Fillable Printable Form 5139
Fillable Printable Form 5139
Form 5139
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PROVIDER AGREEMENT
State Form 51396 (R5 / 5-14) / Part of State Publication 286
INDIANA STATE DEPARTMENT OF HEALTH
By execution of this Agreement, the undersi gned entity (“Provider”) requests enrollment as a Provider in Indiana State Department of
Health (ISDH) Programs. As an enrolled Provider in ISDH Programs, the undersigned entity agrees to provide ISDH Program-covered
services and/or supplies to ISDH participants. As a condition of enrol lment, Provider agrees to the follo wing:
1. To comply with all federal and state statutes and regulations pertaining to ISDH Programs, as the y may be amended from time to
time.
2. To meet, on a continuing basis, the state and federal licensure, certification or other regulatory requirements.
3. To notify ISDH within ten (10) days of any change in the sta tus of Provider’s license, certification, or permit to provide its services
to the public in the State of Indiana.
4. To give written notice to ISDH, at least sixty (60) days before the effective date of the change, for any of the following:
name (legal name), doing business as (DBA), name as registered with the Secretary of State, address (service locatio n), pay to,
mail to, or home office address, Federal tax identification number(s), or change in providers direct or indirect o wnership, interest or
controlling interest.
5. To provide ISDH Program-covered services and/or supplies pursuant to all applicable Federal and State statut es and regulations.
6. To safeguard information about ISDH Program participants including at a minimum:
a. name, address, and social and economic cir c umstances;
b. medical services provided;
c. medical data, including diagnosis and past history of disease or disabil ity;
d. any information receiv ed in connection with the identification of legally liab le third party resources.
7. To release information about ISDH Program participants only to the ISDH, only when in connection with payme nt issues
surrounding providing services for participants.
8. To maintain a written contract with all subcontractors which fulfills the requirements that are appropriate to the service or activity
delegated under the subcontract. No subcontract, however, terminates the legal responsibility to assure that all activities under this
contract are carried out.
9. To submit claims for services rendered by the Provider or e mployees of the provider and not to submit claims for services rendered
by contractors unless the Provider is a health care facility (such as hospital, ICF-MR, or nursing home), or a government agency
with a contract that meets the requirements described in Item 8 of this Agreement. Health care faciliti es and g overnment agencies
may, under circumstances permitted in federal law, subcontract with other entities or individuals to provid e ISDH Program services
rendered pursuant to this Agreement.
10. To abide by the ISDH Program Provider Manual, as amended from time to time, as well as all provider bulletins and notices. Any
amendments to the ISDH Program Provider Manual, as well as provider bulletins and notices, communi cated to Provider shall be
binding upon receipt. Receipt of amendments, bulletins and notices by Provider shall be presumed when mailed or e-mailed to the
billing Provider's current “mail to" physical or email address on file with ISDH.
11. To submit billing in arrears, within on e (1) year of the service date, on ISDH approved cla im forms or ele c tronically via Electronic
Data Interchange (EDI), as outlined in the ISDH Program Provider Manual, bulletins, and banner p ages, in an amount no greater
than Provider's usual and customary charge to the general p ublic for the same service. Any requests for exceptions to these
requirements must be submitted in writing to Children’s Special Health Care Services (CS HCS) and attached to the billing.
12. To be individually responsible and accountable for the compl etion, accuracy, and validity of all claims filed under the Tax ID/NPI
submitted, including claims fil ed by the Provider, the Provider's employees, or the Provide r ' s agents. Provider understands that the
submission of false claims, statements, and documents or the concealment of material fact may be prosecuted under the
applicable Federal and/or State law.
13. To submit claim(s) for ISDH reimbursement only after first exhausting all other sources of reimbursement as required by the ISDH
Provider Manual, bulletins, and ban ner pages.
14. To submit claim(s) for ISDH reimbursement utilizing the appropriate claim forms and codes as specified in the ISDH Provider
Manual, bulletins and notices.
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15. To submit claims that can be documented by Provider as being strictly for:
a. medically necessary medical assistance services;
b. medical assistance services actually provided to the pers on in whose name the claim is being made; and
c. compensation that Provider is legally entitled to receive.
16. To accept payment as payment in full, the amounts determine d by ISDH as the appropriate payment, for ISDH Program covered
services provided to ISDH Program participants. Provider agrees not to bill participants, or any member of a participant's family, for
any additional charge for ISDH Program covered services.
17. The Provider hereby agrees to remove from collections any participant that has been wrongfull y identifie d as delinquent within five
(5) business days of notice from ISDH.
18. To refund within fifteen (15) days of receipt, to ISDH any duplicate or erroneous payme nt received.
19. To make repayments to ISDH, or arrange to have future pa yments from the ISDH withheld, within sixty (60) days of receipt of
notice from ISDH that an investigation or audit has determ ined that an overpayment to Provider has been made. A hospital
licensed under IC 16-21 has o ne hundred eight y (180) days to repay.
