Form Pm 177 - 2012 - Chdp Provider Data Sheet For Local Chdp Program Use Only Page 2

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INSTRUCTIONS FOR COMPLETING PROVIDER DATA SHEET (PM 177)

Type or use blue ink. Leave one space between words and no spaces between letters in a title. Do not use punctuation except if hyphenated name.

Please complete, as necessary, all of the corresponding data elements on the PM 177. This form is to be completed by the local CHDP Program only.

Transaction Code

A. - New - Enter code “A” when a NPI is new to the CHDP Program or when adding a new office site with a different NPI.

B. - Change - Enter code “B” when there is a change to the name, address, phone, email, category, CLIA, tax ID or provider type.

C. - Inactivate - Enter code “C” when inactivating a legacy provider number/ NPI or a single location that has more than one location under the same NPI.

D. - Reactivate - Enter code “D” when reactivating an NPI in the CHDP PMF that has been inactivated.

E. - Add Additional Location - Enter code “E” when adding another service location to an existing provider file under the same active NPI.

F. - Add New Owner - Enter code “F” when reporting new ownership of a business when the NPI number will be retained at the same business location(s).

When conducting transaction “B”highlight in yellow the area of text that is changing (do not

highlight in the left margin to indicate changes).

Primary/Lab Code

Primary Provider - Enter code “1” when approved provider is responsible for provision of all the health assessment components.

Lab Provider - Enter code “3” when approved provider performs only laboratory services.

Category Code

Health Assessment Only - Enter code “1” to indicate approval to participate as a Health Assessment Only Provider.

Laboratory Services Only - Enter code “3” to indicate approval to participate as a Laboratory Services Only Provider.

CCC With Referrals - Enter code “4” to indicate approval to participate as a Comprehensive, Continuous Care Provider that will accept new patient referrals

from the CHDP Program.

CCC Without Referrals - Enter code “5” to indicate approval to participate as a Comprehensive, Continuous Care Provider that does not accept new patient

referrals.

Status Code and Effective Date

Active - Enter code “1” when approved to be a new provider or when reactivating a previous provider. Enter the date the provider can begin to provide

services. (This date can be earlier than the date the PM 177 is submitted. The date must NOT be earlier than the provider’s active date on the Medi-

Cal file.)

Inactive - Enter code “2” when a provider or provider number is inactivated with the CHDP Program. Enter the date inactivated. (If necessary contact

the Children’s Medical Services (CMS), Provider Services Unit to obtain inactivation date from Medi-Cal file.)

Reason for Inactivation

If item 4A is marked “2”-Inactive, indicate the major reason for inactivation using the following codes:

1 = Initiated by Medi-Cal

2 = Noncompliance with CHDP Program standards

3 = Moved out of area

4 = Reimbursement issues

5 = Dissatisfaction with program requirements

6 = Declining client population in service area

7 = Other

Provider ID Number

Enter the provider’s Medi-Cal provider number (10 digit NPI effective November 2007).

Type

Enter the provider type code. Refer to the CHDP Local Program Guidance Manual, “Branch Notification of Provider Data” chapter.

Tax ID Number or SSN

Enter the federal tax ID number as verified by letter from Internal Revenue Service. If unavailable, use social security number (SSN).

Phone Number

Enter the number for use to communicate with provider about claims.

Enter Legal Name/ Owner

Enter owner legal name from service location(s).

10.

Email Address

Optional: Enter the provider email address. Note: only one email per provider number/ NPI.

11.

Name and Current Service Location. This field must be used when adding a new CHDP provider number or when updating an older provider’s service

location (the older service location must match what is in the CHDP PMF).

11A - Enter the provider’s name and title.

11B - Use this line only if necessary to extend name.

11C and 11D - Enter the provider’s service location including suite or room number.

12.

Name and New Service Location. This field must be completed (in conjunction with Number 11) when updating one of the existing service locations

registered to the provider’s single NPI. This field is also used when adding an additional service location for a provider with more than one location

registered to its single NPI.

12A - Enter the provider’s name and title.

12B - Use this line only if necessary to extend name.

12C and 12D - Enter the provider’s new service location when an address has changed or a new service location is being added to the provider’s file.

13.

For Use by Los Angeles County Only – Add County Area Code

14.

“Pay–to” Name and Address

14A - Pay-to name. Note: Enter “County Treasurer” as “Pay-to” for all county facilities.

14B - Use this line only if necessary to extend name.

14C and D - Enter the provider’s P. O. Box or “Pay-to” address.

15.

Other Provider Numbers

Enter all other active provider numbers used by this provider on the Medi-Cal and/or CHDP Provider Files.

16.

CLIA Number

Enter CLIA number for all providers who perform laboratory services. Place an “X” in the appropriate box to indicate type of certificate.

17.

Signature

All PM 177s must be signed by the local CHDP Program Director or Deputy Director.

INFORMATION SUBMITTED MUST MATCH THE INFORMATION ON THE MEDI-CAL PROVIDER MASTER FILE.

NEW PROVIDERS SHOULD NOT SUBMIT CLAIMS UNTIL WRITTEN NOTICE IS RECEIVED FROM THE STATE. PROVIDERS FOR WHOM CHANGES IN INFORMATION ARE SUBMITTED SHOULD

EITHER HOLD THEIR CLAIMS OR USE THE OLD INFORMATION UNTIL THEY RECEIVE NOTICE THAT THE CHANGES ARE IN THE CHDP PROVIDER MASTER FILE.

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PM 177 rev. (01-12)