Printable Sfn 509 Template

1. What is the purpose of the SFN 509 form?

   The SFN 509 form, issued by the North Dakota Department of Human Services Medical Services, serves a crucial role for out-of-state facilities aiming to become North Dakota Medicaid Providers. Its primary function is to gather specific information regarding the Medicaid eligible recipient(s) for whom the out-of-state facility intends to bill North Dakota Medicaid. This includes details on services rendered or to be provided, ensuring that the facility meets the requirements for enrolling as a provider with the North Dakota Medicaid program.

2. Who needs to complete the SFN 509 form?

   This form must be completed by out-of-state facilities seeking to enroll as North Dakota Medicaid Providers. Specifically, it is required when such facilities have, or will have, at least one Medicaid eligible recipient they plan to bill for services rendered. By completing and submitting this form, the facility provides necessary information that aids the Department of Human Services in processing their enrollment application.

3. What information is required on the SFN 509 form?

   Several key pieces of information are required on the SFN 509 form, including:

   • Patient/Recipient Name: The full name of the Medicaid-eligible recipient.
   • Date of Birth: The recipient’s birthdate.
   • Address, City, State, Zip Code: The recipient's current mailing address.
   • Brief Description and Circumstances of Services Rendered: A detailed account of the services provided or to be provided to the Medicaid recipient.
   • Referring Physician: The name of the physician who referred the recipient for the services.
   • Date of Service: The exact or estimated date when the services were or will be rendered.

   This information is vital for evaluating the facility’s eligibility to enroll as a provider with North Dakota Medicaid.

4. Where should the SFN 509 form be sent after completion?

   After being filled out, the SFN 509 form should be sent to the following address:

   Provider Enrollment DHS Medical Services 600 E. Boulevard Avenue-Dept. 325 Bismarck, ND 58505-0250

   This destination is where the Department of Human Services Medical Services team reviews and processes enrollment requests, ensuring all necessary criteria are met for provider participation in the North Dakota Medicaid program.

5. What happens if information on the SFN 509 form is incomplete?

   Incomplete submissions of the SFN 509 form may result in delays or the potential rejection of the enrollment application for becoming a North Dakota Medicaid Provider. It is vital for out-of-state facilities to thoroughly review and ensure all requested information is accurately provided. This completeness enables the Department of Human Services to efficiently process the enrollment request, facilitating timely access to essential medical services for Medicaid recipients.

Filling out forms can often feel like navigating through a maze, especially when it comes to paperwork for healthcare services. The SFN 509 form is a crucial document for out-of-state facilities looking to enroll as North Dakota Medicaid Providers. However, it's easy to stumble over some common pitfalls that can delay or hinder the enrollment process. Let's dive into seven mistakes that are frequently made and how to avoid them.

1. Not providing detailed service descriptions: One common mistake is giving vague information about services rendered. The form requires a brief description and circumstances of the services provided. It's essential to be specific to ensure there are no misunderstandings or delays in the enrollment process.

2. Overlooking the patient/recipient section: Information regarding the Medicaid eligible recipient must be accurate and complete. This includes the patient's name, date of birth, address, city, state, and zip code. Any inaccuracies or missing details can lead to processing delays.

3. Forgetting to include the referring physician's details: The form asks for information about the referring physician. This is a crucial step since it ties the services provided to a medical professional recognized within the network. Omitting this information can question the legitimacy of the claims.

4. Misunderstanding the eligibility criteria: It's necessary to understand that only out-of-state facilities with at least one Medicaid-eligible recipient they plan to bill for services can apply. Failing to meet this criterion or misunderstanding the eligibility can result in unnecessary paperwork and frustration.

5. Ignoring the importance of the date of service: The date of service is more than just a formality. It indicates when the services were (or will be) rendered, which is vital for timely and accurate billing. Neglecting to provide this can lead to misunderstanding or delays in processing the enrollment request.

6. Submitting incomplete or inaccurate forms: This might seem obvious, but even minor mistakes or omissions can complicate the enrollment process. Double-check all provided information for accuracy and completeness before submission.

7. Failure to follow up: Once the form is submitted, the job isn't necessarily done. It's wise to follow up with the ND Department of Human Services Medical Services if you haven't received a response within a reasonable timeframe. Sometimes, forms can get misplaced or overlooked, so a polite inquiry can keep things moving.

To ensure a smooth enrollment process as a North Dakota Medicaid Provider, out-of-state facilities need to navigate the SFN 509 form with care and attention. By avoiding these common mistakes, facilities can help ensure their forms are processed efficiently, allowing them to focus on providing care to those in need.

