Table of Contents
The SFN 509 form serves as a critical document for out-of-state facilities seeking to enroll as North Dakota Medicaid providers. This form is essential for ensuring that these facilities meet specific requirements before they can bill North Dakota Medicaid for services rendered. To initiate the enrollment process, facilities must provide detailed information, including the name, date of birth, and address of at least one Medicaid-eligible recipient. Additionally, a brief description of the services provided, along with the circumstances surrounding those services, is required. This information helps the North Dakota Department of Human Services Medical Services evaluate the request effectively. The completed form must be returned to the Provider Enrollment department, located in Bismarck, North Dakota. It is important for facilities to understand that without fulfilling these requirements, their enrollment cannot be processed.
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Similar forms
The SFN 509 form serves a specific purpose in the context of Medicaid enrollment for out-of-state facilities in North Dakota. Several other documents share similarities with the SFN 509, each serving as a tool for enrollment or verification in healthcare systems. Below are six such documents:
- Medicaid Provider Enrollment Application: This document is essential for healthcare providers seeking to bill Medicaid. Like the SFN 509, it requires detailed information about the provider and the services they intend to offer.
- CMS-855I Form: Used for individual healthcare providers, this form captures essential enrollment information similar to the SFN 509, focusing on qualifications and services rendered.
- Alabama Bill of Sale Form: To ensure you have the necessary documentation, refer to the essential Alabama bill of sale form guide for supporting resources and legal compliance.
- CMS-855B Form: This form is for institutional providers, such as hospitals. It parallels the SFN 509 by requiring information about services provided and the facility's eligibility to bill Medicaid.
- Medicaid Provider Revalidation Form: This document ensures that existing providers continue to meet Medicaid standards. It shares the SFN 509's goal of maintaining up-to-date information on service providers.
- State Medicaid Agency Provider Agreement: This agreement outlines the terms under which a provider can participate in Medicaid. Similar to the SFN 509, it establishes the provider's obligations and the services they will offer.
- Application for Health Insurance Marketplace Coverage: While primarily for insurance coverage, this application requires information about services and eligibility. It echoes the SFN 509's focus on ensuring recipients receive appropriate care.
How to Use Sfn 509
Filling out the SFN 509 form is a crucial step for out-of-state facilities seeking to enroll as North Dakota Medicaid Providers. Completing this form accurately ensures that your request can be processed smoothly. Follow the steps below to fill out the form correctly.
- Begin by entering the Patient/Recipient Name in the designated field.
- Next, provide the Date of Birth of the patient in the appropriate format.
- Fill in the Address of the patient, ensuring all details are accurate.
- Continue with the City, State, and Zip Code of the patient's residence.
- In the section for Brief Description and Circumstances of Services Rendered, provide a concise yet thorough explanation of the services that were provided. This part is essential and must be completed.
- Identify the Referring Physician by entering their name and any relevant information.
- Finally, include the Date of Service when the medical services were rendered.
Once you have completed the form, make sure to review all entries for accuracy. After verifying the information, return the form to the address provided: Provider Enrollment, DHS Medical Services, 600 E. Boulevard Avenue-Dept. 325, Bismarck, ND 58505-0250.
Dos and Don'ts
When filling out the SFN 509 form for North Dakota Medicaid Provider enrollment, it is essential to follow certain guidelines to ensure a smooth process. Here are some dos and don'ts to keep in mind:
- Do provide accurate patient information, including the name, date of birth, and address.
- Do include a detailed description of the services rendered.
- Do ensure that at least one Medicaid eligible recipient is listed.
- Do verify that all information is complete before submission.
- Do return the form to the correct address: Provider Enrollment, DHS Medical Services, 600 E. Boulevard Avenue-Dept. 325, Bismarck, ND 58505-0250.
- Don't leave any required fields blank.
- Don't submit the form without including the date of service.
- Don't provide false or misleading information.
- Don't forget to include the referring physician's details if applicable.
