and you will be required to re-enroll.

If you receive payments directly from the state for services rendered, or bill the state for services rendered, you must submit documents from Section I and Section II.

If you receive payment through an enrolled organization, such as a clinic, or other provider, you only need to submit documents listed under your provider type in Section II unless instructed otherwise.

Section I: 

In addition to the information listed in Section II all providers who receive payment directly from the state will need to upload the following documents:

  1. IRS – Tax Documentation

A copy of one of the following IRS documents must be submitted. The legal name and Tax ID number must be PREPRINTED on the document by the IRS:

    • CP 575 or 147C letter
    • 941 Employers Quarterly Federal Tax Return
    • 8109 Tax Coupon
    • Any IRS document or letter that has the legal name and Tax ID number PREPRINTED on

NOTE: A W-9 or computer printed forms ARE NOT ACCEPTABLE

  1. Business Organizational Structure form.

For the Business Organizational Structure (BOS) form all managing employees and owners must be listed with name, address, SSN, and DOB information. Business entities that qualify as owners must be listed with name, address, and EIN information. These are the definitions used for managing employees and owners:

13 CSR 65-2.010(21) Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day to day operations of the provider, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the provider.

13 CSR 65-2.010(28)  Owner means any individual or entity that has any partnership interest in, or that has five percent (5%) or more direct or indirect ownership of, the provider as defined in sections 1124 and 1124A(a) of the Social Security Act.

In addition to the managing employee and owner information Section VI: Legal Disclosure must be answered yes or no with case information entered if answering yes. This document must be hand signed and dated by a managing employee or owner.

For each business type additional supporting documents are listed. All business types except Sole Proprietors without a DBA are required to register with the Missouri Secretary of State. Businesses based in other states are required to register with the Secretary of State where they are located and register with the Missouri Secretary of State as a foreign entity.

Information for the business registration process is available from the Missouri Secretary of State website:

 

Section II (scroll to find your provider type)

Area Agency on Aging (28) Adult Day Care (29) Aged & Disabled Waiver Homemaker/Chore and Respite (28)
Ambulance (80) Ambulatory Surgical Center (50) Assisted Living Facility (26)
Assistant Behavior Analyst (73) Assistant Physician (21) Audiologist/Hearing Aid Specialist (33)
Behavior Analyst (73) Case Management (18) Certified Community Behavioral Health Clinics (88)
Community Mental Health Center (56) Community Psychiatric Rehabilitation Services (87) Comprehensive Substance Treatment Rehab Services (86)
Consumer Directed Services – CDS (26) CRNA Services (91) Dental Hygienist (74)
Dentist (40) Dialysis Clinic (50) Disease Management (35)
DMH – Developmentally Disabled Waiver (85) Durable Medical Equipment (62) FQHC – Federally Qualified Health Care Center (50)
Hospitals Acute and Children’s Psychiatric Hospitals (01 /02) Home Health Agency (58) Hospice (82)
Independent or Portable X-Ray / IDTF (71) Independent Clinics (50) Independent Lab (70)
MCO – Individual Managed care only, no FFS (83)

MCO – Organizational Managed care only, no FFS (83)

Non-Emergency Transportation (65)
Nurse Midwife (25) Nurse Practitioner (42) Nursing Homes (10)

Occupational Therapist (47)

Optician/Optometrist (32) Optometrist (31)
Pharmacy (60) Physical Therapist (48) Physician Assistant (22)
Physician – MD & DO (20, 24) Physician or other Provider Groups (Independent Clinics) (50) Podiatrist- Surgical Chiropody (30)
Private Duty Nursing (94) Private Home – (ICF/DD Home) (11) Professional Counselor – LPC, PLPC (49)
Psychologist – LP, PLP (49) Public Health Department Clinic (51) Qualified Medicare Beneficiary (75)
Rehabilitation Center (57) Residential Care Facility (26) Rural Health Clinic (59)
School Based (96) Social Worker – LCSW, LMSW (49) Speech Therapist (46)
State Institution – Long Term Care (05) Targeted Case Management (15) Teaching Hospital (55)
Teaching Institution – All Department Hospital (54) Third Party Assessor – Reassessment (27)  

Area Agency on Aging (28)

 All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  3. For every individual listed on the BOS form: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

 

Adult Day Care (29)

All of the documents listed in Section I plus the following documents:

  1. Adult Day Care License
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Adult Day Care – Provider Profile
  4. Adult Day Care – Assurances form
  5. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  6. For every individual listed on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

Aged & Disabled Waiver Homemaker/Chore and Respite (28)

All of the documents listed in Section I plus the following documents:

  1. If services are offered through DMH – Provide a current license.
  2. Current copy of the Certificate of Liability Insurance and Employee Dishonesty Bond
  3. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  4. Advanced Personal Care Addendum (If Personal Care enrolled)
  5. In-Home Services – Assurances
  6. In-Home Services – Provider Profile
  7. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  8. For every individual listed on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

Following your Revalidation approval you will be contacted to complete a new IHS contract.