When navigating the complexities of healthcare administration, particularly for providers engaging with North Dakota Medicaid, the use of various forms and documents is essential to ensure that all regulatory and procedural requirements are met. The SFN 509 form, focusing on "Out-Of-State Enrollment Clarification" for the North Dakota Department of Human Services Medical Services, is a critical piece of documentation. However, it often comes in a package with several other forms and documents to streamline the enrollment process, maintain compliance, and facilitate the provision of care to Medicaid recipients. Understanding these additional documents is key to a smooth administrative process.

• W-9 Form - This Internal Revenue Service (IRS) form is used to provide a Tax Identification Number (TIN) and certification. It's a prerequisite for any entity intending to do business with another entity, including state Medicaid programs, ensuring that all tax-related matters are properly managed.
• Provider Agreement - A contract between the healthcare provider and the North Dakota Department of Human Services. It outlines the responsibilities, terms, and conditions under which the provider is allowed to participate in the Medicaid program. Signing this agreement is a mandatory step for finalizing Medicaid provider enrollment.
• Disclosure of Ownership and Control Interest Statement - This document is required to disclose the ownership and control interests of the enrolled provider. It's essential for transparency and to prevent conflicts of interest or fraud within the Medicaid program. The statement ensures that providers comply with federal and state laws pertaining to disclosure requirements.
• Credentialing Application - Before a healthcare provider can be considered for participation in the Medicaid program, they must undergo a credentialing process. This application gathers detailed information about the provider's qualifications, including education, training, and professional experience, to verify their capability and legality to offer healthcare services.
• Electronic Funds Transfer (EFT) Authorization Agreement - This agreement allows for the direct deposit of Medicaid payments into the provider's bank account. It ensures timely and secure payments, reducing the reliance on physical checks and streamlining the financial transactions between Medicaid and healthcare providers.

In conclusion, while the SFN 509 form is crucial for out-of-state providers wishing to enroll in the North Dakota Medicaid program, the completion and submission of additional forms and documents play an equally important role. These documents collectively ensure that providers are compliant with state and federal regulations, equipped for financial transactions, and vetted for their qualifications to deliver quality healthcare services. Understanding and efficiently managing these documents can significantly enhance the administrative aspects of healthcare provision to Medicaid recipients.

The SFN 509 form, used for out-of-state enrollment clarification by the North Dakota Department of Human Services Medical Services, shows similarities with other forms in the medical and legal fields regarding its structure and purpose. Notably, its design and required information share characteristics with the HCFA-1500 form and the Provider Enrollment Application used in other states. This resemblance is not only in the type of data requested but also in the overarching goal of ensuring compliance and eligibility for provider services within governmental health programs.

The first form that the SFN 509 closely resembles is the HCFA-1500 form, now known as the CMS-1500 form, widely utilized in the healthcare industry for insurance billing, including Medicare and Medicaid. Both forms require detailed patient information, service descriptions, and provider details to process claims or enrollments. The key similarities lie in their focus on patient data, such as name, date of birth, and address, along with specific details about the healthcare services provided. However, while the SFN 509 form emphasizes the enrollment aspect for out-of-state providers wishing to bill Medicaid, the CMS-1500 form is more directly tied to the billing of individual services rendered to patients.

Another document the SFN 509 form parallels is the Provider Enrollment Application forms used by other states for Medicaid. These forms are crucial for any healthcare provider looking to offer services to Medicaid recipients within a specific jurisdiction. Like the SFN 509, these applications collect comprehensive information about the facility or provider, including details about the services they offer and the population they serve. Both sets of documents play a pivotal role in maintaining the integrity and efficiency of Medicaid programs by ensuring that only qualified and eligible providers can bill for services, thereby safeguarding program resources and ensuring patient care is up to standard.

When completing the SFN 509 form for the North Dakota Department of Human Services Medical Services, it's important to follow certain guidelines to ensure the form is filled out correctly and completely. Here are important tips on what you should and should not do:

Things You Should Do

1. Ensure that the patient/recipient's name, date of birth, address, city, state, and zip code are accurately entered, as these details are crucial for the enrollment process.
2. Provide a brief, but detailed, description and circumstances of the services rendered. This information is essential for clarifying the nature of the services for which Medicaid coverage is being requested.
3. Include the name of the referring physician, if applicable, to maintain a clear record of the patient's care pathway and referrals.
4. Confirm that the facility serves at least one Medicaid eligible recipient in North Dakota, as this is a requirement for out-of-state facilities seeking enrollment.

