WYOMING MEDICAID

WYOMING MEDICAID & GOOLD HEALTH SYSTEMS, AN EMDEON COMPANY

PHARMACY PROVIDER ENROLLMENT PACKET

REV. MARCH 2014

Dear Pharmacy Provider Applicant,

Thank you for your interest in becoming a Wyoming Medicaid Pharmacy Provider. The application and other forms must be completed in entirety and will be reviewed by Wyoming Medicaid and the Wyoming Medicaid Pharmacy Fiscal Agent, Goold Health Systems (GHS), an Emdeon company.

Providers are encouraged to review the current Wyoming Medicaid Pharmacy Services Manual for information about provider relations, prescription services, drug utilization review, reimbursement and copayments, plan information, and much more. The provider manual can be accessed on the GHS Wyoming Medicaid website at . Select "Provider Manual" located at the left side of the page to access the current and past provider manuals.

There is no guarantee the pharmacy's application will be approved or that the pharmacy will be assigned a Wyoming Medicaid Provider number. If the pharmacy makes the decision to provide services to a Wyoming Medicaid client prior to approval of the application, the pharmacy does so with the understanding that, if the application is denied, claims will not be payable by Wyoming Medicaid.

Enrollment Requirements & Re-certification The Affordable Care Act of 2011 (ACA) requires that all newly enrolling and re-enrolling Medicaid providers be screened and re-enroll at a minimum of every five (5) years. Prior to the re-enrollment/re-certification, Wyoming Medicaid will notify all pharmacy providers enrolled at the time, that they are required to re-enroll before the re-enrollment deadline. The ACA certification requirements apply during re-enrollment. Pharmacy providers that do not re-enroll by the re-enrollment deadline will be terminated as Wyoming Medicaid Pharmacy Providers.

Enclosed in this packet you will find the following forms: Wyoming Medicaid Pharmacy Provider Enrollment Application Wyoming Medicaid Pharmacy Provider Enrollment Certification Wyoming Medicaid Pharmacy Provider Agreement? Please print two copies of the form. Both copies will need to be completed and signed. If your pharmacy is approved, one copy will be returned to you by GHS for your records. Wyoming Medicaid Pharmacy Point of Sale Agreement Goold Health Systems Trading Partner Agreement ? Please print two copies of the form. Both copies will need to be completed and signed. If your pharmacy is approved, one copy will be returned to you by GHS for your records. This form is to be completed by the entity receiving the 835s. State of Wyoming WOLFS-109a Form (must be accompanied by VOIDED check or State of Wyoming, State

$XGitor's Office, Vendor Payment Direct Deposit (EFT) Bank Certification Formor bank letter) ? Required in order for pharmacy to be set up as a vendor with the State of Wyoming in order to receive payment for paid claims.

* If the pharmacy is currently enrolled and the banking information has not changed, the WOLFS-109(a) does not need to be filled out, however, please indicate on a cover letter that the banking information is the same.

* All forms must be completed for each pharmacy location.

In addition to the attached forms, you are also required to submit copies of the following documents: National Provider Identifier (NPI) Notification document. Wallet Card or Wall Certificate for Pharmacy License or Non-Resident Retail Pharmacy License. A copy of a voided check (only required if not submitting the State of Wyoming, State Auditor's Office, Vendor Payment Direct Deposit (EFT) Bank Certification Form or a bank letter)

Application Correspondence All correspondence related to this application (i.e., enrollment approval/denial, etc.) will be mailed to the physical address listed on the pharmacy application unless otherwise requested in the Enrollment Contact Information section of the Wyoming Pharmacy Provider enrollment application.

Contact Information If you have any questions regarding the enrollment forms, please contact the Enrollment Department at 877-205-8083 x1051 or wyprovider@. We thank you in advance for your prompt return of the above documents to the following address: GHS, Provider Enrollment, PO Box 21719, Cheyenne, WY, 82003.

