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Enrolling as a Medicaid provider in New York State is an essential step for healthcare professionals who wish to serve Medicaid beneficiaries. The Medicaid NY form is designed to facilitate this enrollment process, ensuring that providers comply with the necessary rules and regulations set forth by the New York State Department of Health. This form covers critical areas, including personal information, professional credentials, and ownership disclosures. It's important for applicants to understand that the enrollment process requires complete and accurate information; any omissions could delay or jeopardize enrollment. Additionally, the form outlines the implications of rendering services before completing enrollment, which can lead to financial risks, as claims submitted for services provided prior to the authorized enrollment date will not be reimbursed. Understanding the requirements for both enrolled and non-enrolled physicians in the CAQH system is crucial, as it determines the necessary steps for completing the application. Moreover, the form includes sections for disclosing ownership interests and any potential conflicts, ensuring transparency and compliance with federal regulations. By carefully navigating the Medicaid NY form, providers can establish their eligibility to participate in this vital program, ultimately enabling them to deliver care to those who need it most.
Similar forms
- Medicare Enrollment Form: Similar to the Medicaid NY form, the Medicare Enrollment Form requires personal and professional information from healthcare providers to ensure compliance with federal regulations and eligibility for participation in the Medicare program.
- CAQH Provider Registration: Like the Medicaid NY form, the CAQH Provider Registration collects essential information about healthcare providers, including practice history and credentials, to streamline the enrollment process across various insurance plans.
- National Provider Identifier (NPI) Application: This document shares similarities with the Medicaid NY form in that it requires detailed personal and professional information to assign a unique identifier to healthcare providers for billing and identification purposes.
- State Licensing Application: Both forms require comprehensive details about a provider's qualifications, including educational background, work history, and any disciplinary actions, to ensure that the provider meets state standards for practice.
- Insurance Credentialing Application: This application is akin to the Medicaid NY form as it collects similar information regarding a provider’s qualifications, history, and compliance with regulations, necessary for obtaining privileges with insurance companies.
- Provider Enrollment Application for Commercial Insurance: Similar in structure, this application gathers provider information to enroll in commercial insurance networks, ensuring compliance with respective insurance requirements.
- Emergency Medical Services (EMS) Provider Application: This document parallels the Medicaid NY form by requiring personal and operational information to assess eligibility for EMS provider status and compliance with state regulations.
- Behavioral Health Provider Enrollment Application: Like the Medicaid NY form, this application requires detailed information about a provider’s qualifications and any relevant history to ensure they meet specific standards for behavioral health services.
- Pharmacy Provider Enrollment Form: This form is similar in that it collects detailed information about pharmacy providers to ensure compliance with state and federal regulations for dispensing medications.
- Home Health Agency Application: Similar to the Medicaid NY form, this application requires comprehensive information about agency operations and staff qualifications to ensure compliance with health care regulations for home health services.
Form Preview
New York State Medicaid
Enrollment Form
Thank you for your interest in enrolling with the New York State Medicaid Program. As a Medicaid provider, you agree to comply with the rules, regulations and official directives of the Department including, but not limited to, Part 504 of 18NYCRR (i.e., Title 18). Title 18 can be found by choosing the Laws and Regulations link of the Department of Health’s website, www.health.ny.gov.
You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process. Payment will not be made for any claims submitted for services, care, or supplies furnished before the enrollment date authorized by the Department of Health. If you have any questions, contact the eMedNY Call Center at (800)
New York State’s Personal Privacy Protection Law requires us to inform every person from whom we request personal information why we are requesting information and how we will use it. The information requested will permit proper payments to you as a Medicaid provider, according to the provisions of applicable State and Federal Law and Regulations. Collection of this information is authorized by Section
Physicians Enrolled in CAQH:
1. Complete this form in its entirety. Type/print legibly. Enrollment is not guaranteed.
2. Mail completed form to |
Computer Sciences Corporation |
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PO Box 4603 |
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Rensselaer, NY |
Physicians Not Yet Enrolled in CAQH: |
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1.Go to www.CAQH.org and complete a CAQH Registration Kit and CAQH Provider ID. This will allow you to complete the
2.To complete the CAQH application you will need:
•CAQH Provider ID (included in the registration kit sent from CAQH)
•Previously completed credentialing application (for reference)
•List of all previous practice locations
•Copies of:
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Curriculum vitae (resume) |
IRS Form |
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Current Medical License |
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Malpractice insurance face sheet |
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Current DEA certification (if applicable) |
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Summary of any pending settled malpractice cases |
3.Verify your data entry and Attest.
