St Year Implementation Schedule Year 1 Primarily Institutional Providers 6405 Providers scheduled for reenrollment Providers will be notified when reenrollment is due Important Providers should not submit documentation before being notified ID: 1038159
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1. Provider Re-Enrollment
2. 1St Year Implementation ScheduleYear 1- Primarily Institutional Providers 6405 Providers scheduled for reenrollmentProviders will be notified when reenrollment is dueImportant: Providers should not submit documentation before being notified Schedule is subject to change1
3. Number of Providers2
4. Year 1 Schedule (Per Week)DateProvider Type/ NameTotal ProvidersFeeSite VisitIn Progress01/18/201350- Adult Foster Care50NN01/25/201350- Adult Foster Care48NN02/01/201340- Attendant Care150YN02/08/201340- Attendant Care101YN02/15/201397- Air Transportation35YN27- Adult Day care19YN74- Alternative Res. Fac.66YN02/22/201374- Alternative Res. Fac.150YN03/01/201343*-Ambulatory Surg. Ctr147*03/08/201349- Assisted Living Center56- Boarding HomeB7- Crisis Service Provider81- EPD HCBS 83- Free standing Birthing Ctr.55- Hotels128321113YN* Medicare (fee and site visit performed at federal level )Moderate categorical risk3
5. Schedule Continued…DateProvider Type/ NameTotal ProvidersFeeSite Visit03/15/201336- Assisted Living Homes150YN03/22/201336- Assisted Living Homes150YN03/29/201336- Assisted Living Homes150YN04/05/201336- Assisted Living Homes150YN04/12/201336- Assisted Living Homes150YN04/19/201336- Assisted Living Homes150YN04/26/201336- Assisted Living Homes150YN05/03/201336- Assisted Living HomesA5- Behav. Hlth Therapeutic Home65 109YN05/10/2013A5- Behav. Hlth Therapeutic Home150YN05/17/2013A5- Behav. Hlth Therapeutic Home150YN05/24/2013A5- Behav. Hlth Therapeutic Home05- Clinic5595YN05/31/201205- Clinic 71*- Psychiatric Hospital12921*YN*Medicare (fee and site visit performed at federal level )4
6. Schedule Continued…DateProvider Type/ NameTotal ProvidersFeeSite Visit06/07/201341*- Dialysis Center70- Home Delivered Meals122*20YN06/14/201332- Medical Foods78- Mental Hlth Res. Treat. Ctr.72- Regional Beh. Hlth. Auth.B2- Resid Trtm. Ctr-non-secure B3- Resid Trtment Ctr-non-secureE1- Independent Testing Fac.A2- Level III Behav. Health6612515770YN06/21/2013B1- Resid. Trtment Ctr. secure57- Residential Treatment Fac.A6- Rural Substance Abuse TraB5- Subacute facility (1-16 beds)B6- Subacute facility (17+beds)79- Vision Center02*- Hospital111819411103*YN06/28/201302*- Hospital150** Medicare (fee and site visit performed at federal level )5
7. Schedule Continued…DateProvider Type/ NameTotal ProvidersFeeSite Visit07/05/201302*- Hospital150*07/12/201302*- Hospital150*07/19/201302*- Hospital150*07/26/201302*- Hospital150*08/02/201302*- Hospital150*08/09/201302*- Hospital150*08/16/201302*- Hospital28- Non-Emerg Trans.81*69YN08/23/201328- Non-Emerg Trans.150YN08/30/201330- DME Supplier250YY09/06/201330- DME Supplier207YY22*- Nursing Home43*09/13/201322*- Nursing Home03- Pharmacy103*47YNHigh categorical risk * Medicare (fee and site visit performed at federal level )6
8. Schedule Continued…Date Provider Type/ NameTotal ProvidersFeeSite Visit09/20/201303*- Pharmacy250YN09/27/201303*- Pharmacy250YN10/04/201303*- Pharmacy281YN10/11/201303*- Pharmacy280YN10/18/201303*- Pharmacy150YN7
9. Year 1- Documents CollectedProvider Participation AgreementDisclosure of Ownership Form- Companies and FacilitiesCriminal Offense FormAddress Verification Form/W-9Provider Type Profiles Attendant CareIndependent Testing FacilityNon-Emergency Transportation Provider8