Mo medicaid revalidation application

State and federal regulations require all currently enrolled Medicaid providers to revalidate their enrollment at least every five (5) years.

YOU MUST SUBMIT ALL REQUIRED DOCUMENTATION FOR YOUR PROVIDER TYPE BELOW, OR YOUR REVALIDATION WILL BE REJECTED. THIS COULD CAUSE YOUR MO HEALTHNET ENROLLMENT TO ALSO BE DEACTIVATED.

You will be notified and given an explanation via eMOMED if your revalidation application is rejected. You will be given an opportunity to submit any missing documentation prior to deactivation of your MO HealthNet enrollment. If we do not receive the requested documentation within 30 days of notice, your MO HealthNet enrollment will be deactivated and you will be required to re-enroll.

If you receive payments directly from the state for services rendered, or bill the state for services rendered, you must submit documents from Section I and Section II.

If you receive payment through an enrolled organization, such as a clinic, or other provider, you only need to submit documents listed under your provider type in Section II unless instructed otherwise.

Section I:

In addition to the information listed in Section II all providers who receive payment directly from the state will need to upload the following documents:

A copy of one of the following IRS documents must be submitted. The legal name and Tax ID number must be PREPRINTED on the document by the IRS:

• • CP 575 or 147C letter
  • Any IRS document or letter that has the legal name and Tax ID number Pre-printed
  • Social Security Administration documentation with legal name and Tax ID number Pre-printed

  NOTE: A W-9 or computer printed forms ARE NOT ACCEPTABLE

  1. Business Organizational Structure form
     • Limited Liability Companies, Incorporations, Partnerships, and Public Entities must also submit an Organizational Chart .

  For the Business Organizational Structure (BOS) form all managing employees and owners must be listed with name, address, SSN, and DOB information. Business entities that qualify as owners must be listed with name, address, and EIN information. 13 CSR 65-2.010(25) defines managing employee, and 13 CSR 65-2.010(40) defines ownership.

  In addition to the managing employee and owner information Section VI: Legal Disclosure must be answered yes or no with case information entered if answering yes. This document must be hand signed and dated by a managing employee or owner.

  For each business type additional supporting documents are listed. All business types except Sole Proprietors without a DBA are required to register with the Missouri Secretary of State. Businesses based in other states are required to register with the Secretary of State where they are located and register with the Missouri Secretary of State as a foreign entity.

  Information for the business registration process is available from the Missouri Secretary of State website:

  • Resources: https://www.sos.mo.gov/bsd/onlinereferenceguides
  • Forms: https://www.sos.mo.gov/business/corporations/forms
  • FAQ: https://www.sos.mo.gov/business/faqs
  • Contact: https://www.sos.mo.gov/contact

  Section II (scroll to find your provider type):

  Acupuncture (72)

  Area Agency on Aging (28)

  All of the documents listed in Section I plus the following documents:

  1. Lease or Deed for the location
  2. Submit a current city business license – If a business license is not required submit a statement from the city on city letterhead with explanation.
  3. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
  4. If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  5. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  6. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
  7. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded
  8. Aged & Disabled Waiver – Questionnaire
  9. Provider Self-Assessment – HCBS Setting Requirements

  Adult Day Care (29)

  All of the documents listed in Section I plus the following documents:

  1. Adult Day Care License
  2. Lease or Deed for the location
  3. Application Fee Receipt:Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  4. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  5. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
  6. Adult Day Care – Provider Profile
  7. Adult Day Care – Assurances form
  8. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded
  9. For every individual named on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.
  10. Provider Self-Assessment – HCBS Setting Requirements
  11. HCBS Setting Requirements Assurances form

  Aged & Disabled Waiver Homemaker/Chore and Respite (28)

  All of the documents listed in Section I plus the following documents:

  1. Current copy of the Certificate of Liability Insurance and Employee Dishonesty Bond
  2. Lease or Deed for the location
  3. Submit a current city business license – If a business license is not required submit a statement from the city on city letterhead with explanation.
  4. Please complete the spreadsheet labeled “HCBS Satellite Spreadsheet” to verify all current or past satellite office locations for your agency.
  5. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  6. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  7. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
  8. Advanced Personal Care Addendum (If Personal Care enrolled)
  9. In-Home Services – Assurances
  10. In-Home Services – Provider Profile
  11. Title XIX Participation Agreement
      • Must be signed by Owner or Managing Employee
      • Must be completely filled out and both pages must be uploaded
  12. For every individual named on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.
  13. Provider Self-Assessment – HCBS Setting Requirements (Optional)
  14. EVV data in the Sandata EVV aggregator portal should show complete (verified) EVV visits for all authorized DHSS participants for which claims were submitted to MO HealthNet

  **** Following your site visit approval you will be contacted to complete a new IHS contract ****

  Ambulance (80)

  All of the documents listed in Section I plus the following documents:

