locum tenens physician

 

 

 

 

 

locum tenens physician assistant

locum tenens physician salary

locum tenens physician assistant salary

locum tenens physician jobs

locum tenens physician definition

locum tenens physician meaning

locum tenens physician assistant hawaii

locum tenens physician assistant reddit

locum tenens physician reddit

locum tenens physician assistant california

 

 

 

REGISTRATION OF LOCUM TENENS PHYSICIAN

 

Rev (05/17)

REGISTRATION OF LOCUM TENENS PHYSICIAN

RETURN TO: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602

 42 CFR § 411.351 allows a physician to temporarily stand in the shoes of another.

 Medicaid pays crossover claims from Medicare, and thus the Medicaid time limit for the locum tenens is the same as Medicare.

 The maximum time may not exceed sixty (60) continuous days.

This Physician is the TEMPORARY REPLACEMENT who applies and

will actually perform the services temporarily:

1) ______________________________________________________

Applicant LOCUM TENENS PHYSICIAN - Full Name

2)  (____)_______________________________

 Area Code Phone Number Extension

3) ______________________________________________________

PERMANENT ADDRESS (You may NOT use a PO BOX)

_____________________________________________________

CITY, STATE, ZIP

4) SSN: _________________________________________________

5) Email: ________________________________________________

6) Is a CONTRACT AGENCY involved in this placement?

 YES – SUPPLY NAME & ADDRESS OF AGENCY.

You may attach a sheet, if necessary.

__________________________________________________________

__________________________________________________________

 NO

To my knowledge, I attest that I am not subject to any of the

following:

 A pending criminal or civil investigation regarding the

provision of health care services;

 Formal disciplinary sanction from any such board or

professional association pursuant to KRS 311.565; and

 A federal or state sanction or penalty that would otherwise

bar me from participation in Medicare or Medicaid.

 I certify and attest, by my signature below, under penalty

of perjury, that the information contained herein is true

and faithful.

_________________________________________

Original Signature/Date required of Locum Tenens

Call 1-800-807-1232 for provider billing assistance.

This Physician will be ABSENT during the billing and will not

perform the services:

1) ________________________________________________

Regular Physician - Full Name

2)  (____)____________________________

 Area Code Phone Number Extension

3) _________________________________________________

OFFICE ADDRESS (You may NOT use a PO BOX)

__________________________________________________

CITY, STATE, ZIP

4) Email:_______________________________

5) National Provider Identifier (NPI) for Individual

(Required); must be registered with KY DMS

 _____________________________________________________

6) NPI for Group (Optional); must be registered with KY DMS

____________________________________________________

7) Specific Duration – Not to exceed sixty (60) consecutive

days. Terms like ‘ongoing’ and ‘current’ will not be accepted

_____________ to _____________

MM/DD/YY MM/DD/YY

8) Credentialing Agent:

Name: ___________________________________________

Email: ___________________________________________

__________________________________________

Original Signature/Date required

CHECK OFF FOR REQUIRED ATTACHMENTS

 COPY of valid PHYSICIAN LICENSE and copy of any

applicable board certification for the locum tenens

physician.

 PROOF of malpractice insurance coverage for the locum

tenens physician for period of physician substitution.

THE Q-6 MODIFIER MUST BE USED FOR BILLING SEVICES

PERFORMED BY A LOCUM TENENS PHYSICIAN.

The holder of the valid provider number is required to bill the services

of any locum tenens physician by utilizing the Health Care Procedure

Coding System (HCPCS) with the procedure modifier code “Q-6” in

item 24d of Form HCFA-1500, for every procedure performed by the

locum tenens physician. Failure to bill correctly may be considered a

violation of the terms of the Provider Agreement.

Rev (05/17)

COMPLETING THE REGISTRATION OF LOCUM TENENS PHYSICIANS

In emergencies, the completed and signed form can be faxed to: (502)564-3232

Otherwise mail two weeks in advance to: Kentucky Medicaid PO Box 2110 Frankfort, KY 40602-2110

Note: for this process the “regular, but absent” physician hires the “locum tenens” physician. The temporary physician who

is going to stand-in and actually perform the services for a short duration for the absent physician is the locum tenens physician.

The locum tenens physician or his/her agent may fill out the form. An ORIGINAL SIGNATURE of the locum tenens physician

is required, a signature stamp may not be used, nor can others sign for this physician. Failure to complete and have a valid

original signature on the form in its entirety may result in Medicaid claims not processing timely and completely.

All required documents that are to be attached are for the locum tenens physician. A locum tenens physician shall be otherwise

be required to be in good standing with all applicable regulatory boards and maintain malpractice insurance to ensure the

protection of the Medicaid recipients they treat pursuant to 42 USC §1396a(a)(19).

The locum tenens physician on the left-side box shall enter:

 The locum tenens physician’s full name;

 The phone number of the locum tenens doctor where they can be reached during normal office hours if

clarification or additional information is needed; (please include area code and extensions)

 As post office boxes are transitory, they may not be used. Please indicate a permanent address for the

locum tenens physician;

 The SSN for the locum tenens physician;

 Indicate if the placement is based upon an outside contract agency; if YES, provide the full name and

mailing address of the contract agency. A sheet may be attached to complete this process.

 Credentialing Agent contact information, if applicable.

 

- AND -

 A copy of a valid current physician license for the locum tenens is attached; and

 Proof of the malpractice insurance coverage maintained for the locum tenens physician for the anticipated

period of the services are to be performed is also attached; and

 Signature of the Locum Tenens

The physician who is going to be absent for a short period and will not actually perform the service is the regular, but absent,

physician. A locum tenens billing arrangement is intended to promote the continuation of the billing process for regular, but

absent, physicians and their cooperation in helping the locum tenens to complete of this form may be necessary.

Information regarding the regular, but absent, physician appears on the right-side box, and is completed by the

applicant by supplying:

 The regular, but absent, physician’s full name and their individual Medicaid Provider Number. Show the

group number also, if any billings for the substitute will utilize a group number;

 The signature of the absent Physician;

 The phone number of the physician/billing office that can answer most routine questions;

 As post office boxes are transitory, they may not be used. Please indicate a permanent address for the regular

physician, a physical address where the services will be performed is also allowable; and

 The specific dates the services. They may not to exceed sixty (60) consecutive days. Terms like ongoing or

current will not be accepted. If the services are anticipated to exceed sixty (60) days, then a regular provider

number application must be made concurrent with the locum tenens. A regular provider application may be

secured by calling Medicaid’s fiscal agent toll-free at 877-838-5085. Billing under locum tenens for periods

in excess of sixty (60) consecutive days are specifically not authorized by the Kentucky Medicaid Program.

Questions on proper billing for locum tenens – 1-800-807-1232 Provider Assistance.

 

Download Free