Category(s) of Service: 0464

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Application Fee is NOT Required

Provider Index > DOULA (Pilot Program)

Provider Enrollment & Maintenance

Instructions for doulas enrolling as a provider in the New York State (NYS) Medicaid Doula Pilot Program:

The Department of Health announces the launch of a pilot expansion of the State's Medicaid program to cover doula services for Medicaid fee-for-service and Medicaid Managed Care enrollees. The Medicaid pilot program will be implemented through a phased-in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches in Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached. The doula pilot is a part of the State's multi-pronged initiative to target maternal mortality and reduce racial disparities in health outcomes. A doula is a non-medical birth coach who assists a woman during the prenatal period, labor, delivery, and post childbirth.
Only doulas serving NYS Medicaid eligible clients residing in Erie County and all zip codes in Kings County except 11207, 11212, 11233 will be able to apply for enrollment in the NYS Medicaid Doula Pilot Program.
Once enrolled as a NYS Medicaid provider, doulas will be able to bill NYS Medicaid for up to four prenatal visits, support during labor and delivery, and up to four postpartum visits provided to Medicaid eligible clients residing in the above-mentioned areas.
To become a doula provider for NYS Medicaid Managed Care clients, a doula must first enroll with the NYS Medicaid Program.
Once enrolled as a NYS Medicaid provider, a doula can then reach out to the Managed Care Organizations (MCO) that are participating in the Doula Pilot Program to apply to join the MCO's doula provider network.

For more information about the NYS Doula Pilot Program please visit: https://www.health.ny.gov/health_care/medicaid/redesign/doulapilot/

Provider Training Videos

Complete this Enrollment Form if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment

PRACTITIONER Enrollment Form

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

General Instructions for the Enrollment Form
- Complete ALL items on the form unless otherwise instructed below. Failure to complete all required fields will result in your enrollment form being returned to you which may have an impact on the enrollment effective date.
- Required documents MUST cover the application date and be continuous through the current date.
- Completion of signature field is required and must be original. Initials or rubber stamped signatures will not be accepted.
- Type or legibly print in black or blue ink. Do not use red ink, nor white-out. All attachments will be scanned so they must be legible and on standard 8.5 x 11 paper in good condition.
- Keep a copy of all documents submitted.
- Valid Telephone numbers are required for each service address.
- Do Not submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.
Additional Instructions for the Enrollment Form
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0464
Choose ONE Application Type and check the corresponding box on the Enrollment Form:
- Check New Enrollment if the NPI or Provider listed is not currently enrolled in NYS Medicaid
- Check Revalidation if the NPI or Provider is currently enrolled and you were notified that Revalidation is required per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received
- Check Reinstatement/Reactivation if the provider was previously enrolled but is not currently active.
  Please note: You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process.
NPI: This field is required.

DEA Number & Dates: N/A

License: Leave Blank.

Type of Practice: In the service address field Check the box, Individual (1) from the list.

Place of Service: Enter your office or home address (if NO primary office available) per DOH Policy, then check the box which best describes the site (If applicable).

Association Types: Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role: Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member F: Facility Administrator H: Compliance Officer I: Employee/Lifestyle Coach
M: Managing Employee P: Supervising Pharmacist U: Laboratory Director
Requirements & Additional Forms
- Doula Training Attestation - form #433402 The original signed and dated form affirming your doula training in the core competencies.
- Electronic Funds Transfer (EFT) Authorization - form #701101 NOT REQUIRED IF:
  - submitting a revalidation, reinstatement/reactivation (i.e., if EFT is already in place and no changes are requested).
  - you answered "No" to the question, "If affiliated with a Group, do you have a Private Practice as well?" on page 2 of the Enrollment Form.
- ETIN Certification Statement for New Enrollments - form #490602 (NOT REQUIRED for revalidation, reinstatement, reactivation, or if you are enrolling as a Managed Care Only non-billing provider). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601) after you receive your Provider ID. This form is available here.
- Prior Conduct Questionnaire - form #431001 If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- A Copy of your Doula Training Certificate - OR - if a certificate was NOT provided by your doula training organization (DTO), an original letter (copies will not be accepted) from the DTO that provided your doula training stating you have attended and completed their doula training course (the letter must be signed, dated and on organization's letterhead).
Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID, you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
Maintenance Forms
- Change of Address - form #610101 Complete on the PE Portal
- Disclosure Form for Practitioners - form #380104 Complete on the PE Portal
- Doula Training Attestation - form #433402 Complete on the PE Portal
  The original signed and dated form affirming your doula training in the core competencies.
- EFT Attestation Form - form #701102 Complete on the PE Portal
- Prior Conduct Questionnaire - form #431001 Complete on the PE Portal
  If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
Mailing Instructions
1. Keep a copy of all documents submitted
2. Send the completed enrollment form, required documents and additional forms to:
STANDARD MAILING
New York State Department of Health
DHPCO - Bureau of Provider Enrollment
One Commerce Plaza - 1620
Albany, NY 12210

STANDARD MAILING
New York State Department of Health DHPCO - Bureau of Provider Enrollment One Commerce Plaza - 1620 Albany, NY 12210

Last Updated: 12/2021

Supplemental Information

Provider Training Videos
https://www.health.ny.gov/health_care/medicaid/redesign/doulapilot/
For questions please e-mail DoulaPilot@health.ny.gov

ATTENTION:

At this time, doulas who initiate an application after 2/28/2023 cannot enroll with the NYS Medicaid Erie County Doula Services Pilot. Any applications received after this date will be rejected. Applications submitted and received prior to the 2/28/2023 deadline will be processed. Please visit New York State Doula Pilot Program (ny.gov) for more information.

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director