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The MLTC 62 Nebraska form represents a critical document mandated by the Centers for Medicare and Medicaid Services, under the auspices of the Department of Health and Human Services. As per regulations stipulated in 42 CFR 455.100 through 42. CFR 455.106, its completion is compulsory for entities seeking to enroll or contract with the Nebraska Department of Health and Human Services. The form plays a pivotal role in ensuring transparency and accountability by disclosing ownership/control interests and convictions relevant to Medicare, Medicaid, and other federal health programs. Entities are required to report any changes to their disclosed information by submitting a new form, thereby upholding the integrity and trustworthiness of healthcare providers within the state. Additionally, the form encompasses sections that detail the entity’s basic identifying information, relationships among individuals with ownership interests, managing employees, affiliations with other Medicaid providers, and disclosure of convictions related to healthcare program involvement. This exhaustive disclosure mechanism serves not only as a tool for compliance and verification but also as a safeguard against fraud and abuse in healthcare programs, ensuring that providers operate within the bounds of legal and ethical standards.

Example - Mltc 62 Nebraska Form

Department of Health & Human Services

N E B R A S K A

Nebraska Department of Health and Human Services

NEBRASKA OWNERSHIP/CONTROLLING INTEREST AND CONVICTION DISCLOSURE

Completion of this form is required as mandated by the Centers for Medicare and Medicaid Services, Department of Health and Human Services and applicable regulations as found at 42 CFR 455.100 through 42. CFR 455.106. Disclosure must be made at the time of enrollment or contracting with the Department, at the time of survey, or within 35 days of a written request from the Department. It is the provider’s responsibility to ensure all information is accurate and to report any changes as required by law by completing a new Ownership and Disclosure form.

IDENTIFYING INFORMATION

Name of Entity: (Legal name as it appears on tax identiication form)

 

Provider Number (If currently enrolled in NE Medicaid):

Doing Business As:

 

 

NPI Number

 

Street Address:

 

City:

State:

Zip Code:

Telephone Number:

Fax Number:

 

E-mail Address:

 

IF GOVERNMENT ENTITY OR NON-PROFIT ORGANIZATION, PLEASE CHECK THIS BOX AND GO DIRECTLY TO FIELDS C, D AND E.

A. List the name, address, Federal Employer Identiication Number (FEIN) or Social Security Number (SSN) and Date of Birth (DOB) of each person with an ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more. If more space is needed attach a separate list including the required information.

Name

SSN/FTIN

Name

SSN/FTIN

Name

SSN/FTIN

Name

SSN/FTIN

Name

SSN/FTIN

Address

DOB

Address

DOB

Address

DOB

Address

DOB

Address

DOB

%Interest

%Interest

%Interest

%Interest

%Interest

B. Are any of the above mentioned persons related to one another as a spouse, parent, child, or sibling? If more space is needed

attach a separate list including the required information.

 Yes  No If yes, please name and show relationship.

Name

SSN

Name

SSN

Name

SSN

Name

SSN

Name

SSN

Relationship

DOB

Relationship

DOB

Relationship

DOB

Relationship

DOB

Relationship

DOB

MLTC-62 REV 3/11 (94062)

PAGE 1/3

C. List any person who holds a position of managing employee within the disclosing entity.

If more space is needed attach a separate sheet with the required information.

Name

SSN Name

SSN Name

SSN Name

SSN Name

SSN Name

SSN

Position Title

DOB

Position Title

DOB

Position Title

DOB

Position Title

DOB

Position Title

DOB

Position Title

DOB

D. Does any person, business, organization or corporations with an ownership or control interest (identiied in A or B) have an ownership or controlling interest of 5% or more in any other Nebraska Medicaid Provider? If more space is needed attach a

separate sheet with the required information.

 Yes

 No If yes, please name and show information.

Name

 

 

Other Provider Name

 

 

 

 

SSN/FTIN

 

DOB

 

Name

 

 

Other Provider Name

 

 

 

 

 

SSN/FTIN

 

DOB

 

Name

 

 

Other Provider Name

 

 

 

 

 

SSN/FTIN

 

DOB

 

Name

 

 

Other Provider Name

 

 

 

 

 

SSN/FTIN

 

DOB

 

 

 

 

 

%Interest

%Interest

%Interest

%Interest

E. List any person (identiied in A, B, or C) who has an ownership or control interest in the disclosing entity (provider), or is an agent or employee of the disclosing entity (provider) who has ever been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Waivers, CHIP or the Title XX services since the inception of these programs.