Sincerely, Kristin Karlstrum GHS Pharmacy Provider Enrollment Service

P. 877-205-8083 E. wyprovider@

Tracking #: Approved

Trading Partner #:

Denied

Wyoming Department of Health Medicaid Pharmacy Provider Enrollment Application

MEDICAID USE ONLY Medicaid Provider #: Effective Date: WOLFS (VC) #:

PHARMACY INFORMATION

Do not leave any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. If fields are left blank, application will be incomplete and cannot be processed until all information is received. Select only one box: New Application Change in Ownership Re-enrollment Other: Pharmacy or Legal Business Name:

Business Name: Doing Business As (DBA) ? (Only if applicable):

Physical Address:

Street Address

Phone #:

City

(

)

-

State

ZIP Code

Pharmacy Secure Fax #: (

)

County

-

Pharmacy Email:

@

.

National Provider Identifier (NPI):

NCPDP / NABP #:

Federal Employer Identification Number (FEIN) (aka Tax ID):

Pharmacy Type (select all that apply):

Retail Specialty Mail Order Other:

Primary Taxonomy Code (e.g. 333600000X ? can be found on NPPES website):

*Below, list any additional taxonomy codes listed on the NPI confirmation letter or email for the pharmacy. If applicable, additional taxonomy codes can also be found on the NPPES website for the pharmacy.

List all states where pharmacy is licensed (Attach additional pages, as needed):

*Attach copies of all pharmacy licenses. If licensed in more than 5 states, instead of licenses, include a spreadsheet with the state, license #, effective & expiration dates for all licenses. Still include the state license where the pharmacy is located and a Wyoming license, if applicable.

*Select only one box below.

BUSINESS DESIGNATION/OWNERSHIP TYPE

Sole Proprietor Partnership

Governmental Entity Not for Profit

Limited Liability Company (LLC):

OR

Corporation Partnership

Corporation

Other:

March 2014

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GHS | P. 877-205-8083 | E. wyprovider@

340B

Does this pharmacy participate in the 340B Drug Pricing Program?

If yes, please provide contact name and GHS will contact this person to verify 340B participation and billing process.

Phone #:

(

)

-

Contact Email:

@

YES

NO

.

CORRESPONDENCE *Remittance advices, compliance communication, and other correspondence will be sent to this address.

Correspondence Address:

Address

Phone #:

City

(

)

-

Fax #:

State

(

)

ZIP Code

-

Correspondence Contact:

Contact Email:

@

.

SITE DISCLOSURES Please list any physical locations that will or have the potential to have contact with a claim. *Attach additional pages as needed.

Location Name:

Address:

Street Address

Phone #:

City

(

)

-

Contact:

Activities Conducted (e.g. Dispensing, Billing, Mailing, etc.):

Fax #:

State

(

)

Contact Email:

ZIP Code

-

@

.

PHARMACY QUESTIONS Earliest date services will be provided (Time period must be covered by license/certification):

Why does this pharmacy want to be a Wyoming Medicaid Pharmacy Provider?

/

/

Has any employee of this pharmacy ever been sanctioned, debarred, suspended, excluded or convicted of a criminal offense related to Medicare, Medicaid or any other State or Federal health care program? If yes, select all that apply and attach any applicable documentation.

Sanctioned

Debarred

Suspended

Excluded

YES

NO

Convicted

March 2014

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GHS | P. 877-205-8083 | E. wyprovider@

OWNERSHIP/CONTROL INFORMATION

This section must be completed for each person who has ownership or control interest or is an agent in the pharmacy specified in this enrollment application. Please provide the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5% or more in the disclosing entity.

*All fields are required. Please make copies of the ownership pages for each owner, board member, organization, etc., as needed.

A. Ownership Type:

Owner

Board Member

Controlling Interest

Other:

Name (first, middle initial, last) / Organization:

% of Ownership:

SSN/FEIN:

Date of Birth (if applicable):

/

/

State, Country, County of Birth:

(If applicable)

Current Physical Address:

State Address

Country

County (only required if born in U.S.)

City

State

ZIP Code

Has this person ever been sanctioned, debarred, suspended, excluded or convicted of a criminal offense related to Medicare, Medicaid or any other State or Federal health care program? If yes, select all that

YES

NO

apply and attach any applicable documentation.

