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9PROMISeTM Provider Enrollment Readiness PacketThis packet contains information which will help guide you through the PROMISeProcess.TMProvider EnrollmentUse the following links to go directly to the document you would like to view:TMInstructions for Completing the PROMISeProvidersProvider Enrollment Base Application for ODPODP Provider Types and SpecialtiesExamples of Acceptable Documentation to Verify IRS NumbersExamples of Unacceptable Documentation to Verify IRS NumbersTMPROMISeVersion 3.0Provider Enrollment Packet Checklist-1-

Instructions for Completing the PROMISeTM Provider Enrollment Base Application forODP ProvidersPrint the Provider Enrollment Base Application from the Office of Medical Assistance Programs(OMAP) web site at: http://www.dpw.state.pa.us/omap. To download the application:1. Click the Provider Information hyperlink (on the left side of the screen);2. Click the Provider Enrollment Information hyperlink;3. Click the Enrollment Application/Provider Agreement hyperlink.IMPORTANT NOTES: Applications must be typed or completed by hand using black ink. Out-of-state providers must submit proof of participation in that state’sMedicaid program.Specific Field Completion on and Completion NotesEnter the complete name of the individual or the facility.NOTE: The facility name cannot include a street address.Select Initial Enrollment. Select Individual or Facility. To the right of 2a, write your nine(9) digit MPI number and four (4) digit service location code.If you are re-activating a closed service location that was enrolled in PROMISeTM in the past,check this box.If this is a name change, indicate the old name and the new name.NOTE: To verify your new name, a copy of your Social Security card or FEIN/IRSdocumentation must accompany your application.Leave Blank.IMPORTANT: This cell only needs to be completed if the provider type you are enrolling is ahealthcare provider type (i.e. Provider types 16, 17, 19, or 52- 456 and 520). Complete thissection ONLY IF you are a health care provider and have been issued a National ProviderIdentifier (NPI). Include a legible copy of the NPPES Confirmation letter that shows the NPINumber and Taxonomy(s) assigned to the health care provider applying for enrollment.Enter your ten (10) digit NPI number, and ten (10) digit taxonomy code(s). If you have morethan four (4) taxonomy codes, please attach an additional sheet noting the additional codes.Enter the requested effective date for your action request. Check with your county on whatdate should appear here.NOTE: If claims are submitted prior to the Requested Effective Date in PROMISe , they willbe denied.Enter your provider type number and description. Refer to the ODP Provider Type/SpecialtyCodes list for assistance.NOTE: For each unique provider type and physical address combination, a new applicationmust be completed.Enter your specialty name and code number. Refer to the ODP Provider Type/SpecialtyCodes list for assistance.NOTE: Separate applications are not required for different specialties, only for separateservice locations. You may enter multiple specialty names and codes in this field.Enter N/A.Version 3.0-2-

FieldDescription and Completion Notes8.For individuals only: Enter your Social Security Number.9.NOTES: A copy of your Social Security card, W-2, or document from the IRS containing yourSocial Security Number must accompany your application. If you complete this field, do not complete #9.For facilities only: Enter your Federal Tax ID Number (FEIN).10.11a.11b.12a.12b.13.14.15.16a.NOTES: A copy of the FEIN label or document from the IRS containing your IRS number mustaccompany this application. A W-9 form will not be accepted. If you complete this field, do not complete #8.Enter your legal name as it is filed with the IRS and as it appears on the attached IRSdocumentation.NOTE: It is not necessary that Facility Name in #1 and Legal Name in #10 match; however,the Legal Name in #10 MUST match the name on the IRS documentation.Select No.Enter N/A.Indicate whether the provider operates under a fictitious business or “doing business as”(d/b/a) name.If applicable, enter the statement/permit number and the name.NOTE: Attach a legible copy of the recorded/stamped fictitious business namestatement/permit.For Individuals Only: Enter your date of birth.For Individuals Only: Enter your gender.For Individuals Only: Enter the title/degree you currently hold.Enter your legal entity address. The address must be a physical location. A post office boxis not a valid legal entity address. The zip code MUST contain nine (9) digits.16b.NOTE: The Legal Entity Address is the Home Office Address. It MUST match the BusinessAddress listed in HCSIS.Enter the name of the contact person for the organization.16c.16d.16e.16f.17.NOTE: The Contact Name/Title is the contact person for the corporation or other businessentity (Chief Executive Officer, Chief Financial Office, etc.)Enter the e-mail address for the contact person listed in # 16b.Enter the business phone for the contact person listed in # 16b.Enter the toll free business phone for the contact person listed in # 16b, if applicable.Enter the fax number for the contact person listed in # 16b, if applicableSelect the appropriate box for your business type.18.NOTES: Check one (1) box only. Include incorporation papers from the PA Department of State Corporation Bureau ora copy of your business partnership agreement, if applicable.If you are enrolling to provide a licensed service, enter your license number, issuing state,issue date, and expiration date.Version 3.0-3-

