Category(s) of Service: 0630

If you are ALREADY ENROLLED and need to change your address,

Provider Index > Medicare Cost Sharing Business

Provider Enrollment & Maintenance Instructions

This restricted category of service is only for Medicare-enrolled business/group providers or suppliers who intend to enroll in Medicaid for the sole purpose of submitting claims for cost-sharing for services rendered to dually enrolled Medicare/Medicaid members, thus enabling receipt of a zero-payment remittance advice from Medicaid.

Complete Enrollment in PSP if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
Reporting an OWNERSHIP CHANGE

PSP Login

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

General Instructions for Enrollment in PSP
- Each field is identified as mandatory or optional.
- Incomplete applications can be saved at any time and returned to later for modification or completion as long as the application status is "In Process."
- Providers can upload required documentation (as outlined below).
- Valid telephone numbers are required for each service address.
- Once all required information has been entered and documentation has been uploaded, the application should be reviewed for accuracy, and submitted to the State for review.
Click here to begin
Requirements & Additional Forms
PLEASE NOTE: Only complete applications containing all requirements and additional forms will be accepted for processing. Applications with missing or incomplete information will be rejected and returned
- Application Fee ($750)
- Application Fee Exemption
- ETIN Certification Statement (For new enrollment, i.e., never enrolled)
- Prior Conduct Questionnaire If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- For Changes of Ownership ONLY Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
- IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form (W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4) can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933
Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, form EMEDNY-490602 (i.e., ETIN for providers who have never been enrolled) or the Certification Statement for Provider Billing Medicaid, form EMEDNY-490601 (i.e., ETIN for providers seeking reinstatement), you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
Maintenance Forms
- Change of Address
- Disclosure Form for Businesses
- EFT Attestation Form
- Prior Conduct Questionnaire If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Status Change Form for Businesses

Last Updated: 1/2025

Supplemental Information

Enrollment Application Fee