Medicaid Managed Care Provider Enrollment Questions

Practitioners can use the Enrolled Practitioners Search function. All other provider types can call eMedNY at 1-800-343-9000.

Go to https://www.emedny.org/info/ProviderEnrollment/index.aspx and navigate to your provider type. Print the instructions, enrollment form and any additional forms that may be needed to complete your enrollment package. At this website, you will also find a Provider Enrollment Guide, How Do I Do It? resource guide, and all forms related to enrollment in NYS Medicaid.

No, you do not have to submit another application.

Yes, when completing your application, please select the Reinstatement/Reactivation option on the enrollment form.

Yes, you may enroll as a non-billing Ordering/Prescribing/Referring/Attending (OPRA) provider.

Yes, you may enroll as a non-billing provider by checking the Managed Care Only (Non- Billing) box on the enrollment form.

No

eMedNY prescreens applications for completeness and ensures that all required documentation is present. If an application is not complete or there is missing (but required) documentation, the application is returned to the provider with a "checklist" detailing what is needed for resubmission.

No, failure to provide this information will result in the return of your application. Board members, agents, managing employees and those with a control interest must provide all information requested on the form, including social security numbers. Medicaid is required to collect this information per Federal regulations.

Please visit the Provider Enrollment Application Fee section for up to date information.

Requests for hardship waiver should be sent with your enrollment form and should explain the hardship and justify the waiver, including explaining how your enrollment will ensure beneficiary access to services and supplying relevant business records. New York Medicaid will send your request to the Centers for Medicare & Medicaid Services (CMS) for review pursuant to Section 1866(j)(2)(C)(ii) of the Social Security Act. If the basis of your request is financial, you must include a balance sheet or other financial statement with your justification.

Managed Care Organizations will notify their providers if they are required to enroll with NYS Medicaid.

Provider types that are required to enroll can be found at: https://www.emedny.org/info/ProviderEnrollment/index.aspx

Yes, the letter may be adjusted to provide additional details to the providers. DOH advises against removing content as it provides crucial information about the enrollment requirement. No approval is required for modifications.

No, providers may receive notices from one or more Managed Care Organizations. It is important, however, that they only submit one NYS Medicaid application.

No, provider types that are required to enroll can be found at: https://www.emedny.org/info/ProviderEnrollment/index.aspx

Yes, the Bureau of Managed Care Fiscal Oversight will email a list of actively enrolled fee-for-service providers to the Managed Care Organizations. In December, an updated list will be posted monthly at https://health.data.ny.gov/.

The PowerPoint presentation can be found by clicking here

The 21st Century Cures Act requires all Medicaid Managed Care (MMC) and Children's Health Insurance Program (CHIP) providers to enroll with state Medicaid programs by January 1, 2018.

Please refer to: https://www.emedny.org/info/ProviderEnrollment/transportation/index.aspx for the enrollable provider transportation types.

No, the list is not the same file as the MMIS Validation file. While the information may appear to be similar, the variables and time period may differ between the two files. Plans are required to outreach to all enrollable network providers not found on the list.

The FFS active provider list includes providers who meet the minimum requirements for enrollment and participation in the NYS Medicaid program. Excluded providers are not listed on the FFS active provider list. The FFS active list may include sanctioned providers as not all sanctions exclude a provider from NYS Medicaid. Please see https://exclusions.oig.hhs.gov/ for an explanation of sanctions and exclusions.

The FFS active list is only available and distributed monthly.

Yes, since private duty nurses and nursing registries are enrollable NYS Medicaid provider types required to enroll.

A complete list of enrollable provider types can be found here: https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/index.aspx

If you are a clinical social worker, podiatrist, chiropractor, or physical therapist and are unable to enroll in Medicare because you previously opted out and are within Medicare's two-year opt out period, you MUST submit the two-year "opt out" letter you received from Medicare with your NYS Medicaid application.

Are pharmacies and prescribers required to be enrolled as of 1/1/18?

Claims for drugs prescribed by a non-enrolled provider, after 1/1/2018, can be adjudicated; however, the plan should have a process in place to notify the non-enrolled prescribers that they must enroll into the Medicaid program for a member to continue receiving their prescriptions without an interruption in therapy.