  1. Air Carrier Certificate (if Air Ambulance)
  2. Copy of owners current permanent Ambulance Service License (need trade name and agency license number)
  3. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Ambulatory Surgical Center (50)

  All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Assisted Living Facility (26)

  All of the documents listed in Section I plus the following documents:

  1. Assisted Living Facility License (DHSS)
  2. Lease or Deed for the location
  3. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  4. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  5. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
  6. Assisted Living Facility – Profile
  7. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded
  8. For every individual named on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

  Assistant Behavior Analyst (73)

  Assistant Physician (21)

  Audiologist/Hearing Aid Specialist (33)

  Behavior Analyst (73)

  Case Management (18)

  All of the documents listed in Section I plus the following documents:

  1. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  2. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Certified Community Behavioral Health Clinics (88)

  All of the documents listed in Section I plus the following documents:

  1. Letter from the Department of Mental Health (DMH) stating that the provider has been recognized by the Division of Behavioral Health
  2. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Chiropractor (23)

  Community Mental Health Center (56)

  All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Copy of Department of Mental Health (DMH) certification as a Community Mental Health Center
  3. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Community Psychiatric Rehabilitation Services (87)

  All of the documents listed in Section I plus the following documents:

  1. Copy of Department of Mental Health (DMH) certification as a Community Psychiatric Rehabilitation Services
  2. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Comprehensive Substance Treatment Rehab Services (86)

  All of the documents listed in Section I plus the following documents:

  1. Copy of Department of Mental Health (DMH) certification as a CSTAR provider, Provisional certification is acceptable
  2. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  3. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Consumer Directed Services – CDS (26)

  All of the documents listed in Section I plus the following documents:

  1. Submit a current city business license – If a business license is not required submit a statement from the city on city letterhead with explanation.
  2. Lease or Deed for the location
  3. Please complete the spreadsheet labeled “HCBS Satellite Spreadsheet” to verify all current or past satellite office locations for your agency.
  4. Application Fee Receipt: Click hereor copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
     • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
  5. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  6. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
  7. Consumer Directed Services – Assurances
  8. Consumer Directed Services – Vendor Profile
  9. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded
  10. For every individual named on either the BOS form or the Vendor Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.
  11. Provider Self-Assessment – HCBS Setting Requirements (Optional)
  12. EVV data in the Sandata EVV aggregator portal should show complete (verified) EVV visits for all authorized DHSS participants for which claims were submitted to MO HealthNet
  13. CDS Quarterly Financial and Services Reports should be up to date with MMAC. Contact MMAC.CDS@dss.mo.gov

  **** Following your site visit approval you will be contacted to complete a new CDS contract ****

  CRNA Services (91)

  Dental Hygienist (74)

  Dentist (40)

  Dialysis Clinic (50)

  All of the documents listed in Section I plus the following documents:

  1. Medicare enrolled
  2. Title XIX Participation Agreement
     • Must be signed by Owner or Managing Employee
     • Must be completely filled out and both pages must be uploaded

  Disease Management (35)

  • Title XIX Participation Agreement
    • Must be signed by the Provider and both pages must be uploaded

    DMH – Developmentally Disabled Waiver (85)

    All of the documents listed in Section I plus the following documents:

    1. Current Copy of Department of Mental Health (DMH) Contract for Services
    2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    3. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Durable Medical Equipment (62)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    FQHC – Federally Qualified Health Care Center (50)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled or HRSA Letter
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Hospitals Acute and Children’s Psychiatric Hospitals (01 /02)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Hospital license
    3. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Home Health Agency (58)

    All of the documents listed in Section I plus the following documents:

    1. DHSS Home Health License
    2. Medicare enrolled
    3. AIDS / HIV Waiver addendum (optional)
    4. Medically Fragile Adult Waiver Addendum (optional)
    5. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded
    6. EVV data in the Sandata EVV aggregator portal should show complete (verified) EVV visits for all authorized DHSS participants for which claims were submitted to MO HealthNet

    Hospice (82)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Hospice Certification issued by the DHSS
    3. Hospice Nursing Facility Contract (optional)
    4. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Independent or Portable X-Ray / IDTF (71)

    All of the documents listed in Section I plus the following documents:

    1. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Independent Clinics (50)

    All of the documents listed in Section I plus the following documents:

    1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Independent Lab (70)

    All of the documents listed in Section I plus the following documents

    1. CLIA Certificate (Required)
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    The Laboratory Director named on the CLIA Certificate meets the definition of a managing employee, and must be listed on the Business Organizational Structure form

    MCO – Individual Managed care only, no FFS (83)

    MCO – Organizational Managed care only, no FFS (83)

    All of the documents listed in Section I plus the following documents:

    1. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Non-Emergency Transportation (65)

    All of the documents listed in Section I plus the following documents:

    1. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Nurse Midwife (25)

    1. List of all practice locations– if collaborative is used; each location listed must be on the collaborative agreement. Be sure to list group name, location, and phone.
    2. Prescribing Nurse – Collaborative Agreement for all locations
    3. APRN – CPA Attestation If the CPA is not from the current year the Attestation must be filled out and signed by the provider.
    4. Title XIX Participation Agreement
       • Must be signed by theProviderand both pages must be uploaded.