4.Fax supporting documents to (866)
5.For help completing the CAQH application, please contact the CAQH Help Desk at
6.Once your CAQH enrollment is complete, follow the instructions above for “Physicians Enrolled in CAQH”.
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NY MEDICAID PROVIDER ENROLLMENT FORM
for
PHYSICIANS
Mail to:
Computer Sciences Corporation
PO Box 4603
Rensselaer, NY
Category of Service: _0460_
New Enrollment
(not currently enrolled)
Revalidation
(enrolled; required to revalidate)
NY Provider ID # ___________
(from Letter)
Reinstatement/Reactivation
If Applicant was previously excluded/terminated from the Medicaid Program, complete the Prior Conduct Questionnaire found at www.eMedNY.org and include it with this Enrollment Form
Applicant Name (exactly as it appears on your license/registration) Last, First, MI
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Date of Birth (MM/DD/YYYY) |
SSN |
Are you enrolled in Medicare? |
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No |
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NPI (Individual) |
NPI |
If affiliated with a Group, do you have a |
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Private Practice as well? |
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Yes |
No |
N/A |
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Specialty |
CAQH Provider ID - REQUIRED |
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License # |
State of Licensure if not New York |
Limited License? |
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Yes |
No |
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CONTACT ADDRESS: (for questions during the Application Process) |
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Attention: |
Street Address |
Suite / Department / Floor |
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City |
State |
Zip Code (9 digits) |
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Telephone Number (w/ extension) |
Fax Number |
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CORRESPONDENCE ADDRESS: (where letters and claims forms, if any, should be sent) – PO Box not acceptable
PLEASE NOTE: This address will be used by NY Medicaid but may be replaced if CAQH provides a different address in the future
Attention:
Street Address
Suite / Department/ Floor
City
State
Zip Code (9 digit)
County (if in New York)
Telephone Number (w/ extension)
Fax Number
FOR HOSPITALISTS AND EMERGENCY ROOM PHYSICIANS ONLY
CAQH does not request a “Pay to” Address for your enrollment. Please complete the following for your enrollment file with NY Medicaid:
PAY TO ADDRESS: (indicate where checks & remittance statements should be sent until EFT and
Attention: |
Street Address or PO Box |
Suite / Department/ Floor |
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City |
State |
Zip Code (9 digit) |
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County (if in New York) |
Telephone Number (w/ extension) |
Fax Number |
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DISCLOSURE OF OWNERSHIP AND CONTROL
Completion is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be returned. Visit www.health.ny.gov to review definitions and policy found at 18NYCRR, Section 504.1 before completing this form. .
{If additional space is needed, copy form; all entries must be on the form}
SECTION 1:
Disclosing Entity / Applicant (Individual named on page 2 of this application)
Name
NPI
Home Address - Street
City & State
Zip Code (9 digits)
SSN
Date of Birth (MM/DD/YYYY)
Ownership in Applicant (if required by 18NYCRR, Section 504.1(d)(18)(iv)). Include familial relationship to the Applicant and other Owners (spouse, parent, child, sibling), if any. The address for corporate entities must include every business address. See 42 CFR Part 455.104(b)(1)(i) for more information).
Name of Individual or Entity |
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% of Ownership |
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NPI |
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Address (Home Address if individual) |
City & State |
Zip Code (9 digits) |
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SSN (if individual) |
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FEIN (if entity) |
Date of Birth (if individual) |
Familial Relationship (if individual, if any) |
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(MM/DD/YYYY) |
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SECTION 2:
Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(b)(3)) - (Complete if any identified in Section 1 has an ownership or control interest in ODE)
Name (from Section 1) |
Name of ODE |
NPI or Medicaid ID of ODE |
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Name (from Section 1) |
Name of ODE |
NPI or Medicaid ID of ODE |
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SECTION 3:
Ownership in Subcontractors If the Applicant has an ownership or control interest of 5% or more in a subcontractor and an Owner of the Applicant also has an ownership or control interest in the subcontractor, complete the boxes below. If those identified in this Section have a familial relationship with a person with ownership or control interest in one of these subcontractors, complete Section 4).