If more space is needed attach a separate sheet with the required information.

Name

SSN

Name

SSN

Name

SSN

Conviction Details

DOB

Conviction Details

DOB

Conviction Details

DOB

PROVIDER STATEMENT. I certify that information provided on this form is true, accurate and complete. I will notify Nebraska Department of Health and Human Services of any additions/changes to the information

Sign Here ____________________________________________________________________________________________________

Signature of Provider/Authorized Representative/Agent and Title (Stamped Signature NOT Accepted)

_____________________________________________________________________________________________________________

Print Name

Date

Phone Number

 

 

MLTC-62

 

 

PAGE 2/3

42 C.F.R. Sec. 455.101 Deinitions.

Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.

Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a iscal agent.

Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or

XXof the Act. This includes:

(a)Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);

(b)Any Medicare intermediary or carrier; and

(c)Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title XX of the Act.

Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.

Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

Ownership interest means the possession of equity in the capital, the stock, or the proits of the disclosing entity.

Person with an ownership or control interest means a person or corporation that—

(a)Has an ownership interest totaling 5 percent or more in a disclosing entity;

(b)Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

(c)Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;

(d)Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

(e)Is an oficer or director of a disclosing entity that is organized as a corporation; or

(f)Is a partner in a disclosing entity that is organized as a partnership.

Signiicant business transaction means any business transaction or series of transactions that, during any one iscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total operating expenses.

Subcontractor means—

(a)An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

(b)An individual, agency, or organization with which a iscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.

Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical irm).

Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.

42 CFR § 455.102 Determination of ownership or control percentages.

(a)Indirect ownership interest. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.

(b)Person with an ownership or control interest. In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in the provider’s assets equates to 4 percent and need not be reported.

MLTC-62

PAGE 3/3

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Document Breakdown

Fact Detail
Purpose This form is required for the disclosure of ownership, controlling interests, and conviction details as mandated by the Centers for Medicare and Medicaid Services and applicable regulations in 42 CFR 455.100 - 455.106.
Scope It applies to entities enrolling or contracting with the Nebraska Department of Health and Human Services, at the time of a survey, or within 35 days of a written request from the Department.
Responsibility The provider is responsible for ensuring all information is accurate and for reporting any changes by completing a new Ownership and Disclosure form.
Contents It requires details such as names, addresses, Federal Employer Identification Number (FEIN) or Social Security Number (SSN), and Date of Birth (DOB) of individuals with ownership or control interests, among other information.
Governing Law It operates under the governance of the Centers for Medicare and Medicaid Services, Department of Health and Human Services, with specific criterion laid out in sections 42 C.F.R. §§ 455.100 to 455.106.
Provider Statement The form includes a provider statement section where the provider certifies the truthfulness, accuracy, and completeness of the information provided.

Steps to Writing Mltc 62 Nebraska

Filling out the MLTC 62 Nebraska form is essential for providers seeking to enroll or contract with the Department of Health & Human Services. This form is mandated by the Centers for Medicare and Medicaid Services and is crucial for maintaining transparency regarding ownership, controlling interests, and any past convictions relevant to Medicaid, Medicare, and other federally funded health programs. Completing this form accurately is vital for compliance with federal and state regulations. Below is a step-by-step guide to help you fill out the MLTC 62 Nebraska form correctly.