20. To fully cooperate with federal and state officials and their agents as they c onduct periodic inspections, reviews and audits.
21. Obtain Prior Authorization for certain designated services for participants of various Programs of the ISDH. Failure to obtain a Prior
Authorization, when required, will result in denial of payment and the participant/family may not be billed for the unauthorized
services. A Prior Authorization confirms medical necessity and its relationship to an eli gible medical diagnosis, but is not a
guarantee of payment. Non-em ergency designated services should not be provided until Prior Authorization approval is received
from ISDH. Charges for services provided while their Prior Authorization d etermination is pending, will be the provi der
responsibility, in the event that authorization is denied by ISDH. Authorization of emergenc y services mu st be requested within five
(5) days of services being provided.
22. Upon notification that a participant is enrolled in the CSHCS Program a provider shall, in accordance with this agreement, submit
billing to the CSHCS Program for services provided within the last year while the particip ant was enrolled in the CSHCS Program.
If the participant has already paid for services billed to the CSHCS Program, the CSHCS provider must reimburse participants in
full for all services covered by the CSHCS Program.
23. CSHCS must be billed for all services provided to participants and participant/family may not be billed directly.
24. Payment will be based upon the Medicaid rate, in accordance with state statutes and regulations. Payment as determined by the
CSHCS Program shall be accepted as payment in full. Balances cannot be billed to the family.
25. To cease any conduct that ISDH or its representative deems to be abusive of the ISDH Program.
26. To promptly correct deficiencies in Provider's operations upon request by ISDH.
27. To cooperate with ISDH or its agent in the application of utilization controls as provided in federal and state statutes and
regulations as they may be amended from time to time.
28. To comply with civil rights requirements as mandated by federal and state statutes and regulation by ensuring that no person shall,
on the basis of race, color, national origin, ancestry, disability, ag e, sex, religion or sexual orientation, be excluded from
participation in, be denied the benefits of, or be otherwise subject to discrimination in the provision of a ISDH Program-covered
service.
29. To abide by and agree to the terms and conditions set out in Schedule A (Certification Statement for Providers Submitting Claims),
which is incorporated herein b y refer ence.
30. To furnish to ISDH or its agent, as a prerequisite to the effectiveness of this Agreement, the informati on set out in Schedule B to
this Agreement, which is incorporated herein by reference, a nd to update this information, when it changes.
31. To abide by and agree to the terms and conditions set out in the various addenda applicable to the ISDH Programs, with which the
provider participates, which are incorporated herein by reference.
32. That this Agreement may be terminated as follows:
a. By ISDH for Provider's breach of any provision of this Agreement as determined by ISDH; or
b. By ISDH, or by Provider, upon thirty day (30) written notice.
33. That this Agreement has not been altered, and upo n execution by provider and approval by ISDH, supersedes and replaces any
Provider Agreement previously executed with ISDH, by the Provider.
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THE UNDERSIGNED, BEING THE PROVIDER OR HAVING THE SPECIFIC AUTHORITY TO BIND THE PROVIDER TO THE
TERMS OF THIS AGREEMENT, AND HAVING READ THIS AGREEMENT AND UNDERSTANDING IT IN ITS ENTIRETY, HEREBY
AGREES, BOTH INDIVIDUALLY AND ON BEHALF OF THE PROVIDER AS A BUSINESS ENTITY, TO ABIDE BY AND COMPLY
WITH ALL THE STIPULATIONS, CONDITIONS, AND TERMS SET FORTH HEREIN.
FURTHER, THE UNDERSIGNED HEREBY BINDS ALL SUCCESSORS, ASSOCIATES AND ASSIGNEES TO THE
STIPULATIONS SET FORTH IN THIS AGREEMENT.
Provider-Authorized Signature – All Schedules
NOTE - The owner or an auth o rized officer of the business entity must co mplete this section.
I certify, under penalty of law, that the information stated in Schedule B is correct and complete to the best of my knowledge.
I am aware that, should an investigation at any time indicate that the information has been falsified, I may be considered for
suspension from the program and/or prosecution for Fraud. I hereby authorize the Indiana State Department of Health to
make any necessary verifications of the information provided herein, and further authorize and request each educational
institution, medical/license board or organization to provide all information that may be required in connection with my
application for participation in the Indiana State Department of Health Programs.
This Agreement may be executed simultaneously or in two or more counterparts, each of which shall be deemed an original
but all of which together shall constitute one and the same instrument. The parties agree that this Agreement may be
transmitted between them electronically or digitally. The parties intend that electronically or digitally transmitted signatures
constitute original signatures and are binding on the parties. The original document shall be promptly delivered, if requested.
Doing business as (DBA) name of provider
Name of officer Title Telephone number
( )
Signature Date (month, day, year)
NOTE: Failure to complete this section will result in ISDH returning the application for incomplete information.