Claims for medications dispenses by a non-enrolled pharmacy, after 1/1/2018, can be adjudicated. MCOs are being instructed by the State to amend provider contracts no later than 7/1/2018 to include a provision that requires providers to enroll with the State's Medicaid Program and are strongly urged to contact their non-enrolled pharmacy providers to submit their enrollment application as soon as possible to avoid claim denials and interruption in therapy for their members. Pharmacies choosing not to amend their provider contracts and enroll with the State Medicaid program will be terminated from participation and members will be notified of need to obtain medications from another pharmacy that is enrolled in NYS Medicaid if such is not available through their current provider.

Members and providers (including prescribing providers) are encouraged to contact the MCO and obtain direction to an in-network pharmacy or other provider, if available. In the event no in-network pharmacy or provider is available, MCO's can allow that services be provided by the pharmacy, or any other provider (including prescribers) so that the medication can be dispensed, or services provided. Per the 2016 Medicaid and CHIP Managed Care Final rule, "out-of-network" providers under single case agreements are not considered "network" providers and therefore are not subject to the requirements at 438.602(b). Out-of-network providers do not have to be screened and/or enrolled in the State's FFS program. Additionally, emergency room physicians are only subject to 438.602(b) to the extent they meet the definition of a network provider in 42 CFR 438.2.

The list of active providers, including pharmacies, is posted on the Open Data NY site and provided to the MCOs monthly. The most recent list can be accessed via the link below:
https://health.data.ny.gov/Health/Medicaid-Fee-for-Service-Provider-Listing/keti-qx5t

Additionally, the State also provides a listing of providers pending enrollment decision. Starting in mid-February this list will be available and updated monthly via the webpage below: https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/index.aspx

Planned Parenthood dispensing sites are considered non-pharmacy sites and therefore are not able to enroll as pharmacy providers

Yes, each pharmacy location must enroll and have its own Medicaid ID number.

All in-state and out of state pharmacies that provide services to Medicaid and Medicaid Managed Care members are required to enroll in the New York State Medicaid Program pursuant to the 21st Century Cures Act. This requirement also applies but is it not limited to: specialty, mail order, infusion and long-term care pharmacies; as well as out of state pharmacies and those pharmacies providing unique or limited distribution drugs. For instructions and required documentation needed for enrollment please visit https://www.emedny.org/info/ProviderEnrollment/pharm/Option2.aspx

Plans should have a process in place to notify the non-enrolled pharmacy providers that they must enroll into the Medicaid program for a member to continue receiving their prescriptions without an interruption in therapy.

Section 5005(b)(1) of the 21st Century Cures Act amended Section 1902(a) of the Act now requires, as a condition for participation in the Medicaid program, all ordering, prescribing, and referring (OPRA) providers be enrolled in the state Medicaid programs. Effective 01/01/2018 this requirement includes participating OPRA providers of Medicaid Managed Care (MMC) plans. Enrollment in the Medicaid program as a non-billing provider does not require the provider to participate in any MMC plans or the Medicaid Fee-for-Service (FFS) program, however, it does allow the member to utilize their Medicaid coverage for prescriptions, ordered and referred services. MMC plans are expected to verify these providers are enrolled in NYS Medicaid.

Yes. Per DOH regulations; supervising pharmacists are required to enroll in the New York State Medicaid program if employed at a pharmacy that renders services to Medicaid beneficiaries, and as a prerequisite of the pharmacies own enrollment. Supervising Pharmacists must complete a practitioner enrollment form with the required documentation and complete a separate screening and credentialing enrollment process that is compliant with State and Federal rules and regulations. The enrollment form and requirements can be found at: https://www.emedny.org/info/ProviderEnrollment/spharm/index.aspx

There are no exemptions or waivers. Non-resident pharmacies that fill prescriptions for members participating in the State's Medicaid Managed Care program must enroll. However, the process is streamlined for those pharmacies whom submit an enrollment and check the Managed Care Only (Non- Billing) box on the form. Those pharmacies will not need to submit an electronic transmitter identification number (ETIN) or an Electronic Fund Transfer (EFT) form, and will not need additional reviews that are typical for FFS Billing Pharmacy enrollment approval.