Document Example
ND DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES
SFN 509
Medical Services has received a request from your facility to become a North Dakota Medicaid Provider. Before your enrollment can be processed, you will need to answer the questions below. Out-
Patient/Recipient Name |
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Date of Birth |
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Address |
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City |
State |
Zip Code |
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Brief Description and Circumstances of Services Rendered (This must be completed)
Referring Physician
Return to: Provider Enrollment DHS Medical Services
600 E. Boulevard
Date of Service
File Breakdown
| Fact Name | Details |
|---|---|
| Form Purpose | The SFN 509 form is used for out-of-state facilities to enroll as North Dakota Medicaid providers. |
| Eligibility Requirement | Out-of-state facilities must have at least one Medicaid-eligible recipient to bill North Dakota Medicaid. |
| Governing Law | This form is governed by North Dakota Medicaid regulations. |
| Submission Address | Completed forms should be returned to Provider Enrollment, DHS Medical Services, 600 E. Boulevard Avenue-Dept. 325, Bismarck, ND 58505-0250. |
| Required Information | Providers must include the patient’s name, date of birth, address, and a description of services rendered. |
| Date of Service | The form requires the date when the services were provided to the patient. |
| Referring Physician | Information about the referring physician must also be included on the form. |
| Version Date | The current version of the SFN 509 form is dated December 2003. |
Common mistakes
Filling out the SFN 509 form can be straightforward, but many make common mistakes that can delay their enrollment as a North Dakota Medicaid Provider. One frequent error is failing to provide a complete description of the services rendered. This section is crucial, as it gives context to the request. Omitting details can lead to misunderstandings or outright rejection of the application.
Another mistake involves incorrect or incomplete patient information. Applicants often overlook the importance of accurate data, such as the patient’s name, date of birth, and address. Any discrepancies in this information can create significant issues, including delays in processing or even denial of the application.
Many applicants also neglect to include the referring physician's information. This oversight may seem minor, but it is essential for verifying the legitimacy of the services provided. Without this detail, the application may be deemed incomplete, leading to unnecessary back-and-forth communication with the Department of Human Services.
Additionally, applicants sometimes forget to indicate the date of service. This is a critical component of the form, as it establishes the timeline for the services rendered. Incomplete dates can raise questions about the validity of the claim, further complicating the enrollment process.
Lastly, failing to follow the submission guidelines can result in delays. Whether it’s not returning the form to the correct address or not using the latest version of the form, these small mistakes can have significant consequences. Ensuring that all instructions are carefully followed is essential for a smooth enrollment process.
FAQ
What is the purpose of the SFN 509 form?
The SFN 509 form is used by out-of-state facilities seeking to enroll as Medicaid providers in North Dakota. This form ensures that the facility meets the necessary requirements to bill North Dakota Medicaid for services rendered to eligible recipients.
Who needs to fill out the SFN 509 form?
Out-of-state medical facilities that wish to provide services to North Dakota Medicaid recipients must complete the SFN 509 form. This includes hospitals, clinics, and other healthcare providers that will be billing for services provided to at least one eligible patient in North Dakota.
What information is required on the SFN 509 form?
The form requires specific details about the patient, including their name, date of birth, address, and the services rendered. Additionally, it asks for a brief description of the circumstances surrounding those services, as well as the name of the referring physician. This information is crucial for processing the enrollment request.
How does an out-of-state facility prove eligibility for Medicaid billing?
To prove eligibility, the out-of-state facility must indicate on the SFN 509 form that they have at least one Medicaid-eligible recipient for whom they will be billing North Dakota Medicaid. This requirement ensures that only facilities providing services to eligible patients can enroll.
Where should the completed SFN 509 form be sent?
Once completed, the SFN 509 form should be returned to the Provider Enrollment department at the North Dakota Department of Human Services. The mailing address is 600 E. Boulevard Avenue, Dept. 325, Bismarck, ND 58505-0250.
What happens after submitting the SFN 509 form?
After the form is submitted, the North Dakota Department of Human Services will review the application. If everything is in order and the facility meets the necessary criteria, the enrollment will be processed, allowing the facility to bill Medicaid for eligible services.
Is there a deadline for submitting the SFN 509 form?
While there is no specific deadline mentioned, it is advisable to submit the form as soon as possible to avoid delays in enrollment. Prompt submission ensures that the facility can begin providing services to eligible recipients without unnecessary interruptions.
Can the SFN 509 form be submitted electronically?
The current process requires the SFN 509 form to be submitted by mail. However, it’s always a good idea to check with the North Dakota Department of Human Services for any updates or changes to submission methods.