Step 1 (Required Unless Exempt) - National Provider ID (NPI)
Before enrolling in the NYS Medicaid Program most providers must apply and receive an NPI from the National Plan and Provider Enumeration System website. A list of provider types that do not need an NPI can be found on the HIPAA FAQs page: PR05
- To obtain the NPI application form, go to the NPPES website (https://nppes.cms.hhs.gov/NPPES/Welcome.do) and contact the NPPES via phone, email or mail (see this information at bottom of their welcome page.)
- To locate a list of provider types that do not need an NPI: Click on the NPI Information link on the eMedNY Homepage. Then click on How Can I Tell if I need an NPI for NYS Medicaid? (Or Click Here)
Step 2 (Required) - The Enrollment Application
A NYS Medicaid Enrollment Application must be submitted by a prospective provider. The completed application will be reviewed by NYS Department of Health. The determination will be sent to the provider, in writing, upon approval or denial of the application. If more information is necessary to process the application, the provider will be notified as to what information is needed and where to send it. If the application is approved, the provider will be notified of his/her provider ID Number and the effective date when services may be provided to an enrolled client.
Effective August 23, 2013 a completed Certification Statement and an Electronic Funds Transfer (EFT) Authorization Form must be submitted with the Enrollment Application for all billing providers.
Step 3 (Required) - Provider Manuals
Before rendering service to a client, providers need to become familiar with the policies and procedures of the Medicaid Program which are located on the emedny.org website.
- Select Provider Manuals from the main menu. (Or click here: http://www.emedny.org/ProviderManuals/index.aspx.)
- For providers who choose to bill electronically, there are Companion Documents that describe how the electronic transaction must be formatted based on HIPAA requirements. The documents are located on the emedny.org website, under the eMedNYHIPAASupport tab, then choose 5010/D.0 Companion Guides (CGs). (Or, click here: https://www.emedny.org/HIPAA/5010/transactions/index.aspx.)
- In addition to the provider manuals and companion guides, NYS Medicaid publishes a monthly newsletter known as the Medicaid Update. The newsletter is available on the New York State Department of Health website. The Medicaid Update highlights changes to Medicaid policy and procedures and should be reviewed by providers each month.
- To view the NYS Medicaid Update, go to the NYSDOH website (http://www.health.ny.gov/), click on Medicaid, then Medicaid Update. (Click here to go directly there.)
- The Medicaid Update is also available electronically. The newsletter will be delivered monthly to your designated email address in a Portable Document Format (PDF). To receive the Medicaid Update electronically, please send your email address along with your MMIS Provider ID Number to the following email address: firstname.lastname@example.org.
Those providers who cannot receive the Update via email may send a written request, along with Provider ID Number, to the following mail address:
NYS Department of Health,
Office of Health Insurance Programs,
Attention: Medicaid Update Editor,
Corning Tower, Room 2029,
Albany, New York 12237
Step 4 (Required) - Client Eligibility Verification
Providers must verify the eligibility of the client via the Medicaid Eligibility Verification System (MEVS) before rendering service. The MEVS manual located on the emedny.org website and considered part of the provider manual, gives detailed instructions for the available methods for verifying eligibility and the meaning of messages returned by MEVS. MEVS will verify eligibility for any current or past date and give information about clients who are enrolled in Medicaid Managed Care plans or who have Medicare or other insurance coverage. If other coverage exists for the client, the provider will need to bill the other insurance first as Medicaid is the Payer of Last Resort.
- To locate the MEVS Manual, go to emedny.org, click on Provider Manuals, click on MEVS Manual, then you will see a PDF document for a MEVS Manual. (Or, click here.)
Step 5 (Optional) - Prior Approval
Certain services require prior approval (PA) by the appropriate NY State or county office before a claim can be submitted. Please review the provider manual specific to your provider type to obtain information regarding PA requirements. If PA is required, there are various methods for submitting a PA request. Paper PA forms are available to enrolled providers by calling 1-800-343-9000. Electronic PA requests may also be submitted via ePACES (see below – Step 8).