    Nurse Practitioner (42)

    1. List of all practice locations– if collaborative is used; each location listed must be on the collaborative agreement. Be sure to list group name, location, and phone.
    2. Prescribing Nurse – Collaborative Agreement for all locations
    3. APRN – CPA Attestation If the CPA is not from the current year the Attestation must be filled out and signed by the provider.
    4. Title XIX Participation Agreement
       • Must be signed by theProviderand both pages must beuploaded.

    Nursing Homes (10)

    All of the documents listed in Section I plus the following documents:

    1. DHSS Nursing Home license or hospital affiliation
    2. If Nursing Home is enrolled in Medicare there will not be a fee required.
    3. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Occupational Therapist (47)

    Optician/Optometrist (32)

    All of the documents listed in Section I plus the following documents:

    1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Optometrist (31)

    Pharmacy (60)

    All of the documents listed in Section I plus the following documents:

    1. Copy of Current License
    2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    3. Long Term Care Form (if applicable)
    4. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    The pharmacist in charge meets the definition of a managing employee, and must be listed as part of the Business Organizational Structure form

    Physical Therapist (48)

    Physician Assistant (22)

    Physician – MD & DO (20, 24)

    Physician or other Provider Groups (Independent Clinics) (50)

    All of the documents listed in Section I plus the following documents:

    1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Podiatrist- Surgical Chiropody (30)

    Private Duty Nursing (94)

    All of the documents listed in Section I plus the following documents:

    1. Submit one of these items:
       • NPI which is enrolled as Medicare-certified Home Health Agency and a MO HealthNet Home Health Agency provider
       • Accreditation through the Joint Commission for Accreditation of Health Organization (JCAHO) or the Community Health Accreditation Program (CHAPS)
       • Private Duty Nursing (PDN) Addendum
    2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    3. Medically Fragile Adult Waiver Addendum (optional)
    4. AIDS / HIV Waiver addendum (optional)
    5. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Private Home – (ICF/DD Home) (11)

    All of the documents listed in Section I plus the following documents:

    1. DMH Certification
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Professional Counselor – LPC, PLPC (49)

    Psychologist – LP, PLP (49)

    Public Health Department Clinic (51)

    All of the documents listed in Section I plus the following documents:

    1. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Qualified Medicare Beneficiary (75)

    All of the documents listed in Section I plus the following documents:

    Rehabilitation Center (57)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Residential Care Facility (26)

    All of the documents listed in Section I plus the following documents:

    1. Residential Care Facility License (DHSS)
    2. Lease or Deed for the location
    3. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    4. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
    5. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
    6. Residential Care Facility – Profile
    7. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded
    8. For every individual named on either the BOS form or the Provider Profile: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.

    Rural Health Clinic (59)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    School Based (96)

    All of the documents listed in Section I plus the following documents:

    1. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Social Worker – LCSW, LMSW (49)

    Speech Therapist (46)

    State Institution – Long Term Care (05)

    All of the documents listed in Section I plus the following documents:

    1. DMH License
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Targeted Case Management (15)

    All of the documents listed in Section I plus the following documents:

    1. Current Copy of Department of Mental Health (DMH) Contract for Services
    2. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    3. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Teaching Hospital (55)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Teaching Institution – All Department Hospital (54)

    All of the documents listed in Section I plus the following documents:

    1. Medicare enrolled
    2. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded

    Third Party Assessor – Reassessment (27)

    All of the documents listed in Section I plus the following documents:

    1. Application Fee Receipt: Click here or copy and paste this link into your browser to pay the fee at the state vendor’s website (https://magic.collectorsolutions.com/magic-ui/Login/mo-medicaid-audit) – Each enrolled EIN must pay a fee. If your entity has multiple enrollments under the same EIN, you are only required to pay one fee, regardless of the number of NPIs you have enrolled.
       • If the fee has been paid to Medicare or another State Medicaid Agency in the past 2 years, just write that information on an uploaded document, or add a note prior to submission.
    2. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
    3. Missouri Department Of Revenue document. The legal business name and MO EIN number must be PREPRINTED on the document by the MO Department Of Revenue. The Vendor No Tax Due Letter is not acceptable for this item.
    4. Current Copy of Training Certification
    5. Provider Reassessor Terms and Conditions
    6. Title XIX Participation Agreement
       • Must be signed by Owner or Managing Employee
       • Must be completely filled out and both pages must be uploaded
    7. For every individual named on either the BOS form or the Training Certification: Provide SSN, DOB, physical address, alias information, and recent FCSR screening results.