  1. Identifying Information: Fill in the name of the entity, provider number (if already enrolled in NE Medicaid), "Doing Business As" name (if applicable), NPI Number, street address, city, state, zip code, telephone number, fax number, and email address.
  2. If you are filing this form for a government entity or a non-profit organization, check the appropriate box and skip to fields C, D, and E directly.
  3. Section A - Ownership or Control Interest: List the names, addresses, Federal Employer Identification Number (FEIN) or Social Security Number (SSN), and Date of Birth (DOB) for each person with an ownership or control interest of 5% or more. Include the percentage of interest held. Attach a separate list if more space is needed.
  4. Section B - Relationships: Indicate whether any persons listed in section A are related as a spouse, parent, child, or sibling. If "Yes," provide their names, SSN, relationship, and DOB. Attach additional pages if necessary.
  5. Section C - Managing Employees: List any person holding a position of managing employee within the disclosing entity, including their name, SSN, position title, and DOB. Use additional sheets if the space provided is insufficient.
  6. Section D - Interests in Other Nebraska Medicaid Providers: Mark "Yes" or "No" to indicate if any person, business, organization, or corporation identified in sections A or B has an ownership or controlling interest of 5% or more in any other Nebraska Medicaid Provider. If "Yes," provide the names and show the information. Attach more pages as needed.
  7. Section E - Convictions: List any person identified in A, B, or C who has been convicted of a criminal offense related to their involvement in Medicare, Medicaid, CHIP, or Title XX services programs. Provide names, SSN, conviction details, and DOB. Include additional pages for more entries if required.
  8. Provider Statement: Review your entries, ensuring all information provided is true, accurate, and complete. Sign and print your name in the designated area at the bottom of the form, also providing your title, the current date, and contact phone number. Remember, stamped signatures are not accepted.

After you have completed the form, double-check all information for accuracy and completeness. Submit the form to the appropriate department as indicated by the Nebraska Department of Health & Human Services. Reporting any changes to this information promptly is crucial for remaining in compliance with state and federal regulations. Keep a copy of the completed form for your records.

FAQ

What is the MLTC-62 Nebraska form?

The MLTC-62 Nebraska form is a document issued by the Nebraska Department of Health and Human Services. Its primary purpose is to disclose information regarding ownership, controlling interest, and any convictions of those involved with Medicaid, Medicare, Waivers, CHIP, or Title XX services. It requires complete transparency from providers at the time of enrollment, contracting, survey, or upon request.

Who is required to complete the MLTC-62 Nebraska form?

Entities and providers enrolling or contracted in Nebraska Medicaid must complete the MLTC-62 form. This includes organizations with a direct or indirect ownership or control interest of 5% or more, managing employees of the entity, and those with certain criminal convictions related to Medicare, Medicaid, Waivers, CHIP, or Title XX services programs.

What information is needed to fill out the form?

To fill out the MLTC-62 form, the following information is required:

  1. Legal name of the entity, provider number (if applicable), business address, contact details, and government entity or non-profit status.
  2. Names, addresses, Social Security or Federal Employer Identification Numbers (SSN/FEIN), dates of birth, and percentage of interest for individuals with ownership or control interest.
  3. Information about any relationships among those with ownership or control interest.
  4. Details of managing employees within the entity.
  5. Information about any person or entity with a significant ownership or controlling interest in other Nebraska Medicaid providers.
  6. Conviction details of any person involved with the provider who has been convicted of crimes related to involvement in Medicare, Medicaid, or other specified programs.

Are government entities or non-profit organizations exempt from parts of the form?

Yes. Government entities or non-profit organizations are instructed to check a specific box on the form and proceed directly to certain sections, bypassing the need to fill out portions that are more relevant to for-profit entities.

If persons related as a spouse, parent, child, or sibling have ownership or controlling interests in the disclosing entity, their names, relationship to each other, SSN, and date of birth must be disclosed in the specified section of the form.

What should I do if there's a change in the information provided?

If there are any additions or changes to the information previously provided, it is the provider's responsibility to ensure the Nebraska Department of Health and Human Services is notified by submitting an updated MLTC-62 form.

How does one disclose an indirect ownership interest?

Indirect ownership interest is disclosed by providing detailed information on each entity in which there's an indirect ownership stake that pertains to the disclosing entity. This involves a calculation of the percentages of ownership through each layer of entities, as outlined in the guidelines of the form.

What are the consequences of not fully completing the MLTC-62 form?

Failure to completely and accurately fill out the MLTC-62 form can result in the delay or denial of Medicaid enrollment or contracting. It may also lead to legal ramifications due to non-compliance with the Centers for Medicare and Medicaid Services and the Department of Health and Human Services regulations.

Where can I submit the completed MLTC-62 Nebraska form?