Owner’s Name (from Section 1) |
Subcontractor Name |
Tax Identification Number |
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Owner’s Name (from Section 1) |
Subcontractor Name |
Tax Identification Number |
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SECTION 4:
Familial Relationship in Subcontractors (Complete if those identified in Section 3 have a *familial relationship with a person with ownership or control interest in one of the subcontractors identified in Section 3).
*parent, child, sibling, spouse
Owner’s Name (from Section 1) |
Subcontractor’s Name |
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Name & Familial Relationship |
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Owner’s Name (from Section 1) |
Subcontractor’s Name |
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Name & Familial Relationship |
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SECTION 5:
Agents and Managing Employees (e.g. office manager, administrator, director or other individuals who exercise operational or managerial control over the day to day operations of the provider. Although unusual, if None, indicate NONE in the first "Name" field below. Include familial relationship to the Applicant (spouse, parent, child, sibling), if any. If additional space is needed, copy form; all entries must be on the form.
Name |
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Association Type (see instructions) |
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Home Address - Street |
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City & State |
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Zip Code (9 digits) |
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SSN |
Date of Birth (MM/DD/YYYY) |
Familial Relationship |
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Name |
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Association Type (see instructions) |
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Home Address - Street |
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City & State |
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Zip Code (9 digits) |
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SSN |
Date of Birth (MM/DD/YYYY) |
Familial Relationship |
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Name |
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Association Type (see instructions) |
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Home Address - Street |
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City & State |
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Zip Code (9 digits) |
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SSN |
Date of Birth (MM/DD/YYYY) |
Familial Relationship |
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SECTION 6:
Respond to these questions on behalf of: 1. the Applicant
2.all individuals and entities identified in Sections 1 & 5
3.any entity in which the Applicant has a 5% or more ownership
1.Have any of the individuals/entities (1, 2 and 3) been terminated, denied enrollment, suspended, restricted by Agreement or otherwise sanctioned by the Medicaid Program in New York or in any other State, Medicare, or any other governmental or private medical insurance program?
Yes |
No |
2.Have any of the individuals/entities (1, 2 and 3) ever been convicted of a crime related to the furnishing of, or billing for, medical care or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals in any State?
Yes |
No |
3.Have any of the individuals/entities (1, 2 and 3) ever had their business or professional license or certification, or the license of an entity in which they had an ownership interest over 5% ever been revoked, suspended, surrendered, or in any way restricted by probation or agreement by any licensing authority in any State?
Yes |
No |
4.Is there currently pending any proceedings that could result in the above stated sanctions for the individuals/ entities (1, 2 and 3)?
Yes |
No |
NOTE: If you answered “Yes” to any of the questions above, you must complete and submit the “Prior Conduct Questionnaire” available at www.emedny.org.
5. Do you, including any entity in which you have ownership, have any unpaid balances owed to the NY
Medicaid Program? |
Yes No |
If yes, indicate amount $_____ |
If yes, has payment been arranged? Yes |
No If yes, attach verification of arrangement. |
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If no, this enrollment will be reviewed by the OMIG
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SIGNATURE AND AFFIRMATION
By signing this enrollment form for participation in the New York State Medicaid Program, the Applicant/Provider understands and agrees to the following:
As a Medicaid Provider you agree to comply with the rules, regulations and official directives of the Department including, but not limited to Part 504 of 18NYCRR which can be found at the Department of Health’s website, www.health.ny.gov
In addition, pursuant to 42 CFR, Part 455.105, by enrolling in the Medicaid Program you agree to disclose the following regarding business transactions within the next 35 days upon request of the Department or the Secretary of Health and Human Services.
(1)Information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the
(2)Any significant business transactions between the provider and any wholly owned supplier, or between
the provider and any subcontractor during the
As a Medicaid Provider you agree to abide by all applicable Federal and State laws as well as the rules and regulations of other New York State agencies particular to the type of program covered by this enrollment application.
