Tiopa - Extra Service Form

TYPE OF ENROLLMENT	Quantity	Price
NEW PRACTICE		$1,900.00
JOINING AN EXISTING GROUP		$900.00
ADDITIONAL PROVIDER TO NEW PRACTICE		$900.00
ADD ADDITIONAL LOCATION TO MCAID price only valid at initial request		$50.00

TYPE OF ENROLLMENT	Quantity	Price
NEW PRACTICE		$600.00
JOINING EXISTING		$250.00
ADDITIONAL PROVIDER JOINING NEW PRACTICE		$250.00
ADD AN ADITIONAL LOCATION OR MAKE UPDATE TO ENROLLMENT		$75.00
REVALIDATION		$300.00

TYPE OF ENROLLMENT	Quantity	Price
NEW PRACTICE		$1,200.00
JOINING EXISTING		$500.00
ADD ONE PROVIDER TO ADDITIONAL LOCATION		$500.00
REVALIDATION		$500.00
ADD AN ADDITIONAL LOCATION PRICE ONLY VALID WITH INITIAL REQUEST		$50.00

You will be charged by provider per location!	Quantity	Price
Medicare		$75.00
Medicaid		$300.00
Both - Medicare & Medicaid		$375.00

Legal Business Name*
Tax ID*
Tax Classification*
AS INDICATED ON YOUR W9
First day that you plan to see patients in this office:*

MonthDayYear
IMPORTANT: This date MUST be within 60 days of opening in order to apply for Medicare! I can only apply 60 days prior to opening. If you put a date and you are not open and Medicare completes a site visit prior to opening your application will be denied and no refund will be issued.
Are you joining an existing group?*

YESNO
Do you have a type 2 NPI?*

YESNO
Type 2 Group NPI*
Are you interested in CAQH set up or maintenance?*

YESNO
Upload IRS Letter CP 575 (SS4)

Cancelof
State Certification of Formation

Cancelof
Please click NEXT to continue

How many owners are in your practice?
Type in the first three below. If more please attach it to the form.
Select the best option*

I am a provider opening a new practice where I am the sole owner.I am not a medical provider opening a new practice.I am a provider opening a new practice with multiple owners (this includes spouses).

List the owners who have more than 5% ownership. A copy of the Driver's License of ALL owners is required. *

	FirstName	Last Name	Medical Provider?	DOB	Percent Owned	SSN	State & DL # (UPLOAD A COPY)
Owner 1
Owner 2

Please click NEXT to continue

EFT Information

We ONLY enroll EFT information for Medicare and Medicaid.
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Phone
Bank Contact

First NameLast Name
Bank Contact Email
example@example.com
Voided Check or Bank Letter

This is a secure uploader and is password protected.
Cancelof
Please click NEXT to continue

MEDICARE

The following items are for the use of medicare enrollment
Please log in to your CMS I&A account and authorize TIOPA to complete your enrollment. Follow the steps below.

1. Type in your username and password.

a. If you do not know your username click “Retrieve Forgotten User ID”

i. Type in your email address that is connected to your CMS account.

ii. If you do not know the email or do not have access to that email, complete the user Information side. All Red Starred Items are required.

iii. You will get your username and then be required to change your password.

b. If you know your username but not your password, click “Forgot Password”

i. Fill out your username and then you will be prompted to change your password

2. Effective September 1st, 2019 it is required to complete a two-step verification (Multi-factor Authentication [MFA]). If not already completed, set up the Primary and Alternative methods.