The completed form should be submitted to the Nebraska Department of Health and Human Services as part of the entity's Medicaid enrollment or contracting process. The exact submission instructions and address are typically provided by the Department or can be found on their official website.

Common mistakes

When individuals and entities complete the MLTC 62 form for the Nebraska Department of Health and Human Services, mistakes can occur. These errors can lead to delays in the processing of applications or even lead to non-compliance with state and federal regulations. Highlighting some of the common mistakes may help in preventing them.

One common error is the incomplete filling out of the form. Every question and field on the MLTC 62 form is designed to collect specific and necessary information. Leaving sections blank or providing incomplete answers can result in the form being returned for correction. This necessitates a vigilant review of the entire form before submission to ensure that all required information is provided.

Another frequent mistake is not updating the form when changes occur. It is the responsibility of the provider to submit a new Ownership and Disclosure form to report any changes as mandated by law. Neglecting to report these updates can lead to inaccuracies in the recorded information, potentially affecting compliance and the status of the provider with the Department of Health & Human Services.

Misunderstanding the definitions and terms used throughout the form leads to incorrectly completed sections. For instance, terms such as "indirect ownership" and "managing employee" have specific definitions that impact how information should be reported. Misinterpreting these terms can cause errors in the disclosure of ownership interests and the identification of key personnel. It’s essential to carefully review the definitions provided in the form’s instructions to ensure accurate reporting.

Another error is the failure to disclose related parties. The form requires information about any relationships among owners or between owners and managing employees, such as family ties. An oversight in disclosing these connections can lead to incomplete or misleading information being presented to the Department.

Moreover, a significant mistake is not attaching additional sheets when needed. The form provides limited space for entries, and some entities may have more information to report than the form can accommodate. It's crucial to attach separate lists with the required information to ensure a comprehensive disclosure.

Submitting outdated information is also a common mistake. The accuracy and timeliness of the information provided on the MLTC 62 form are critical. Providers must ensure that all details, including addresses, contact numbers, and legal identifiers, are current and correct.

Lastly, overlooking the requirement for an original signature on the form can lead to its rejection. The form explicitly states that stamped signatures are not accepted. This requirement underscores the importance of accountability and verification in the submission process.

  1. Incomplete filling of the form.
  2. Not updating the form with changes.
  3. Misunderstanding definitions and terms.
  4. Failure to disclose related parties.
  5. Not attaching additional sheets when needed.
  6. Submitting outdated information.
  7. Overlooking the requirement for an original signature.
  8. Neglecting to review the form for accuracy before submission.

Addressing these errors can lead to a more streamlined and compliant process, ultimately supporting the integrity and objectives of health care administration in Nebraska.

Documents used along the form

Completing the MLTC 62 form, a crucial document for individuals and entities interacting with Nebraska's Medicaid services, is just the first step in ensuring compliance with the Department of Health and Human Services' requirements. This form, mandating disclosure of ownership, controlling interests, and any past convictions relevant to Medicare, Medicaid, and other healthcare programs, is paramount for upholding transparency and integrity within healthcare provisions. However, it's often not the only documentation required. Several additional forms and documents may be needed alongside the MLTC 62 form, each serving a unique purpose in the broader context of healthcare regulation and compliance.

  • CMS-855A: This is the Medicare enrollment application for institutional providers. It is essential for any entity looking to become a Medicare provider, detailing the operational and structural framework of the organization.
  • CMS-855B: Specifically designed for clinics, group practices, and certain other suppliers, this form helps these entities enroll in the Medicare program.
  • CMS-855I: Required for individual practitioners wishing to enroll in the Medicare program, this form collects detailed personal and professional information.
  • CMS-855R: This form is used when a physician or non-physician practitioner is reassigning their Medicare benefits to an organization, enabling the payment for services to go directly to said organization.
  • SSA-827: A form for Authorization to Discard Information to the Social Security Administration, facilitating the release of medical records and other personal information necessary for determining eligibility in various programs.
  • IRS W-9: Request for Taxpayer Identification Number and Certification, this document is often required for tax and identity verification purposes.
  • Nebraska Medicaid Provider Agreement: This contract establishes the participation terms between the Medicaid provider and the state of Nebraska, outlining compliance obligations and payment terms.
  • Privacy and Compliance Training Certifications: Most healthcare entities and providers require evidence of completed training in patient privacy and healthcare compliance, often tied to federal laws like HIPAA.
  • Business Associate Agreement (BAA): For entities that handle protected health information (PHI), a BAA is critical to ensure that all parties comply with HIPAA's privacy and security rules.
  • Provider Background Screening: Various states require background checks for providers participating in Medicaid or Medicare, screening for prior convictions or sanctions that might disqualify them from enrollment.