Rosters showing the outcome of your PA requests will be mailed to you unless you sign up to receive these rosters electronically. To sign up for receiving PA rosters electronically in PDF format, first sign up for ePACES, then complete the request form.
- The Prior Approval Roster Request Form is available at emedny.org, under Information, eMedNY Paper Forms, Prior Authorization Forms. (Or, click here.)
Step 6 (Required) - Claims Submission
Providers are given several options for submitting claims to the NYS Medicaid Program. Most providers today submit claims electronically. In fact, approximately 97% of claims submitted to the Medicaid Program are sent in an electronic format. Electronic claim transactions that are currently processed by eMedNY are the 837 Professional (837P), the 837 Institutional (837I), the 837 Dental (837D) and NCPDP (pharmacy claims). Details for electronic claim submissions are below:
The status of claims (paid, pended or denied) submitted via the ePACES batch feature is generally available within 24 hours. For professional claims, ePACES allows for the submission of claims in “real-time”. Real-time means that the claims are processed instantaneously and the provider can view the status of a real-time claim within seconds. There is no need to wait for a remittance statement to be mailed to find out about the status of submitted claims. Today, via ePACES, providers know right away if there is a problem with the claim and, if approved, the payment amount.
- Electronic claims must be submitted in a HIPAA-compliant format. View 5010/D.0 Companion Guides by clicking here.
- Many providers avail themselves of Medicaid's FREE software call the Electronic Provider Assisted Claim Entry System (ePACES). ePACES is an internet-based program that will allow an enrolled provider to submit claims as well as many other types of transactions in a HIPAA-compliant format.
Enrollment in ePACES requires a Medicaid Provider ID number and an internet address. To start the ePACES enrollment process contact the eMedNY Call Center at 1-800-343-9000. Please note that while a provider can sign up for ePACES without an ETIN, an ETIN is required before claims can be submitted via ePACES.
ePACES supports the following types of transactions:
- Claims: Professional (batch or real-time) Institutional and Dental
- Claim Status Requests
- Prior Approval Requests
- Eligibility Verification
- Paper Claim Forms – For Providers who absolutely have no choice but to submit paper claims, there are paper claim forms available. (Note that once a provider is fully enrolled, a supply of paper claim forms will be mailed to the Provider.) Information regarding paper claims is located by clicking on Information, then eMedNY Paper Forms. Or click here.)
Step 7 (Optional) - Remittance Options
The processing of most Medicaid transactions is performed by the eMedNY fiscal agent for the NYS Medicaid Program. eMedNY processes transactions 24 hours a day, 7 days a week and issues checks and remittance statements weekly, for processed claims. Medicaid checks and paper remittances are held for two weeks and two days before issuing to the provider.
Electronic remittances are issued in a HIPAA-compliant format known as the 835 or 820; therefore software is required to interpret the remittance information.
PDF Paper Remittances
There are many advantages to receiving a PDF version of the paper remittance:
- The remittance will not be held with your Medicaid check for two weeks but released to you two weeks earlier.
- You will know when the PDF is available in your eXchange account; and you will not have to wait for the mail.
- The remittance can be downloaded and stored electronically for ease of retrieval and you can still print a hard copy.
- The remittance can be word searched to help locate specific claims.
- The PDF will look exactly like the paper remittance with which you are already familiar.
- Remittances can be printed with Adobe Reader® (6.0 release or higher required) which is available free of charge.
In order to receive the New York Medicaid paper remittance advice in a PDF format through eMedNY eXchange, click here.
Thank you for your interest in enrolling in the New York State Medicaid Program.
INQUIRIES: Questions should be directed to the eMedNY Call Center at 1-800-343-9000. Before submitting claims, providers may also phone the Call Center to request training from a eMedNY Regional Representative.