3. Click “Send Verification Code” if this has already been completed.

4. Enter code received in the box and you will be brought to the home screen.

5. Click on the “My Staff” tab, then click “Add Staff”

6. Complete the information Alesha Ferro (alesha.ferro@tiopa.org) and she will receive a PIN that will then link us to your account. Be sure that you have the Employer box checked – select Access Manager as the role and PECOS and NPPES are selected.
I, First Name* Last Name* , confirm that I have completed or will complete the steps above on this date, Date* . I know that without this step being completed, that this can and will delay the enrollment into medicare, thus potentially delaying enrollments with other networks. Signature*
Select One:

Sole Owner of a PA, PC or LLC: You are the only owner of a business, set up as a corporation, through which you give healthcare services.Your business is legally separate from your personal assets.Self-Employed/Sole Proprietor: You give all your healthcare services from a facility that you own, lease or rent.You are the only owner of a business that gives healthcare services.You and your business are legally one and the same. You are personally responsible for any of the business's financial obligations.You report the business's income and losses on your personal tax return.Group Member Only: You give all your healthcare services as an employee of a group practice or clinic.You have an arrangement with your employer to send in Medicare claims and get paid for the services you have given.Group Member and is Self-Employed: You give some healthcare services as an employee of a group practice or clinic.You have an arrangement with your employer to send in Medicare claims and get paid for the services you have given.You also give some healthcare services from a facility that you own, lease or rent.The income you make through self-employment is part of your personal assets.Disregarded Entity: You are the only owner of a business, set up as a corporation, through which you give healthcare services.You and your business are considered legally one and the same.
Group PTAN(s)
Upload CMS 460-PAR Form

Cancelof
CMS 460 Form
Yes No I store electronic medical records. My program for electronic medical records is ex: eCW, athena, etc
Please click NEXT to continue

Are you already Board Approved by TIOPA?

YesNo
Upload your TSCA

Cancelof
CAQH Username
If Unknown, please call 1-888-599-1771
CAQH Password
If Unknown, please call 1-888-599-1771
Please click NEXT to continue

BCBS
Group BCBS ID
Your specialty requires hospital privileges. Please list BCBS In network hospital below:

Demographic Changes

Type in the new address you wish to add to medicaid or medicare. Note this is only for medicare and medicaid. The update for the networks requires a separate form available on the tiopa.org/provider-resources. You will be charges per provider on these demographic changes, not per group.
Address Type

Primary PracticeAdditional PracticeBilling/RemittanceMailing/Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Location Contact Email
example@example.com
Please click NEXT to continue

Authorization Statements
Additional Files that are needed

NOT COMMON* Can be sanction letters, additional DL for owners, etc
Cancelof
I understand that not authorizing e-signatures disqualifies me to be able to use TIOPA for it's extra services.

I authorize TIOPA to use electronic signatures on my behalf.I DO NOT authorize TIOPA to use electronic signatures and WILL NOT CONTINUE WITH EXTRA SERVICES through TIOPA.
I hereby give TIOPA, Inc. permission to access the accounts listed above and complete the submission for enrollment. I understand that all enrollment times vary and are at the discretion of CMS Medicare and TMHP Medicaid.

I understand that I must FIRST grant access to TIOPA in order to begin the process and no applications can or will be submitted until connection requests are completed.

I understand that if this form is completed incorrectly or with omitting information, this will cause delays in enrollment cause approval time to take longer. I understand that it is solely the provider's responsibility to provide all information accurately and promptly for submissions to take place.

I understand that if requested items are not received within 90 days or after three requests that my extra services request with TIOPA will be suspended and no longer queued a priority, and can be canceled if the on-hold application remains stagnant.

I understand that submission of enrollment does not guarantee approval or participation.

I understand that I or my office staff are responsible for letting TIOPA know via email to provider.relations@tiopa.org of any address changes and understand that an additional change fee is required, if not completed by myself or the office staff.

I understand that any change of information (ie Demographic Update) are NOT covered and must be specifically requested and an additional fee of $75-$500 is required per change.

Physical Therapy Practices could be required to pay an additional $631 to Texas Medicaid Health Partnership (TMHP) directly, as it is considered an "institutional-based" practice.

DME enrollments require additional fees that are paid directly to CMS Medicare and are not included in the TIOPA fees.

I authorize that this form has been completed accurately to the best of my ability.
Signature*

Clear
Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Please verify that you are human*
Should be Empty:

EFT Information

MEDICARE

Medicaid Information

Texas Vaccine for Children Program:

Provider Required Questions

Ownership/ Controlling Interest Questions

BCBS

Demographic Changes

Authorization Statements