For those providers for whom the Mandatory Compliance Law applies (see www.OMIG.ny.gov), the Provider has certified via the Office of the Medicaid Inspector General’s web site referenced above that the provider and its affiliates have adopted, implemented and maintains an effective compliance program that meets the requirements of Social Service Law Section
Unannounced site visits by Medicaid, CMS or their agents/designated contractors may be a condition of initial and continued enrollment. In addition, the provider and/or owners (defined as at least a 5 % interest) may be required to consent to criminal background checks including fingerprinting.
As a Medicaid Provider you agree to notify this Department immediately of any changes supplied in this enrollment agreement, including impending ownership changes.
The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that executive compensation, bonuses, incentives and costs of administration exceed reasonable levels.
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR SECRETARY, AS APPROPRIATE.
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Applicant / Provider’s Signature (original; no stamps) |
Date (MM/DD/YYYY) |
______________________________________________________ |
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Name & Telephone Number of Person who Prepared Application |
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Common mistakes
Filling out the New York State Medicaid Enrollment Form can be a straightforward process, but many applicants make common mistakes that can delay their enrollment. Understanding these pitfalls can help ensure a smoother application experience.
One frequent mistake is incomplete information. Applicants often fail to fill out all required fields, thinking that some details are optional. However, every section marked as required must be completed to avoid processing delays. Double-checking the form for completeness before submission is crucial.
Another issue arises from illegible handwriting. If the form is not typed or printed clearly, it can lead to misunderstandings or misinterpretations of the information provided. Using a typewriter or printing neatly by hand can help prevent this problem.
Providing incorrect personal information is also a common error. Applicants sometimes mix up dates of birth or Social Security Numbers. This can lead to significant complications in the enrollment process. Always verify that personal details are accurate and match official documents.
Some applicants neglect to include their CAQH Provider ID when required. This ID is essential for those already enrolled in CAQH, and failing to provide it can result in delays. Ensure that this ID is included if applicable.
Not verifying data entry before submission is another mistake. Many applicants skip this step, which can lead to simple typographical errors that could have been easily corrected. Always take a moment to review the completed form before sending it off.
Missing signatures can also cause problems. Applicants sometimes forget to sign the form or provide a stamp instead of an original signature. An original signature is necessary for the application to be valid, so make sure to sign where indicated.
Some applicants fail to provide a correct correspondence address. This address is where important communications will be sent. If it is incorrect or a P.O. Box is used when not allowed, it could hinder the enrollment process.
Additionally, applicants might overlook the need to include supporting documents. Items such as the IRS Form W-9 or current medical licenses are often required. Not including these documents can lead to delays or rejection of the application.
Finally, not following the submission instructions can lead to issues. Each application must be mailed to the specified address and in the correct format. Ensure that you follow all guidelines to avoid unnecessary setbacks.
By being aware of these common mistakes, applicants can improve their chances of a successful enrollment in the New York State Medicaid Program. Taking the time to review the application carefully can save time and frustration in the long run.
More About Medicaid Ny
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What is the purpose of the New York State Medicaid Enrollment Form?
The New York State Medicaid Enrollment Form is designed for healthcare providers who wish to enroll in the Medicaid program. By completing this form, providers agree to follow the rules and regulations set by the Department of Health. This includes compliance with Part 504 of 18NYCRR, which governs the Medicaid program. Enrollment is essential, as services provided before enrollment may not be reimbursed.
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What information is required to complete the form?
To fill out the Medicaid Enrollment Form, providers need to provide various details, including:
- Personal information such as name, date of birth, and Social Security Number (SSN).
- National Provider Identifier (NPI) and any relevant medical licenses.
- Contact information for both application inquiries and correspondence.
- Details about ownership and control interests, if applicable.
Failure to provide complete information can lead to delays or rejection of the application.
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What happens if I submit claims before completing the enrollment process?
Providers are at financial risk if they provide services to Medicaid beneficiaries before completing the enrollment process. The Department of Health will not make payments for any claims submitted for services rendered before the official enrollment date. It's crucial to finalize enrollment to ensure reimbursement for services provided.
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What should I do if I am not yet enrolled in CAQH?