 

Ambulance (80)

All of the documents listed in Section I plus the following documents:

  1. Air Carrier Certificate (if Air Ambulance)
  2. Copy of owners current permanent Ambulance Service License (need trade name and agency license number)
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Ambulatory Surgical Center (50)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Assisted Living Facility (26)

All of the documents listed in Section I plus the following documents:

  1. Assisted Living Facility License (DHSS)
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Assisted Living Facility – Profile
  4. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  5. For every individual listed on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

Assistant Behavior Analyst (73)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Assistant Physician (21)

  1. Collaborative Agreement
  2. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Audiologist/Hearing Aid Specialist (33)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Behavior Analyst (73)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Case Management (18)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Certified Community Behavioral Health Clinics (88)

All of the documents listed in Section I plus the following documents:

  1. Letter from the Department of Mental Health (DMH) stating that the provider has been recognized by the Division of Behavioral Health
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Community Mental Health Center (56)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Copy of Department of Mental Health (DMH) certification as a Community Mental Health Center
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Community Psychiatric Rehabilitation Services (87)

All of the documents listed in Section I plus the following documents:

  1. Copy of Department of Mental Health (DMH) certification as a Community Psychiatric Rehabilitation Services
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Comprehensive Substance Treatment Rehab Services (86)

All of the documents listed in Section I plus the following documents:

  1. Copy of Department of Mental Health (DMH) certification as a CSTAR provider, Provisional certification is acceptable
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Consumer Directed Services – CDS (26)

All of the documents listed in Section I plus the following documents:

  1. If offering services to DMH provide a copy of DMH license
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Advanced Personal Care Addendum (If Personal Care enrolled)
  4. Consumer Directed Services – Assurances
  5. Consumer Directed Services – Vendor Profile
  6. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  7. For every individual listed on either the BOS form or the Vendor Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

Following your Revalidation approval you will be contacted to complete a new CDS contract.

 

CRNA Services (91)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Dental Hygienist (74)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Dentist (40)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Dialysis Clinic (50)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Disease Management (35)

DMH – Developmentally Disabled Waiver (85)

All of the documents listed in Section I plus the following documents:

  1. Copy of Department of Mental Health (DMH) Contract for Services
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Durable Medical Equipment (62)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

FQHC – Federally Qualified Health Care Center (50)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Hospitals Acute and Children’s Psychiatric Hospitals (01 /02)

All of the documents listed in Section I plus the following documents:

  1. Hospital license
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Home Health Agency (58)

All of the documents listed in Section I plus the following documents:

  1. DHSS Home Health License
  2. Medicare enrolled
  3. AIDS / HIV Waiver addendum (optional)
  4. Medically Fragile Adult Waiver Addendum (optional)
  5. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Hospice (82)

All of the documents listed in Section I plus the following documents:

  1. Hospice Certification issued by the DHSS
  2. Hospice Nursing Facility Contract (optional)
  3. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Independent or Portable X-Ray / IDTF (71)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Independent Clinics (50)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Independent Lab (70)

All of the documents listed in Section I plus the following documents

  1. CLIA Certificate (Required)
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

The Laboratory Director named on the CLIA Certificate meets the definition of a managing employee, and must be listed on the Business Organizational Structure form

MCO – Individual Managed care only, no FFS (83)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

MCO – Organizational Managed care only, no FFS (83)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Non-Emergency Transportation (65)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Nurse Midwife (25)

  1. List of all practice locations – if collaborative is used; each location listed must be on the collaborative agreement. Be sure to list group name, location, and phone
  2. Prescribing Nurse – Collaborative Agreement for all locations
  3. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Nurse Practitioner (42)

  1. List of all practice locations – if collaborative is used; each location listed must be on the collaborative agreement. Be sure to list group name, location, and phone
  2. Prescribing Nurse – Collaborative Agreement for all locations
  3. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Nursing Homes (10)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Occupational Therapist (47)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Optician/Optometrist (32)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Optometrist (31)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Pharmacy (60)

All of the documents listed in Section I plus the following documents:

  1. Copy of Current License
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Long Term Care Form (if applicable)
  4. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

The pharmacist in charge meets the definition of a managing employee, and must be listed as part of the Business Organizational Structure form

Physical Therapist (48)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Physician Assistant (22)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Physician – MD & DO (20, 24)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Physician or other Provider Groups (Independent Clinics) (50)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Podiatrist- Surgical Chiropody (30)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Private Duty Nursing (94)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Medically Fragile Adult Waiver Addendum (optional)
  3. AIDS / HIV Waiver addendum (optional)
  4. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Private Home – (ICF/DD Home) (11)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Professional Counselor – LPC, PLPC (49)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Psychologist – LP, PLP (49)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Public Health Department Clinic (51)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Qualified Medicare Beneficiary (75)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Rehabilitation Center (57)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Residential Care Facility (26)

All of the documents listed in Section I plus the following documents:

  1. Residential Care Facility License (DHSS)
  2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Residential Care Facility – Profile
  4. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  5. Current FCSR screening results for all individuals listed on the BOS form or Provider Profile. Please include SSNs, DOBs, and aliases for screening purposes.

Rural Health Clinic (59)

All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

School Based (96)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Social Worker – LCSW, LMSW (49)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

Speech Therapist (46)

  1. Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

State Institution – Long Term Care (05)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Targeted Case Management (15)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Teaching Hospital (55)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Teaching Institution – All Department Hospital (54)

All of the documents listed in Section I plus the following documents:

  1. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded

Third Party Assessor – Reassessment (27)

All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
    • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission. 
  2. Current Copy of Training Certification
  3. Provider Reassessor Terms and Conditions
  4. Title XIX Participation Agreement
    • Must be signed by Owner or Managing Employee
    • Must be completely filled out and both pages must be uploaded
  5. For every individual listed on either the BOS form or the Training Certification: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.