KMAP BULLETIN: Medical Group Practice Service Location Enrollment Requirements

Date: 11/30/18

KMAP GENERAL BULLETIN 18223 (PDF)

The Kansas Medical Assistance Program (KMAP) has made changes to the medical group practice provider enrollment requirements. All medical group practices are required to complete a separate enrollment application for each service location through the Provider Enrollment Wizard. All individual providers under that group practice Tax Identification Number (TIN) will enroll once and affiliate with all group practice service locations as appropriate.

With the implementation of the new Provider Enrollment Wizard, medical group practices should complete a unique Group (G) application for each service location. All individual providers under that group practice TIN should complete one Individual Group (IG) application and affiliate with the group practice service locations where they will be seeing patients. This will be accomplished by listing the KMMS identification (ID) numbers of the group practice service location(s) on the IG application. Any additional associations between the IG provider and other existing group practice service locations can be completed through a maintenance request with KMAP. Visual representations of the new process, entitled New Group Enrollment Process and Individual Within a Group (IG) Enrollment, are provided on Pages 4 and 5 of this publication.

To enroll with KMAP, providers can access the Provider Enrollment Wizard. Providers can contact KMAP at 1-800-933-6593 with any additional questions including details regarding their current status with KMAP.

Medical Group Practice Service Location Enrollment Requirements Q&As

Does this apply to KMAP or KanCare MCOs?

The enrollment and billing instructions contained in this bulletin are specific to KMAP. However, after January 1, 2019, all KMAP enrollments will be passed along to the MCOs for credentialing and contracting with the implementation of Stage 1.5 of the Provider Enrollment Wizard. For MCO specific billing instructions, use the following links: Aetna, Amerigroup, Sunflower, UnitedHealthcare.

How is a group defined?

A group practice is a provider organization of at least two physicians organized as a single legal entity sharing the same Tax Identification Number (TIN) as defined in 42 CFR §411.352. The group practice may have one or multiple service locations. The group practice may also have one or multiple National Provider Identifiers (NPIs).

How is a service location defined?

A service location is defined as a permanent, physical office location or space belonging to, or rented by, the practice for the purpose of providing services to patients. The service location must be a component or subpart of the billing provider’s NPI.

How do I determine what a service location is and when a new enrollment is required?

If the service location has office hours and is owned, leased, or rented by the group practice or parent TIN and is a component or subpart of the billing provider’s NPI, the location is operating as its own practice location and a separate enrollment is required. If the location is not owned, rented, or leased and is an external organization to the billing provider’s NPI, this is not considered an additional service location.

If the service location where services are rendered belongs to my group practice and has the same NPI and TIN, how should this be reflected on claims?

For paper claims, the NPI, address, and other identifying information of the group practice service location is submitted in Box 33 (billing service location). No information should be populated in Box 32 (service location). The performing provider’s information should be the individual within that group (IG provider). The billing provider field (Box 33) should always include the NPI and location of the billing provider or its subparts or components. Reference the 1500 Claim Form and instructions on the Forms page of the KMAP website. A visual representation entitled CMS1500 Billing/Service Location Flow is provided on Page 6 of this publication.

For 837 transactions, the NPI, address, and other identifying information of the group practice service location is submitted in Loop 2010AA (billing provider). No information should be populated in Loop 2310C (service location). The performing provider’s information is submitted in either Loop 2310B (header) or 2420A (detail). Loop 2010AA should always include the NPI and location of the billing provider or its subparts or components. Reference the 5010 implementation guides for detailed instructions. A visual representation entitled 837 Billing/ Service Location Flow is provided on Page 7 of this publication.

Provide examples of a situation where enrollment of an additional group service location would not be required.

Example 1: If your organization supports Rural Health Clinics (RHCs) and sends providers to those RHC locations to see patients on a rotating basis, the location of the RHC does not require a unique service location enrollment by your organization. The RHC has its own NPI and enrollment with KMAP.

Example 2: If your organization provides services at a hospital, this does not require a unique service location enrollment by your organization. The hospital should have its own NPI and KMAP enrollment.

If the service location where services are rendered does not belong to my group organization (such as in the example above), how should this be reflected on claims?

For paper claims, the information of the IG’s associated group practice service location is submitted in Box 33 (billing service location). The NPI, address, and other identifying information for the RHC is submitted in Box 32 (service location). The performing provider’s information should reflect that of the IG. Reference the 1500 Claim Form and instructions on the Forms page of the KMAP website. A visual representation entitled CMS1500 Billing/Service Location Flow is provided on Page 6 of this publication.

For 837 transactions, the information of the IG’s associated group practice (for example, Clinic on Mulvane) is submitted in Loop 2010AA (billing provider). The NPI, address, and other identifying information for the RHC is submitted in Loop 2310C (service location). The performing provider’s information is submitted in either Loop 2310B (header) or 2420A (detail). Reference the 5010 implementation guides for detailed instructions. A visual representation entitled 837 Billing/Service Location Flow is provided on Page 7 of this publication.

How do we enroll all of our midlevel practitioners and APRNs? Would they be part of the group or a different group?

Any practitioner that is a member of the group would need to enroll as part of the group.

We have multiple offices within the same building that provide different services. Will these each be different service locations?

If the specialties all fall under the group NPI, then no, that location would be one service location with all specialties listed. If other services are provided outside of the physician group NPI, these would be separate enrollments. There are instances when a single physical location may house multiple provider types or NPIs within the same building. There is not a change to this current enrollment practice which requires a new and unique enrollment for each provider type and NPI regardless of the shared physical address.

What is a KMMS ID and where do I find it?

A unique KMMS ID is assigned to each group practice location enrollment. This ID enables the system to differentiate between service locations. An IG provider must obtain the KMMS ID for each group service location they wish to affiliate to from the group practice and enter the ID number(s) on the application. An existing IG may also affiliate to an existing group practice location through a maintenance request to KMAP. The IG must obtain the appropriate KMMS ID from the group practice in order to affiliate.

Click here to see the flow charts.