Group Provider Enrollment (Qualified Service Providers) Page

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You use the Qualified Service Providers page to add or edit a group provider's information to the enrollment application about his or her Qualified Service Provider designation for delivering Home and Community Based Services (HCBS) to the aged and disabled.

Agency Qualified Service Provider Fields

Field	Description
County(s) where service will be provided.	The county(s) served by you as a QSP. To select the counties served: To move an item from the Available list to the Selected list, select the item, and then click (the right arrow). To move an item from the Selected list to the Available list, select the item, and then click (the left arrow). To select or clear multiple items, press CTRL and click the items.

Field

Description

County(s) where service will be provided.

The county(s) served by you as a QSP.

To select the counties served:

To move an item from the Available list to the Selected list, select the item, and then click (the right arrow).
To move an item from the Selected list to the Available list, select the item, and then click (the left arrow).
To select or clear multiple items, press CTRL and click the items.

Agency Qualified Service Provider Global Endorsements Fields

Field	Description
These fields indicate the global endorsements for which you qualify and for which you have sought qualification. Global endorsements are tasks requiring special skill and approval that apply to all clients requiring this endorsement for which you provide care. To move an item from the Available list to the Selected list, select the item, and then click (the right arrow). To move an item from the Selected list to the Available list, select the item, and then click (the left arrow). To select or clear multiple items, press CTRL and click the items.
QSP Global Endorsements	Select the endorsements for which you have qualified.
QSP Global Endorsements Sought	Select endorsements for you have sought or are seeking qualification.

Field

Description

These fields indicate the global endorsements for which you qualify and for which you have sought qualification. Global endorsements are tasks requiring special skill and approval that apply to all clients requiring this endorsement for which you provide care.

To move an item from the Available list to the Selected list, select the item, and then click (the right arrow).
To move an item from the Selected list to the Available list, select the item, and then click (the left arrow).
To select or clear multiple items, press CTRL and click the items.

QSP Global Endorsements

Select the endorsements for which you have qualified.

QSP Global Endorsements Sought

Select endorsements for you have sought or are seeking qualification.

Qualified Service Provider Questionnaire Fields

Field	Description
If you are an Agency Qualified Service Provider, initial each of the following to indicate your understanding and agreement.	Enter your initials in the in the box preceding each statement to indicate your agreement.

Field

Description

If you are an Agency Qualified Service Provider, initial each of the following to indicate your understanding and agreement.

Enter your initials in the in the box preceding each statement to indicate your agreement.

Non-Medical Provider Fields

Field	Description to the person
To a non-medical eligible recipients for whom you provide services, click Add Medicaid Eligible Recipients. Existing recipients are listed in a table. To edit, in the Medicaid Eligible Recipients table, click the appropriate row. After you edit or add information, on the Medicaid Eligible Recipients action bar, click Save. If you are a transportation provider, you must provide a copy of your current valid driver's license and proof of insurance.
Medicaid ID	Enter the recipient's Medicaid identification number.
Last Name	Enter the recipient's first name.
First Name	Enter the recipient's last name.
MI	Enter the recipient's middle initial .
Suffix	Enter the recipient's suffix from drop-down list.
Does the recipient reside in the same household?	Select Yes or No. If Yes, enter a brief explanation.
Is the recipient a Foster Child or Adult?	Select Yes or No.
What is your relationship to the person you are providing services?	The relationship between you and the person for whom you provide services.

Field

Description to the person

To a non-medical eligible recipients for whom you provide services, click Add Medicaid Eligible Recipients. Existing recipients are listed in a table. To edit, in the Medicaid Eligible Recipients table, click the appropriate row. After you edit or add information, on the Medicaid Eligible Recipients action bar, click Save. If you are a transportation provider, you must provide a copy of your current valid driver's license and proof of insurance.

Medicaid ID

Enter the recipient's Medicaid identification number.

Last Name

Enter the recipient's first name.

First Name

Enter the recipient's last name.

Enter the recipient's middle initial .

Suffix

Enter the recipient's suffix from drop-down list.

Does the recipient reside in the same household?

Select Yes or No. If Yes, enter a brief explanation.

Is the recipient a Foster Child or Adult?

Select Yes or No.

What is your relationship to the person you are providing services?

The relationship between you and the person for whom you provide services.