The 21st Century Cures Act (Act) requires all enrollable Medicaid Managed Care (MMC) and Children´s Health Insurance Program providers to enroll with Medicaid programs. A list of all enrollable providers can be found at https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/index.aspx

NYS Medicaid recognizes that many plans contract with PBMs for their specific networks. These networks might be contracted through the PBM to provide services to many different plans, commercial and governmental. It is also recognized that individual pharmacies within a PBM's specific network might choose to not accept the contract amendment requiring enrollment with NYS Medicaid. DOH will be providing guidance to MCOs on the next steps for network termination and appropriate remittance messages to providers who refuse to accept the contract amendment by 7/1/2018.

MMC plans are expected to have system overrides and edits in place to allow for the payment of claims for items prescribed by unlicensed residents, interns and foreign physicians' in training programs.

Yes, LHCSAs are required to enroll as a MMIS provider. There are 1,412 licensed LHCSAs in NYS. The majority have MMIS numbers. If you have a question regarding a specific LHCSA, MMIS information can be provided by contacting: MLTC Compliance Reporting

As of 4/1/18, CFCO services for home and community based services will be implemented for both Medicaid Managed Care and Managed Long-Term Care Plans. The CFCO services being implemented on 4/1/18 are services that are already in place in both plans and will not require non-traditional MMC providers to enroll.

If the duly licensed Article 28 and Article 36 operates for the exclusive use as a PACE network provider, then MMIS enrollment is not required. If, however, that Article 28 and/or Article 36 is utilized for other lines of managed care business (a PACE that also operated a Partial; or contracts with other MCOs) or conducts any FFS business, then the Article 28 Article 36 must enroll.

Although the practitioner types listed (i.e., PT, OT, RN) are not required to enroll, they can enroll as either a billing or OPRA provider. Please visit eMedNY.org for the specific requirements: https://www.emedny.org/info/ProviderEnrollment/index.aspx

NYS enrolls providers with LCHSA licenses in two different ways. The requirements for each are located at the links provided.

1. COS 0264 Personal Care Agency (For Billing for Personal Care Aid Services) - No NPI is required. - https://www.emedny.org/info/ProviderEnrollment/personal_care/index.aspx
2. And as a COS 0523/0524 Nurse Registry (For Billing for the Nurse Portion of the services) - The LHCSA license would have to also reflect nursing or nurse services - https://www.emedny.org/info/ProviderEnrollment/nurseReg/index.aspx

Enrollment applies to Managed Long-Term Care (MLTC) lines of business Partial CAP, MAP and Medicaid Advantage.
The requirement does not apply to PACE and FIDA providers.

No, Social Day Centers are not subject to the enrollment requirement.

Yes, contracts terminated by the MCO are required to provide notice and appeal rights except when the termination is based on imminent harm, determination of fraud, or final disciplinary action by a state licensing board or governmental agency which impairs health care professional’s ability to practice

Until further guidance is issued by the Department, plans may execute single case agreements with providers not currently enrolled with FFS.

DOH will be providing MCOs with templates in the future. Drafts have been completed and will be sent out to MCOs and the trade associations for comment.

As stated above, DOH will be providing MCOs with templates in the future. Plans will be provided the template notices for providers and members upon finalization of the documents. DOH will provide guidance regarding timeframes for notice distribution.

The file format will not change; however additional fields may be added in the future.

The Pending Provider file is updated approximately the 1st and 15th of each month. The Pending file is located on the eMedNY site at: https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/index.aspx

The dataset the pending provider list is pulled from, does not contain the application date so it cannot be added to the list.

The LHCSA may only choose one selection on the enrollment application. Please read the information below to determine which type of enrollment to select.

• If the LHCSA meets the requirements to participate as a billing provider, they will select billing as this will supersede the (non-billing) application as there are less requirements for managed care only (non-billing) application.
• If the LHCSA is currently servicing ONLY Managed Care Network providers AND they do not meet the requirements to enroll as a billable provider they need to send in an application and select managed care only (non-billing). The LHCSA can later become a FFS billing provider by updating its enrollment record.

CDPAP providers need to enroll see directions on website. CDPAP Fiscal Intermediary are only managed care so you would check the Managed Care only box as they are not a billing service provider.

Deeming is related to the screening of providers but does not fulfill the complete enrollment requirement of providers.

New York State will not be introducing any new encounter edits.

The data source that is used to produce the Medicaid Fee for Service Provider file is not the same data source used for the PNDS, so PNDS specialty cannot be added to the Provider file.