Letter to CMS - Medicaid Managed Care Policies - Agency for ...

APPLICATION ITEM
42 12. Fingerprint cards must be submitted for all individuals listed
below, with a completed Background Screening Manager List, as
provided in the Forms section of this application:
a. Shareholders (five percent or more ownership);
b. Partners of your business and subcontractors, including any
third party administrators (for PSNs only);
c. Individual officers;
d. Directors;
e. Managers (any person who can make or direct decisions that
have an impact on services rendered to recipients);
f. Financial records custodian;
g. Medical records custodian; and
h. Individuals who hold signing privileges on the depository
account.
If an individual has submitted fingerprints to the Agency or to the
Office of Insurance Regulation in the last 12 months, the
applicant need only state such and does not need to include
another set of fingerprints for the individual.
Agency for Health Care Administration
Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
Confirm receipt of fingerprints and processing fees
for all required individuals:
All listed on CMS-1513
All listed trustees and associates
Managers identified in Question 160 of the
Health Plan Application and with Officer,
Director, Manager title included on the
organizational charts submitted.
All listed in response to Question 28
(Records Custodians) and Questions 29
(Owner(s) and Operator(s)), of the Medicaid
Provider Enrollment Application
If applicant states that fingerprints were submitted to
the Agency in the past 12 months, verify in FMMIS.
In the Provider panel, click Related Data, then
Other, then Owner. You can search by Business
Name, First and Last Name, or Tax ID (FEIN or
SSN). Click on a row to see detail in the Owner
Data Table. The bottom of the screen will show the
provider IDs with which the individual is associated.
If applicant states that fingerprints were submitted to
OIR in the past 12 months, verify with OIR. Contact
information is Gwen.Chick@floir.com
For healthcare applicants with hospital ownership,
completed fingerprint cards must be submitted. No
hospital exemption applies.
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 11 of 19
INITIALS &
DATE
COMPLETED