Steps 3 and 4 of the DDA Medicaid Waiver Provider Application Review Process walks potential service providers through the application packet submission, checklist and pre-screening processes. The full process is also available as a downlable PDF document.

Step 3: Submission of Application Packet

All prospective providers are required to submit a completed DDA Medicaid Waiver Provider Application to the Provider Application Specialist in the Provider Resource Management Unit, and must include all supplemental information requested on the provider application checklist.

Check List

1. List of Board Members and their affiliations.
2. Roster of key Personnel, their resume, and position descriptions:
   1. President/Vice President
   2. Director of Nursing
   3. Chief Executive Officer
   4. Program Director
   5. Chief Financial Officer
   6. Director of Quality Management
   7. Incident Manager
   8. Background checks for unlicensed Key Personnel
3. Description of ownership and list of major owners.
4. Address of provider-operated sites from which services will be provided.
5. Copy of most recent audited financial statement of the organization.
6. Completed provider application.
7. Basic organizational documents - Organizational chart.
8. Articles of Incorporation.
9. By-laws or similar documents regulating conduct of provider's internal affairs.
10. Business license, Certificate Authority (if none, Certificate of Good Standing per state).
11. Insurance Documentation.
12. Criminal background checks, as needed.
13. Organizational policies & procedures such as personnel policies, operational procedures, health & safety, human rights, incident reporting, behavioral support policies, staff training, protection of individual funds, Incident management, Quality improvement, program forms with descriptions.
14. Program policies & procedures for each waiver service to be provided.

Step 4: Pre-Screening of Application and Application Review

When DDS/DDA receives the Medicaid application and the required supplemental materials, the documentation is reviewed by the assigned Provider Application Specialist (PAS) to determine if all the required information is present.

• The PAS or other designated Provider Resource Management (PRM) staff use the Readiness Checklist to guide the review.
• The PAS or designee will also review reports, if applicable, from other District, Federal and/or state agencies and examine responses.
• Applicants will be notified when the readiness review has been completed.

If the prospective provider submits an application and all required information is present, the prospective provider will be scheduled for a face-to-face interview with the Provider Review Committee.

This process continues with Provider Readiness Process - Steps 5 thru 7.