Introduction to Provider Enrollment

Step 1 (Required Unless Exempt)   Obtain an National Provider ID (NPI)

Most providers must receive an NPI from the National Plan and Provider Enumeration System (NPPES).

• Determine your provider type: A list of provider types that do not need an NPI are found on HIPAA FAQs page: PR05
• If you are required to receive an NPI, go to the NPPES website https://nppes.cms.hhs.gov

Step 2 (Required)   Submit an Enrollment Application for Your Provider Type

A NYS Medicaid Enrollment Application must be submitted by prospective providers.

Go to the Provider Index page on this site. Each Provider enrollment form has:

• a separate instructions document for field-specific instructions, additional forms and/or documentation
• The enrollment form to be submitted
• Links to all additional forms that may be submitted based on provider type

Applications that are missing one or more requirements will be sent back to the enrollee for completion.

Step 3     Application Review by NYS DOH

Complete applications will be reviewed by NYS Department of Health. 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.

Step 4     Notification of Determination by NYS DOH

A written determination of approval or denial of the submitted application will be sent to the provider.

If the application is approved, a letter containing the provider's MMIS ID Number, the effective date when services may be provided to an enrolled client, and other information related to their enrollment will be sent to the enrollee.

Step 1 (Required)   Receive an ETIN

As a result of filling out the ETIN Certification Statement for New Providers, you will receive notice in the mail of the ETIN that has been generated for you.

If you wish to affiliate with an already existing ETIN, you may submit a Certification Statement for Currently Existing ETINs here. Wait for confirmation of set up with the second ETIN before submitting claims with it.

Step 2 (Required)   Learn Medicaid Billing Policies and Procedures

Before rendering service to a client, providers need to become familiar with the policies and procedures of the Medicaid Program.

• Begin with Information for All Providers: https://www.emedny.org/ProviderManuals/AllProviders/index.aspx
• Select the Provider Manual for your type from the Provider Manuals Page. Each manual contains (where applicable):

• Policy Documents
• Institutional or Practititioner Billing Guidelines
• Provider-specific Billing Guidelines
• Prior Approval Guidelines
• NYS DOH Provider Communications

Step 3 (Optional)   Sign-up for the Medicaid Update

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 receive the Medicaid Update via email in PDF format, send an email requesting inculding your MMIS Provider ID Number to medicaidupdate@health.ny.gov.
• If you cannot receive the Update via email, send a written request including your 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

Current and previous issues of the NYS Medicaid Update may be found at the NYSDOH website http://www.health.ny.gov/

Step 4 (Required)   Determine how you will submit claims to eMedNY

Providers are given several options for submitting claims to eMedNY

Option 1: HIPAA Compliant Claim Formats Submitted Directly to eMedNY

HIPAA-compliant 837 Professional (837P), Institutional (837I), 837 Dental (837D), NCPDP (pharmacy) and formats directly to eMedNY or through a Service Bureau. There are Companion Documents that describe how the electronic transaction must be formatted based on HIPAA requirements located under eMedNYHIPAASupport tab, then choose 5010/D.0 Companion Guides (CGs) here: https://www.emedny.org/HIPAA/5010/transactions/index.aspx

Option 2: Medicaid's Electronic Provider Assisted Claim Entry System (ePACES) web-based application

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. ePACES supports the following types of transactions:

• Claims: Professional (real-time* or batch**) Institutional and Dental
• Claim Status Requests**
• Prior Approval Requests
• Eligibility Verification

*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.
**The status of claims (paid, pended or denied) submitted via the ePACES batch feature is generally available within 24 hours.

Option 3 Paper Claim Forms

For Providers who absolutely have no choice but to submit paper claims, there is information available regarding paper claims, located by clicking on Information, then eMedNY Paper Forms.

(Note: Once a provider is fully enrolled, a supply of paper claim forms will be mailed to the Provider.)

Step 5 (Optional)   Setting up Remittance Advice Receipt and Payment 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.

Remittance Advices are generated every week for claims submitted from Thursday to Wednesday prior, and are available in multiple formats.

• Electronic
  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 Remittance Advice
  PDF version of the paper remittance is viewed with Adobe Reader® (6.0 release or higher required) which is available free of charge. This Remittance Advice format may be downloaded and stored electronically. Additionally, it is not held with any corresponding paper Medicaid check for two weeks but released to you two weeks earlier. In order to receive the New York Medicaid paper remittance advice in a PDF format through eMedNY eXchange, click here.
• Paper
  Medicaid checks and paper remittances are held for two weeks and two days before being issued to the provider.

ENQUIRIES: 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.

Payments will be sent to the bank account used for Electronic Funds Transfer unless the form sent with your enrollment packet was rejected, in which case you will receive paper checks. See Electronic Funds Transfer (EFT) Authorization Form - #701101 for more information.

Step 6 (Optional)   Submitting Claims

Multiple steps are required to submit claims to eMedNY.

a) Verify Client Eligibility via MEVS or ePACES

Providers must verify the eligibility of the client via the Medicaid Eligibility Verification System (MEVS) before rendering service.

The MEVS manual gives detailed instructions for the available methods for verifying eligibility and the meaning of messages returned by MEVS. MEVS verifies a client's eligibility for any current or past date of service and gives information about their enrollment in Medicaid Managed Care plans, 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. The MEVS Manual is found under Provider Manuals, in MEVS and Supplemental Documentation.Click Here for the MEVS Manual

b) Submit Prior Approval as Required

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, they may be submitted by:

• Paper PA forms are available to enrolled providers by calling 1-800-343-9000.
• Electronic PA requests may also be submitted via ePACES

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 Electronic Prior Approval Request Form

The Prior Approval Roster Request Form is available at emedny.org, under Information, eMedNY Paper Forms, Prior Authorization Forms.