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Introduction

MCOs should use this form to enroll providers who are currently not in the BWC provider system
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).

The manually completed form shows both individual and business provider information. You must complete a separate form for each provider needing enrolled. You must review your BWC provider file for duplicate information to ensure the information you're submitting is not a current record with BWC.

Required information

Provider

• National provider identifier (NPI) number
• Provider/Practice name
• Provider type (See drop-down list options.)
• Practice type (a) Individual; (b) Sole proprietor; or (c) Business
• 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. Individuals enrolling who are not businesses do not need an IRS W-9 form submitted. BWC classifies a person as a business when they have registered themselves with the IRS and submit a W-9 form checking the box designated "individual/sole proprietor/single member LLC." BWC enrollment unit splits this into two practice types, and you must determine the proper one to choose – Sole proprietor or Business, which includes single member LLC and all other business types on the W-9.

• Sole proprietors are persons enrolled only once instead of an individual enrollment and a group practice enrollment. W-9 Example: line 1: John Smith/Line 2: (DBA) Smith Clinic. This would be a sole proprietor if he submits a W-9 as John Smith DBA Smith Clinic and checked the designated box. LLC is not included on the W-9 in lines 1 or 2. Dr. Smith's individual NPI must be added to the sole proprietor record. (This is the CMS directive for NPI's for sole proprietors).
• Single member LLCs are included with all other business practice types on the W-9 in the BWC system. They would be enrolled as a group. The person would be individually enrolled as their provider type and include their individual NPI (for eligible providers), and the single member LLC or other business type is an incorporated tax ID therefore is enrolled as a group practice. We would usually have an organizational NPI for eligible medical providers, but not always. The W-9 submitted would have the above box checked, with line 1 as: John Smith, line 2 as: Smith Clinic LLC. You will see the LLC designation on the W-9 form.
• You must review the W-9 to determine proper BWC practice type selection, or contact the provider if you are unsure.

Injured worker

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

MCO information

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

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