These documents collectively ensure a thorough vetting process, promoting accountability and safeguarding patient interests within Nebraska's healthcare system. The interplay between these forms allows regulatory bodies to maintain a high standard of care, ensuring that only qualified, ethical, and compliant entities and individuals are allowed to participate in these critical healthcare programs. It accentuates the ongoing commitment to transparency, quality, and integrity that is vital for the trust and reliability of Nebraska's healthcare services.

Similar forms

The MLTC-62 Nebraska form, which requires disclosing ownership or controlling interests and any convictions related to Medicaid, Medicare, or other government health programs, is similar in nature and objectives to several other documents used in healthcare and legal fields. These documents share a common goal of ensuring transparency, fulfilling regulatory compliance, and preventing fraud within healthcare services. Understanding how these forms are similar helps to appreciate the broad framework of legal and ethical compliance in healthcare administration.

The CMS-855A Medicare Enrollment Application is another document that bears resemblance to the MLTC-62 form. Like the MLTC-62, the CMS-855A is designed for healthcare providers to disclose information about ownership, management, and control interests, along with any criminal convictions of those involved with the facility or service. Both forms are essential for enrollment and continuation in federal health programs and aim at safeguarding the integrity of these programs by ensuring that providers meet certain standards and are forthcoming about their operations and affiliations.

The Disclosure of Ownership and Control Interest Statement (DHHS Form 1513) is also akin to the MLTC-62. This form, used by various states’ Departments of Health and Human Services, requires detailed information about individuals or entities with significant ownership or control over healthcare providers. Similar to the MLTC-62, the DHHS Form 1513 mandates disclosures about family relationships among those with ownership interests and about any convictions related to government health programs. Both forms are instrumental in preventing conflicts of interest and ensuring that only reputable providers are involved in delivering healthcare services under government programs.

The Provider Enrollment and Chain/Ownership System (PECOS) statements are part of an online system that parallels the objectives of the MLTC-62 form. PECOS allows providers to electronically submit their ownership, control, and managing employee information as part of the Medicare enrollment process. Like the MLTC-62, PECOS is designed to streamline the disclosure process and ensure that federal health programs are aware of the individuals and entities behind healthcare services. Both systems require updates when there are significant changes in ownership or control, reflecting the ongoing commitment to transparency and compliance in healthcare provisioning.

Understanding these documents and their purposes underscores the importance of compliance and ethical responsibility in the healthcare industry. Each form, while serving a specific function or pertaining to a particular program, is interlinked by the common goal of ensuring that healthcare providers operate within the bounds of law and maintain a high standard of integrity.

Dos and Don'ts

When completing the MLTC 62 Nebraska form, it's crucial to approach the task with attention to detail and accuracy. This document plays a significant role in maintaining transparency and compliance with the Department of Health and Human Services' mandates. Below are some guidelines to ensure that the submission process is both smooth and in alignment with the required standards.

Do:
  • Verify the accuracy of all provided information: Ensure that every detail entered on the form, from the names to the percentages of interest, is correct and current. This includes double-checking the spelling of names, accuracy of addresses, and all numerical values provided.
  • Include all necessary attachments: If the space provided on the form is insufficient, attach separate sheets that include all required information. Make sure that these attachments are clearly labeled and referenced within the main form to ensure easy navigation and review.
  • Disclose all relationships: If any persons listed on the form have family or business relationships with each other, disclose this information comprehensively. Transparency regarding relationships helps in identifying potential conflicts of interest or other relevant considerations.
  • Keep a copy for your records: Once the form is completed and before it's submitted, ensure you make a copy for your records. This will be crucial for reference, especially if there are follow-up questions or a need for clarification from the Department.
Don't:
  • Use a stamped signature: The form requires a handwritten signature from the provider, authorized representative, or agent. Stamped signatures are not accepted and can result in the rejection of the form.
  • Omit conviction details: If any person identified in the form has a conviction related to their involvement in Medicare, Medicaid, Waivers, CHIP, or Title XX services programs, these details must be disclosed. Not providing this information can lead to significant legal and operational consequences.
  • Delay updates to the form: Should any changes occur that affect the information provided on the form, such as changes in ownership or control percentages, address changes, or new convictions, update the form promptly within the 35-day window as required by law.
  • Overlook the provider statement: The provider statement at the end of the form is a certification of the truthfulness and completeness of the information provided. It's essential not to rush through this section. Understand its implications fully before signing and dating the document.

