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Non-Certified Enrollment Application (MEDCO-15)

Introduction

MCOs should use this form to enroll providers who are currently not in the BWC provider system or to reactivate enrollment for currently inactive providers.
Note: This form is not publicly available, but may be also used by other internal customers needing a provider enrolled only for reimbursement purposes (e.g., CAT nurse for home modification providers, etc). 

Complete a separate online form for each enrollment or reactivation. Before beginning, review your BWC provider file to determine if the provider is a: 

  • New enrollment that currently does not exist (Note: Records that add a different provider type are considered new enrollment). 
  • Reactivation of an existing inactive provider in the provider file.

You must enter the inactive BWC number when selecting the reactivation option. Current BWC record information will populate on all pages and must be reviewed and updated to the most current information. Document uploads are required in both new and reactivation entries. Practice Type determination is very important for both new and reactivated records. Practice type information may change and must be closely reviewed for accuracy. See additional detail below.  
 


Required information 

New or reactivated provider 

  • National provider identifier (NPI) number
  • Provider/Practice name
  • Provider type (See drop-down list for options.)
  • Business type: a) Individual; b) Sole proprietor; or c) All other business types
  • Federal tax ID number 
  • Credential information: type, ID number, effective dates, state
  • Practice/Reimbursement/Correspondence addresses
  • Telephone number
  • Fax number

Important – Please read: Choosing correct practice type for BWC – it’s important to determine correct practice type (individual, sole proprietor, or business) for the BWC system.  

  • Individual Practice: Individuals who are not businesses and do not need an IRS W-9 submitted.  

    BWC classifies a person as a business when they submit a W-9 checking the box designated “individual/sole proprietor/single member LLC.” BWC enrollment unit splits these W-9s into two practice types 1) Sole proprietor practice type or 2) Business practice type and you must determine the proper one to choose.
     
  • Business practice type includes single member LLCs and all other business types on the W-9. This must be determined on all enrollments. 
  • Sole proprietor practice types are persons that have not incorporated as a different business type on the W-9.  They are enrolled only once instead of an individual enrollment and a group practice enrollment. Dr. John Smith enrolls, submits W-9 as follows: Line 1: John Smith; Line 2: (DBA) Smith Clinic.  This would be a sole proprietor practice type if he submits a W-9 checking the box ‘individual/sole proprietor/single member LLC’, is a provider type 67-MD, with no LLC designation. Dr. Smith’s individual NPI must be added to the record. This is the CMS directive for NPIs for sole proprietors.
  • For single member LLCs on the W-9, these are included as a business practice type in the BWC system. These require two enrollments: the person would be individually enrolled as their provider type, and the single member LLC as a business entity therefore the tax ID is enrolled as a group practice (type 12) with themselves as the provider member.   The W-9 submitted would have the above box checked, with Line 1 as: John Smith MD LLC; Line 2 as: Smith Clinic.   You will see the LLC designation on the W-9.
  • You must review their W-9 to determine proper BWC practice type selection or contact the provider if you are unsure.  For reactivation submissions, if an individual changes practice type to business practice type (sole proprietor, etc.) you must upload a W-9 in the Document Uploads section.  

Injured worker 
Injured worker claim number, date of service, if care ongoing (CAT nurse enrollment only – policy number) 

MCO information 

  • Provider enrollment termination date (if indicated)
  • MCO/CAT nurse representative info
  • Date
  • Phone/Fax/Email  

If you have all the required information on hand, simply click the start button to begin. 

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