Details on New Information Required on Applications for Individual Providers

It was previously announced that effective July 26, 2020, NCTracks will store, capture and validate the following:

  • Print, sign and upload an Individual Agreement.
    • The office administrator (OA) cannot complete this for the provider.
  • Any conditions that might impact ability to perform job duties
  • Malpractice settlement history (past five years)
  • Work history as a health professional (past five years, if more than six month gap, explanation of gap)
  • Malpractice insurance (coverage type and amount)
  • Highest level of education

Additional information providers should note:

  • If additional information is required for the processing of the application, the application will be in a “returned” status and the provider will be contacted. The Upload Documents page will allow the provider to upload supporting documentation (such as copies of certifications) if necessary.
  • Providers should NOT upload malpractice judgement/settlement documentation or school transcripts on the Upload Documents page. If applicable, the provider will receive an email with instructions on where to send the documentation.
  • When entering their work history, if the enrolling provider is currently a resident or intern, he/she should enter the details of that residency/internship such as:

Job Title: Resident

Company Name: Healthcare Facility XYZ

Start Date:  Date residency/internship began

End Date: 12/31/9999 if still a resident/intern

  • In addition to entering required certifications, individual providers are now requested to add all board certifications. Enrollment, re-enrollment and manage change request (MCR) applications will still inform the provider with specific text of what certifications are required for the taxonomy entered on the application.

 

Please see the chart below with further details on application requirements and supporting documentation that may be required:

New Supplemental Data on Provider Application

This information is ONLY applicable to individual providers submitting an Initial Application, Re-Enrollment Application or Re-verification Application. The exclusion sanction questions will also be added to MCR applications.

 

Supplemental Information

 

Requirements

 

Data Fields

 

Supporting Documentation

Work History

- Provider must enter the past five years of health related work history

 

- Provider must provide explanation of any gaps of six months or more in writing

 

Verification: None required

- Company Name

- Job Title

- Start Date

- End Date

 

Notes: If the job is still current, enter 12/31/9999.

If the enrolling provider is a resident/intern, enter Resident as the job title.

Written documentation explaining any gaps in health related work history of six months or more that occurred in the past five years must be uploaded.

Education

- Provider must enter his highest level of education completed

 

Verification: GDIT will source verify using LexisNexis (LN)

- School Name

- Degree

- Start Date

- Graduation Date

If unable to source verify using LN, the application will be returned to provider to obtain an official transcript.  This transcript can be a SEALED certified transcript mailed to NCTracks or an electronic copy sent directly from the school.

Mailing Address: 

Provider Enrollment

PO Box 300009

Raleigh, NC 27622

 

The email address will be provided in the Request for Additional Information if needed.

Board Certifications (including DEA)

- In addition to certifications required for a taxonomy code, individual providers are now requested to add all board certifications

- Providers will have the ability to add additional board certifications in reverification applications

 

Verification: GDIT will source verify using LexisNexis (LN)

No new fields

 

 

 

 

 

If unable to source verify, the application will be returned to the provider to upload certification documentation.

 

Malpractice Insurance Coverage

-Provider answers ”yes”/”no” to whether  they currently have malpractice insurance coverage

 

Verification: None required

If “yes”, must provide:

- Malpractice Type

- Insurance Agency     Name

- Amount

- Effective Date

- Expiration Date

None

Exclusion/Sanction

 

 

 

 

-Provider must answer two  additional questions

(added L and M to the list of exclusions)

 

 

 

 

 

Verification: Supporting documentation required if answered “yes” to either question.

L. Does the enrolling provider have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position?

If “yes,” provider must upload supporting documentation.

 

M. Has the enrolling provider had any malpractice judgements or settlements in the past five years?

 

 

 

 

 

 

If “yes”, the provider must send only the malpractice judgement/settlement documentation from the malpractice insurance agency via email. The email address will be sent in the Request for Additional Information letter.

*DO NOT UPLOAD MALPRACTICE JUDGEMENT/SETTLEMENT DOCUMENTATION to the provider record/Upload Documents page. Other documentation may be uploaded if requested, however, malpractice judgement/settlement documentation should never be uploaded.

NOTE: Since this is highly confidential information, it must be sent to a secure email address and will be filed in a RESTRICTED area.

Individual Provider Agreement

-Individual provider must sign and date the agreement

- The Office Administrator (OA) may not sign for the provider

See Individual Provider Agreement sample under Quick Links on the Providers home page.

The “XXXX” information will be preprinted on the form from the application.

Upload signed and dated agreement

 

 

 

 

 

 

 

M20184-R-2303-3