Misconceptions

Understanding the MLTC 62 Nebraska form requires clear information to dispel common misconceptions. Here are five frequently misunderstood aspects of the form:

  • The form is only for new Medicaid providers. This is incorrect. While the form is required for new enrollees, existing providers must also complete it at the time of survey, upon contracting, or within 35 days of a request from the Department. The form is crucial for both new and current providers to maintain transparency about ownership and any controlling interests.
  • All sections must be filled out by every entity. This is not always the case. Government entities or non-profit organizations are instructed to skip sections A and B, moving directly to sections C, D, and E. This instruction streamlines the process for these entities, focusing only on relevant information.
  • Disclosure of convicted persons is limited to ownership roles. Misunderstanding often surrounds section E. It requires the listing of any person with ownership or an employee with a controlling interest who has been convicted of a criminal offense related to their involvement in Medicare, Medicaid, CHIP, or Title XX services. This encompasses a broader range of individuals beyond those with an ownership interest, including managing employees and agents.
  • Personal relationships among owners are irrelevant. Contrary to this belief, section B specifically inquires about the existence of relationships like spouse, parent, child, or sibling among listed individuals with an ownership or control interest. This information is vital for transparency and avoids conflicts of interest within the Medicaid provider's structure.
  • Only direct ownership interests need to be reported. Both direct and indirect ownership interests of 5% or more must be disclosed, as outlined in sections A and B. Understanding and accurately reporting these interests ensure compliance with federal regulations and allows for a comprehensive view of the entity's ownership structure.

Proper completion and understanding of the MLTC 62 Nebraska form are fundamental to the compliance process for Medicaid providers. Dispelling these misconceptions ensures entities are accurately and fully disclosing required information, aligning with federal and state regulations designed to maintain the integrity of the healthcare system.

Key takeaways

Completing the MLTC-62 form is a critical step for health service providers in Nebraska for Medicaid enrollment or contracting. Here are eight key takeaways that providers need to understand about this form:

  • The MLTC-62 form serves as a declaration of ownership, controlling interest, and any past convictions related to Medicare, Medicaid, or other health programs. Completing it accurately is mandated by the Centers for Medicare and Medicaid Services.
  • It is vital for the provider to disclose all information at the time of enrollment, during a survey, or within 35 days of receiving a written request from the Nebraska Department of Health and Human Services.
  • Any person or entity with a direct or indirect ownership or control interest of 5% or more in the disclosing entity, or in any subcontractor related to the disclosing entity, must be listed in Section A of the form.
  • In section B, if any of the listed individuals are related to each other as a spouse, parent, child, or sibling, this relationship must be disclosed. This helps in identifying potential conflicts of interest or biases.
  • Managing employees who have significant control over the operations of the disclosing entity must be identified in section C. This ensures transparency in who is managing the services provided.
  • Section D requires disclosure if any person, business, organization, or corporation listed earlier also holds a comparable interest in any other Nebraska Medicaid Provider. This is critical to prevent any conflicts of interest within the system.
  • Past criminal offenses related to Medicare, Medicaid, or other health programs by any person with an ownership or controlling interest must be disclosed in section E. This protects the integrity of health programs.
  • The provider's statement at the end of the form is a declaration of the accuracy and completeness of the information provided. It must be signed by an authorized representative, with a clear admonition that a stamped signature is not acceptable.

Understanding these elements of the MLTC-62 Nebraska form ensures compliance with legal requirements and aids in maintaining the transparency and integrity of health services provided within the state.

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