Things You Should Not Do

• Do not leave any required fields blank. Incomplete forms may delay or invalidate the enrollment process.
• Do not provide false or misleading information. Accuracy is paramount to the enrollment and billing processes.
• Avoid submitting the form without the date of service for the rendered services. This date is critical for processing your request.
• Do not forget to send the completed form to the Provider Enrollment at DHS Medical Services at the address provided, as failure to do so will result in processing delays.

When dealing with the SFN 509 form, which is crucial for out-of-state providers wishing to enroll in North Dakota Medicaid, many misconceptions can arise. Understanding these misconceptions is essential for ensuring that the enrollment process is handled correctly.

• Misconception 1: The SFN 509 form is only for new medical providers.

  This is not the case. While the form is indeed used for the enrollment of out-of-state providers in North Dakota Medicaid, it is also necessary for existing providers who need to update or clarify their enrollment information, particularly when it relates to billing for services rendered to a North Dakota Medicaid recipient.

• Misconception 2: Any out-of-state provider can become a North Dakota Medicaid provider.

  Not exactly. To be eligible, out-of-state facilities must be providing services to at least one Medicaid-eligible recipient from North Dakota. This requirement ensures that only providers with a genuine connection to North Dakota Medicaid recipients undergo the enrollment process.

• Misconception 3: The form can be submitted online.

  As of the last available information, the SFN 509 form must be submitted via mail to the Provider Enrollment section of the DHS Medical Services in Bismarck, ND. This detail is crucial for timely processing and requires attention to avoid delays.

• Misconception 4: The SFN 509 form is a one-time submission.

  Providers should be aware that periodic updates or clarifications regarding their enrollment status may necessitate resubmission of the form. These could stem from changes in the services provided, the patient population served, or compliance with updated Medicaid policies.

• Misconception 5: Personal identification information of the provider is not necessary.

  Contrary to this belief, detailed provider information, including the name of the patient/recipient and the services rendered, is crucial. This information assists the Department of Human Services in identifying the provider and the eligibility of the services for Medicaid coverage.

• Misconception 6: Any service provided to a North Dakota Medicaid recipient is eligible for coverage.

  Services billed must be eligible under North Dakota Medicaid's coverage guidelines. Providers should verify service eligibility prior to submission to ensure compliance and prevent denial of coverage.

• Misconception 7: There is no deadline for form submission.

  Timely submission of the SFN 509 form is essential, especially if it relates to billing for services already rendered. Delays in submission can lead to delays in reimbursement and may affect the provider's enrollment status.

• Misconception 8: Submission of the SFN 509 form guarantees enrollment.

  Submission of the form is only the first step. The application goes through a review process, and providers may be required to submit additional information or clarification. Only upon successful review and meeting all of North Dakota Medicaid's criteria will enrollment be granted.

Understanding these misconceptions can greatly aid providers in the enrollment process, ensuring that they provide all the necessary information accurately and comply with North Dakota Medicaid's requirements. This knowledge not only streamulates the enrollment process but also helps maintain a compliant and efficient billing process for out-of-state providers.

Filling out the SFN 509 form accurately is essential for out-of-state facilities intending to be providers for North Dakota Medicaid. To ensure the process goes smoothly and to stand the best chance of a successful enrollment, consider these key takeaways:

• Understand the Purpose: The SFN 509 form is specifically designed for out-of-state providers that need to enroll with North Dakota Medicaid. It's a preliminary step, requiring detailed information about the services provided to Medicaid recipients.
• Eligibility Criteria: A critical eligibility criterion for out-of-state facilities is that they must already be servicing, or intend to service, at least one Medicaid-eligible recipient from North Dakota.
• Complete All Sections: Every part of the form must be filled out comprehensively. This includes the patient or recipient's name, date of birth, address, and a brief description and circumstances of the services rendered.
• Accuracy Is Key: Ensure that all information provided is accurate and truthful. The description of the services rendered should be concise yet detailed enough to give a clear understanding of the care provided.
• Include Referring Physician Information: The name of the referring physician is a crucial piece of information that must be included in the form. This ties the medical service provided back to a medical professional recognized within the system.
• Know Where to Send the Form: Completed forms should be sent to the Provider Enrollment office at DHS Medical Services, with the address provided on the form. Ensure that the address is correctly noted to avoid any delays in processing.
• Keep a Copy: It's advisable to keep a copy of the filled form for your records. This will be useful for future reference or in case the form gets lost in transit and needs to be resent.

By attentively following these guidelines, out-of-state facilities can navigate the enrollment process with North Dakota Medicaid more efficiently. Remember, the SFN 509 form is your first step toward becoming an authorized Medicaid provider in North Dakota. Hence, taking the time to fill it out accurately and completely is well worth the effort.