Receive an Approval Letter from DIDD Provider Enrollment Coordinator.

Contact per letter’s instructions, Julia Jinnette by phone, email or letter.

Provider Agreement is generated by region in DIDD Contract Services.

DIDD Approval is secured. DIDD Approved Provider Agreement

is mailed to Vendor/Provider.

Vendor receives Provider Agreement Packet. Vendor signs Provider Agreement (must sign 2

places for each region). Vendor completes all forms included with the

Provider Agreements. Vendor returns all completed forms and signed

Agreement/s in Return Envelope. DIDD Contract Services receives, logs, assigns

Agreement Number (in house contract number) and routes Agreement/s to TennCare.

TennCare returns signed/fully executed Agreement/s.

Contract Services logs, emails executed Agreement/s to Regional Offices.

Contract Services routes provider packet (all documentation needed to assign site codes) to Business Services.

Business Services notifies Regional Office of codes and forwards provider packet to TennCare.

Regional Office mails or emails executed Agreement to Vendor/Provider.

Copy of each applicable Business/Professional License. Copy of Proof of Insurance. Completed & signed Forms:

› Disclosure Form for Provider Entities or Provider Person.› Substitute W-9.› Service Provider Registration.› TennCare No.3 Provider Application (Provider Entities)› TennCare No.2 Individual Joining A Group (Provider Person)› TennCare Provider Participation Agreement (Provider Person)› TennCare National Provider Identifier (NPI) Collection Form

(clinical providers)› ACH (Automated Clearinghouse) with voided Check.› Request for Staff LOGIN ID.› Check List of Items to Return (ORANGE SHEET).

Disclosure Form must be completed, all boxes marked with information or “n/a”, signed and dated.

Service Provider Registration Form completion can be waived, if Provider prints off Web registration & returns with packet: (www.state.tn.us/finance/rds/ocr/register.html)

ACH (Automated Clearinghouse) form must be accompanied by a voided Check.

TennCare No.3 Provider Application will have items that are not applicable or unknown at this time, leave blank.

TennCare No.2 Individual Joining A Group Application will have items that are not applicavle or unknown at this time, leave blank.

TennCare NPI Collection Form will have items that are not applicable or unknown at this time, leave blank.

Substitute W-9 must be completed and signed. Request for Staff LOGIN ID must be completed

and signed.

COPY OF PROOF OF INSURANCE MUST BE INCLUDED IN RETURN PACKET.

COPY OF EACH APPLICABLE LICENSE (PROFESSIONAL AND/OR BUSINESS) MUST BE INCLUDED IN RETURN PACKET.

Errors in processing can delay receipt of fully executed Provider Agreement. Most common:

Failure to sign pages 25 and 26 of the Agreements.

TennCare forms not completed/signed. Copy/s of applicable License not included. Copy/s of Proof of Insurance not included. White-out on signature page. (Line thru

and print correct name, then sign above it).

Service Provider Registration not returned – *see note*› *Registration must be done on-line.

Printout of online registration is acceptable.

Failure to complete the Checklist (including the email address) and Failure to return it.› Email address on Checklist is illegible.

ACH form not completed, voided Check not included.

Adding or Removing Services Changes in services are processed by

using the Amendment format. The Amendment is usually a two-page document that has the “new” services listed and the three signature lines. It is a simple process that is necessary to ensure that the provider is responsible only for the approved services authorized by the contract process.

An Amendment must be processed to add a new service to existing services. Copy of applicable license must be returned with Amendment.

An Amendment must be processed to remove a service no longer being provided. If license are not renewed, the Amendment must be used to remove the service from the Provider’s obligations.

Receive an Approval Letter from DIDD Provider Enrollment Coordinator.

Contact per letter’s instructions, Julia Jinnette by phone, email or letter.

Provider Amendment is generated in DIDD Contract Services.

DIDD Approval is secured. DIDD Approved Provider Amendment is

mailed to Vendor/Provider.

Provider contacts DIDD Contract Services to add or remove services.

Contract Services initiates Amendment, secures DIDD approval signature and mails to Provider.

Provider signs and returns Amendment along with applicable License.

Contract Services routes to TennCare for signature. When returned from TennCare, Contract Services

emails fully executed copies to Regional Office. Contract Services routes amendment packet (all

documentation needed to assign site codes or inactivation) to Business Services.

Business Services notifies Regional Office of codes and forwards amendment packet to TennCare.

Regional Office forwards a fully executed copy to Provider.

CHANGE IN OWNERSHIP/LEGAL STRUCTURE:The DIDD Provider Manual Section 5.3 states that a new application must be submitted any time a change in ownership occurs. The purchasing agency may not bill DIDD for services rendered until a new provider agreement has been established and signed by DIDD, TennCare, and the new agency. An agency may not continue to bill DIDD using the previous agency's billing numbers and site codes once a change has occurred. Services may not be billed retroactively, should an agency provide services before a new provider agreement has been established. It is imperative that a new application be submitted as soon as a decision to change ownership has been determined, as the application process may take several or weeks, or months.For agencies licensed to provide Professional Support Services through the Department of Health(DOH), Rule 1200-8-34-.03 states that,a proposed change of ownership must be reported to the department [DOH] a minimum of thirty (30) days prior to the change. A new application and fee must be received by the department before the license may be issued.

Changes in Agency Contact Information Changes in Ownership February 15, 2007 Page 2 of 2Circumstances constituting a change in ownership may include, but are not limited to:

› Partnership changes› Corporation changes› Leasing Changes › Transfers

(Please refer to 1200-8-8-.02(e) and 1200-8-34-.03(b)).Other agencies licensed through DOH and/or licensed through the Department of Mental Health and Developmental Disabilities (DMHDD) are also required to submit a new application and fee before a change in ownership can occur. (See Rules 0940-5-2-.09 and 1200-8-8-.02(d)).

Pursuant to the Section 5.c. of enclosed Executive Order 41 regarding Prohibition of Illegal Immigrants, the State of Tennessee is required to obtain a signed Attestation Re Personnel Used in Contract Performance Form from each provider that is under contract with the Department of Intellectual and Developmental Disabilities (DIDD). This form must be completed twice a year, in order to comply with the Governor’s order.

Any questions regarding the contract process, contact: Julia Jinnette :

(615) 253-6817 or julia.jinnette@tn.gov State of Tennessee requires a fully

executed agreement before any service can be authorized or payments made.

Under no circumstances should a provider begin work WITHOUT a fully executed agreement.