Sanctioned

Debarred

Suspended

Excluded

Convicted

Is this person the spouse, parent, child or sibling of a person with ownership or control interest? If yes, give name of person, relationship and indicate their percentage of ownership:

YES

NO

Name:

Relationship:

% of Ownership:

Name:

Relationship:

% of Ownership:

Name:

Relationship:

% of Ownership:

B. Does the person/organization listed above in section A have ownership or controlling interest of 5% or more in another organization that bills for publicly funded health care programs? If yes, please list applicable

YES

NO

businesses below.

Legal Business Name:

Employer ID # (FEIN):

% of Ownership:

Legal Business Name:

Employer ID # (FEIN):

% of Ownership:

C. Is the enrolling pharmacy a subsidiary company or joint venture? If yes, fill in the following information YES NO about the parent company/joint business.

Legal Business Name of Parent Company/Joint Business:

Address:

Street Address

Phone #:

City

(

)

-

Employer ID # (FEIN):

Fax #:

State

(

)

ZIP Code

-

March 2014

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GHS | P. 877-205-8083 | E. wyprovider@

PHARMACIST & MANAGING/DIRECTING EMPLOYEE INFORMATION

This section must be completed for each person who is an agent or managing/directing employee in the pharmacy specified in this enrollment application.

*If any of the following information changes, please notify GHS at 877-205-8083 or wyprovider@ as soon as the change occurs.

Please make copies of this section for the Pharmacist in Charge, Managing/Directing employee, etc., as needed.

A. Select title:

Pharmacist in Charge

Managing/Directing Employee

Other:

Name (first, middle initial, last):

NPI:

License #:

SSN:

Date of Birth:

/ /

State, Country, County of Birth:

State

Country

County (only required if born in U.S.)

Has this person ever been sanctioned, debarred, suspended, excluded or convicted of a criminal offense related to Medicare, Medicaid or any other State or Federal health care program? If yes, select all that

YES

NO

apply and attach any applicable documentation.

Sanctioned

Debarred

Suspended

Excluded

Convicted

BILLING/PAYMENT INFORMATION

Has this pharmacy previously billed Wyoming Medicaid?

YES

NO

Is this pharmacy Medicare Certified to bill for durable medical equipment?

YES

NO

YES

NO

Will the pharmacy submit claims to Wyoming Medicaid electronically through the Point of Sale (POS) system?

Will the pharmacy payments go to a corporate office, third party trading partner, or entity other than the YES NO pharmacy's physical address? Please list location name and address below of where pharmacy payments will go, whether the answer is yes or no.

*Physical check will only be mailed to this address if an Electronic Funds Transfer (EFT) payment cannot be issued.

Location Name:

Payment Address:

Address

Phone #:

City

(

)

-

State

Secure Fax #: (

)

ZIP Code

-

Billing/Payment Contact:

Contact Email:

@

.

Does the pharmacy have an entity or billing agency that bills on its behalf? If yes, please provide the following YES NO information.

Business Name:

Address:

Address

Phone #: Contact:

City

(

)

-

Fax #:

State

(

)

Contact Email:

ZIP Code

-

@

.

March 2014

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GHS | P. 877-205-8083 | E. wyprovider@

OUT OF STATE PHARMACY PROVIDERS

Does the pharmacy currently have any Wyoming Medicaid clients needing services? If yes, please provide the YES NO Wyoming Medicaid client ID number(s) below.

Does the pharmacy provide medications not readily supplied by an in-state Wyoming retail or hospital YES NO pharmacy? If yes, please provide the name of the drug(s) and example NDC numbers below.

Does the pharmacy have a Wyoming Board of Pharmacy License or does it plan to obtain one?

Is the pharmacy a compounding pharmacy that plans to mail compound prescriptions into the State of Wyoming?

YES

NO

YES

NO

If there is any additional information you feel will help Wyoming Medicaid in the assessment of your application, you may enter it here. Attach additional pages, as needed.

ENROLLMENT CONTACT INFORMATION

*Please use blue ink when signing form. Original signature is required to process application.

Contact Name:

Contact Title:

Contact Phone #: (

)

-

Contact Email:

@

.