If you are not enrolled in the Council for Affordable Quality Healthcare (CAQH), you must first complete the CAQH Registration Kit. This registration will provide you with a CAQH Provider ID, which is necessary for completing the online application in the Universal Provider Datasource (UPD). After obtaining your CAQH Provider ID, follow the specific instructions outlined in the enrollment form.
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How is personal information handled according to New York State law?
The New York State Personal Privacy Protection Law mandates that individuals providing personal information must be informed about the reasons for the request and how the information will be used. The information collected is necessary for proper payment processing and may be subject to audits by state and federal authorities. It is essential to provide accurate information to avoid issues with enrollment.
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What is the significance of signing the enrollment form?
By signing the enrollment form, you affirm your commitment to comply with all applicable rules and regulations governing the Medicaid program. This includes agreeing to disclose any relevant business transactions and notifying the Department of any changes in ownership or operational control. Signing the form also acknowledges that providing false information may lead to legal consequences.
Misconceptions
Here are four common misconceptions about the New York Medicaid Enrollment Form:
- Misconception 1: Completing the form guarantees enrollment.
- Misconception 2: All submitted claims will be paid, regardless of enrollment status.
- Misconception 3: Personal information requested is optional.
- Misconception 4: The form can be submitted via email or online.
Many people believe that simply filling out the form ensures they will be enrolled in the Medicaid program. However, enrollment is not guaranteed. The application must be reviewed and approved by the Department of Health.
Some providers think they will receive payment for services rendered before their enrollment is finalized. This is incorrect. Payment will not be made for any claims submitted for services provided before the authorized enrollment date.
It is a common belief that providing personal information on the form is optional. In reality, failing to provide the required information can prevent successful enrollment and may delay payment for services.
Some applicants assume they can submit the enrollment form electronically. However, the completed form must be mailed to the specified address. Ensure you follow the instructions carefully to avoid any issues.
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Nyc Op 98 - Relevant sections of the form are organized for clarity to ensure proper completion.
Key takeaways
Here are key takeaways for filling out and using the New York State Medicaid Enrollment Form:
- Complete the Form Accurately: Ensure that all sections of the form are filled out completely and legibly. Incomplete forms may be returned.
- Understand Financial Risks: Do not provide services to Medicaid beneficiaries until you have completed the enrollment process. Claims submitted before enrollment will not be paid.
- Contact Information: Provide a reliable contact address and phone number for any questions during the application process.
- CAQH Registration: If not already enrolled in CAQH, complete the registration process before submitting the Medicaid form.
- Required Documentation: Include necessary documents like your medical license, IRS Form W-9, and malpractice insurance when applicable.
- Disclosure of Ownership: Be prepared to disclose ownership interests and relationships as required by federal regulations.
- Signature Requirement: The application must be signed by the applicant. Stamped signatures are not acceptable.
- Stay Informed: Regularly check for updates or changes to the enrollment process on the New York State Department of Health website.
Medicaid Ny: Usage Guide
Filling out the New York State Medicaid Enrollment Form is an important step for healthcare providers seeking to participate in the Medicaid program. Completing this form accurately ensures that your application is processed smoothly. Here’s how to fill it out step-by-step.
- Obtain the form: Download the New York State Medicaid Enrollment Form from the official website or request a physical copy.
- Fill out your information: Provide your name exactly as it appears on your medical license, date of birth, and Social Security Number (SSN).
- Indicate your enrollment status: Choose whether you are a new applicant, revalidating, or reinstating your enrollment.
- Complete contact information: Enter your contact address, email, and phone number for any inquiries during the application process.
- Provide correspondence address: Fill in the address where you want all letters and claims to be sent. Note that a PO Box is not acceptable.
- Disclose ownership information: If you have ownership in other entities, complete the relevant sections about ownership and control interests.
- Answer questions: Respond to questions regarding any past sanctions or issues related to your enrollment in Medicaid or other programs.
- Sign and date the form: Your signature is required to affirm that the information provided is accurate. Make sure to date the form as well.
- Mail the completed form: Send the form to the address specified: Computer Sciences Corporation, PO Box 4603, Rensselaer, NY 12144-4603.
After submitting your form, you will wait for a response from the New York State Department of Health. They will review your application and notify you of your enrollment status. If any issues arise, they may contact you for additional information or clarification.