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

Go to Provider Index, click on the button for the applicable enrollment type, click on the provider type, and follow all subsequent instructions.

Step 3     Application Review by New York State Department of Health

Applications will be reviewed by staff from the New York State Department of Health. If there are any questions, staff will reach out to the provider electronically. If contacted, it is important to respond as soon as possible.

Step 4     Notification of Enrollment Determination

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

If the enrollment is approved, the determination will include the provider’s Medicaid provider ID (MMIS number or PID), the effective date of the enrollment, and other important information related to a provider’s enrollment in the Medicaid Program.

Step 1 (Required)   Receive an ETIN

Electronic Transmitter Identification Number, or ETIN as it is commonly referred to, is required to perform any electronic transaction in eMedNY, including sending claims and files, and to access ePACES. To obtain an ETIN:

• newly enrolling providers must complete the Certification Statement for Provider Billing Medicaid - form 490602 , or
• providers who want to affiliate to an existing ETIN, e.g., a provider who is new to a group, should use the Certification Statement for Provider Billing Medicaid - form 490501.

Providers must wait for confirmation of set-up with the 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
• 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

New York State Medicaid publishes a monthly newsletter, the Medicaid Update, which 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 in PDF format via email, send an email request, including your MMIS Provider ID, to medicaidupdate@health.ny.gov.

Copies of current and past issues of the Medicaid Update can also be downloaded from the New York State Department of Health website.

Step 4 (Required)   Determine How You Will Submit Claims to eMedNY

Providers have three options for submitting claims to eMedNY:

Option 1: HIPAA-Compliant Claim Formats That Are Submitted Directly to EMEDNY

HIPAA-compliant Professional (837P), Institutional (837i), Dental (837D), and Pharmacy (NCPDP) formats can be submitted directly to eMedNY or through a Medicaid-enrolled Service Bureau. Companion Guides that describe formatting requirements for electronic transactions can be found under the eMedNY HIPAA Support tab on eMedNY.

Option 2: Medicaid's Web-Based Application, the Electronic Provider Assisted Claim Entry System (ePACES)

ePACES allows a Medicaid-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:

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

*Real-time means that claims are processed instantaneously, and the provider can view the status of the claim within seconds.
**The status of claims submitted via the ePACES batch feature is generally available within 24 hours.

Option 3: Paper Claim Forms

If you have no other choice but to submit paper claims, please contact the eMedNY Call Center at (800) 343-9000. A representative will order claim forms and have them mailed to you.

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

eMedNY, the fiscal agent for the New York State Medicaid Program, processes most of the Medicaid transactions related to claims and payment. Transactions are processed 24/7, and checks and remittance advices are issued weekly. Remittance advices are generated for the Thursday to Wednesday prior and are available in the following formats:

• Electronic
  electronic remittances are issued in a HIPAA-compliant format known as the 835 or 920; therefore, specific software is required to interpret the remittance information.
• PDF
  PDF versions of remittances are viewed with Adobe Reader® (version 6.0 or higher), which is available free of charge on Adobe.com. PDF remittances are available immediately and can be downloaded and saved electronically.

  To receive PDF remittances through eMedNY eXchange, please complete and submit the Electronic or PDF Remittance Advice Request form.

• Paper
  Medicaid checks and paper remittances are held for two weeks and two days before being issued to the provider.

Medicaid payments will be sent to the bank account used for electronic funds transfer unless the form sent with an enrollment packet was rejected. In that case, the provider will receive paper checks. Please see Electronic Funds Transfer (EFT) Authorization Form - #701101 for more information.

Questions related to remittances can be directed to the eMedNY Call Center at (800) 343-9000. Providers can also request training from an eMedNY Regional Representative by contacting the Call Center.

Step 6 (Optional)   Submitting Claims

The Medicaid Eligibility Verification System (MEVS) verifies a member's eligibility for coverage on any date and provides information about their enrollment in Medicaid managed care plans, Medicare, or other insurance plans. Additionally, the MEVS/DVS Provider Manual provides detailed instructions for verifying eligibility and explanations of MEVS error messages. The MEVS/DVS Provider Manual is found here.

To submit claims to eMedNY, providers must:

1. Verify member eligibility via MEVS or ePACES. Please note: if a member is covered by other insurance, that insurance must be billed first since Medicaid is the payer of last resort.
2. Ensure prior approval had been obtained, if applicable.

Certain services require prior approval (PA) by the appropriate State or county office before a claim can be submitted. Please review the provider manual specific to your provider type for information regarding PA requirements. If a PA is required, it can be submitted electronically via ePACES.

Providers can sign up to receive electronic PDF rosters that list their PA determinations by:

• Signing up for ePACES access, and
• Completing the Electronic Prior Approval Request Form.

Paper prior approval request forms are available by contacting the eMedNY Call Center at (800) 343-9000, and a paper Prior Approval Roster Request Form is available here.