I certify that the above information is true and correct to the best of my knowledge.

Signature

Date

*Unless otherwise noted below, all correspondence related to this application (i.e., enrollment approval/denial, etc.) will be mailed to the physical address listed on this application.

Address

City

State

Zip Code

March 2014

Page 5 of 5

GHS | P. 877-205-8083 | E. wyprovider@

Wyoming Medicaid Pharmacy Provider Enrollment Certification

MUST BE FILLED OUT FOR EACH PHARMACY LOCATION

I, as an authorized agent, certify the following:

1. I have read the contents of the Wyoming Provider Enrollment Application and the information contained herein is true, correct and complete. If I become aware that any information in the Wyoming Provider Enrollment Application is not true, correct or complete, I agree to notify Wyoming Medicaid or Goold Health Systems, an Emdeon company (GHS) of this fact immediately.

2. I authorize Medicaid or GHS to verify the information contained herein. I agree to notify Medicaid or GHS of any changes in this form within 30 days of the effective date of the change. I understand that a change in the incorporation of the pharmacy provider organization or the status as a group biller will require a new enrollment.

3. I am familiar with and agree that the pharmacy will abide by the State/Federal laws, regulations and program instructions that apply to my provider type. The State/Federal laws, regulations and program instructions are available through Medicaid. I understand that payment of a claim by a State/Federal health care program is conditioned on the claim and the underlying transaction complying with such laws, regulations and program instructions (including the anti-kickback statute and the Stark law), and on a provider being in compliance with any applicable conditions of participation in any federal health care program.

4. No owner, director, officer, or employee of the company or other organization on whose behalf I am signing this certification statement, or any contractor retained by the company or any of the aforementioned persons, currently is subject to sanction under Medicare/Medicaid or other State/Federal Program or debarred, suspended or excluded under any other federal agency or health care program, or otherwise is prohibited from providing services to Medicaid/Medicare or other State/ Federal health care program beneficiaries.

5. I agree that any existing or future overpayment to the pharmacy by the State/Federal health care program(s) may be recouped by the State/Federal health care program(s) through withholding future payments.

6. I understand that only the Medicaid provider number for the pharmacy provider who performed the service or to whom benefits were reassigned under current State/Federal health care program regulations may be used when billing State/Federal health care program(s) for services.

7. I understand that if the pharmacy does not submit claims within a 12 month period, the pharmacy's provider agreement will be inactivated, and the pharmacy will have to enroll again. If a claim is billed and reversed it will be considered as an inactive claim and not considered as meeting the requirements of an active pharmacy provider.

8. I understand Wyoming Medicaid reserves the right to inactivate a provider agreement if the service(s) for which the provider agreement was entered into no longer exists (i.e. client(s) no longer require the services the pharmacy was enrolled to provide, pharmacy no longer provides the services for which it enrolled to provide, the services provided by the pharmacy can be met by a Wyoming Medicaid Service Area (WMSA) provider).

9. I understand that any omission, misrepresentation or falsification of any information contained in the Wyoming Pharmacy Provider Enrollment Application or contained in any communication supplying information to any State/Federal health care program(s) to complete or clarify the Wyoming Pharmacy Provider Enrollment Application may be punishable by criminal, civil, or other administrative actions including revocation of State/Federal health care program(s) provider number(s), fines, penalties, damages, and/or imprisonment under Federal Law.

10. The pharmacy will not knowingly present or cause to be presented a false or fraudulent claim for payment by any State/Federal health care programs, and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.

11. I, as an authorized agent of the pharmacy who is applying for a Medicaid provider number, further certify that I am an officer, chief executive officer, or general partner of the business organization that is applying for the State/Federal health care program provider number.

*Please use blue ink when signing form. Original signature is required to process form.

__________________________________________________________________________________________

Pharmacy Name

__________________________________________________________________________________________

Name & Title of Authorized Agent Completing Form

__________________________________________________________________________________________

Signature

Date

__________________________________________________________________________________________

Email Address

Phone Number

March 2014

Page 1 of 1 GHS | P. 877-205-8083 | E. wyprovider@

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