Field19.20a.Description and Completion NotesNOTES: This block refers to the license issued by the Department of Public Welfare - alsoreferred to as the Certificate of Compliance. A copy of your license must accompany your application. Attach the page of thelicense that pertains to the service location.Enter N/A.Enter a valid service location address. This address should already be entered in HCSIS.Select Pay-to, Mail-to and/or Home Office, if applicable.NOTES: The address must be a physical location, not a post office box. The zip code MUST contain nine (9) digits. The Service Location information in PROMISe MUST match what is in HCSIS. For Pay-to, Mail-to, and/or Home Office locations different from the Service Locationaddress entered in # 20a, complete the additional Home Office/Mail-To/Pay-To pagewithin the application. If the Pay-to, Mail-to and/or Home Office are all the same asthe Service Location address, write "N/A" on the additional page.Answer questions and enter your e-mail address, if applicable.20bc.20d.20e.Enter N/A.Enter the contact information for this address.20f.20g.20h.20i.NOTE: The Contact Person should be the PROMISeTM billing contact for your organization.Enter the toll free business phone for the contact person listed in # 20e, if applicable.Enter the fax number for the contact person listed in # 20e, if applicableEnter the e-mail address for the contact person listed in # 20e.Select whether you or your staff are able to communicate in any language other than English.20j.20k.20l.21ae.21f.22.NOTE: American Sign Language (ASL) is considered another language.List the language(s), other than English, in which you or your staff are able to communicate.Answer questions pertaining to the Americans with Disabilities Act (ADA). These questionsrefer to the Service Location Address entered in # 20a.Enter the appropriate Provider Eligibility Program(s) (PEP) in which you participate.NOTES: Use Consolidated, P/FDS and MR Base for all Provider Types except 52, CommunityResidential Rehabilitation. If the location is for Provider Type 52, enter Consolidated and MR Base only. If you do not provide waiver services, enter MR Base only.Complete ALL confidential information questions in this section.NOTE: If you answer Yes to any of the questions, provide a detailed explanation (on aseparate piece of paper) and attach it to your application.Include full details on any Yes responses to the proceeding questions.Sign the application (CEO or CFO) and print your name, title and date.NOTE: BLACK ink must be used for the signature.Version 3.0-4-

Field23.23a.23b.23c.23d.23e.23f.23g.Description and Completion NotesUse this field only to add a Mail-to, Pay-to and/or Home Office address to thepreviously defined service location entered in # 20a.NOTES: Use as many fields as necessary to list details for all applicable locations. This sheet cannot be used to add a service location. You must complete a newapplication to add a service location.Enter the corresponding location for a Mail-to, Pay-to and/or Home Office location thatis different from # 20a.Indicate whether you are adding a Mail-to, Pay-to and/or Home Office address. It canbe any combination of these.Enter the e-mail address of the contact person for this address.Enter the name and title of the contact person for this location.Enter the toll free business phone for the contact person listed in # 23d, if applicable.Enter the fax number for the contact person listed in # 23d, if applicableEnter the e-mail address for the contact person listed in # 23d.Additional Notes: When you have completed the PROMISe Provider Enrollment Application, reviewthe PROMISeTM Provider Enrollment Packet Checklist. Page 13 can be omitted when submitting your application. All providers MUST sign and date Page 14, the Provider Agreement for OutpatientProviders, included in the online PROMISe Provider Enrollment Base Application. Complete ALL SPACES as required on the application with either your correctinformation, or N/A. Return your application and other documentation to ODP PROMISeTM ProviderEnrollment via FAX at 1-717-783-5141 or mail to:ODP Provider EnrollmentRoom 413Health & Welfare BuildingHarrisburg, PA 17101Version 3.0-5-

ODP Provider Types and SpecialtiesProvider iption160Registered Nurse161Licensed Practical Nurse170Physical Therapist171Occupational Therapist172Respiratory Therapist173Speech/Hearing Therapist190General Psychologist191192Clinical NeuropsychologistClinical Health Psychologist193Psychoanalytic Psychologist194School Psychologist195Clinical Psychologist196Clinical Child Psychologist197Counseling Psychologist198Industrial Organizational Psychologist199Behavioral Psychologist201Forensic Psychologist202Family Psychologist203Biofeedback: Applied Psychophysiologist204Clinical Geropsychologist205Psychopharmacologist206207Trtmt of Alcol and other Psycav Sbstc UseDsordrsCognitive Therapist208Behavioral Therapist Consultant548Therapeutic Staff Support549Mobile Therapy559Behavioral Specialist Consultant26Transportation267Non-emergency51Home and CommunityHabilitation362410Attendant Care/Personal AssistanceServiceAdult Day Services510Home and Community Habilitation511Respite Care - InstitutionalVersion 3.0-6-

52535455Community ResidentialRehabilitationEmployment CompetitiveIntermediate ServiceOrganizationVendorVersion 3.0512Respite Care – Home Based513Respite Care – Out of Home514Adult Training - 2380515Pre-Vocational – 2390516Transitional Work Services517Visual & Mobility Therapy518Recreation533Educational Service571Home Finding456CRR- Adult520Child Residential Services – 3800521Adult Residential – 6400522Family Living Homes – 6500523Host Home/Children524Unlicensed530Job Finding531Job Support540ISO – Agency with Choice541ISO – Fiscal/Employer Agent267Non-emergency430Homemaker Agency431Homemaker/Chore Services543Environmental Accessibility Adaptations552Adaptive Appliances/Equipment553Habilitation Supplies554Respite, Overnight Camp555Respite, Day Camp-7-

Examples of Acceptable Documentation to Verify IRS NumbersThe following documents are acceptable as verification of the IRS/SSN number:NOTE: Only the applicable portions of the documents have been included. IRS Form CP575 Form 8109 – Federal Tax Deposit CouponVersion 3.0-8-