home
|
self help
|
glossary
|
site map
What's New
What's New
Archives
Information
Information
Practitioner Administered Drug
(PAD) Search Tool
eMedNY Paper Forms
Pharmacy Formulary File
Enrolled Practitioners SEARCH (including OPRA)
Timely Billing Information
Utilization Threshold Program
ICD-10
New Medicare Cards
Request for Financial Reports
Request for Provider Reports
Provider
Enrollment
Medicaid Managed Care Network Providers
National Diabetes Prevention Program (NDPP)
Provider Index
Provider Maintenance Forms
Provider Enrollment Guide
Application Fee
How Do I?
OPRA FAQs
Change of Address
Revalidation Information
Request for Provider Reports
Provider
Manuals
Provider Manuals
Information for all Providers
MEVS and Supplemental Documentation
Provider Outreach
and Training
Training Calendar & Registration
Training Videos
Contact Provider Outreach
Additional Resources
About Provider Outreach
Contacts
eMedNY Contacts
Healthcare-related Links
NYS DOH Contacts
eMedNY HIPAA
Support
Overview
What's New
834 FAQs
FAQs
Privacy and Security
Transaction Instructions
Issues Form
Online Resources
Crosswalks
Edit/Error Knowledge Base (EEKB) Search Tool
eMedNY
Tools Center
ePACES
eXchange
NYRx
Provider Enrollment
Maintenance Portal
Web Portal
Wage Parity
Electronic Visit Verification (EVV)
Enter Facilities
Practioner's NPIs
LISTSERV®
Submitter Dashboard
PAXpress
go Green
Request for Financial Reports
Request for Payoff Balance
Request for Provider Reports
Medicaid Updates
PTAR
PTAR Overview
Archives
PTAR Login
Category(s) of Service:
0405
Application Fee is
REQUIRED
.
Click here
for more information.
Provider Index
> Eye Prosthesis Supplier / Occularist
Provider Enrollment & Maintenance
Complete this Enrollment Form 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
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 the Enrollment Form
Complete
ALL
items on the form
unless
otherwise instructed below. Failure to complete all required fields will result in your enrollment form being returned to you which may have an impact on the enrollment effective date.
Required documents must be valid on the application date and continuously valid through the current date.
An original signature is required. Initials or rubber-stamped signatures will not be accepted.
Type or legibly print in black or blue ink. Do not use red ink, nor white-out. All attachments will be scanned so they must be legible and on standard 8.5 x 11 paper in good condition.
Keep a copy of all documents submitted, as requests for copies cannot be honored.
Valid telephone numbers are required for each service address.
Do Not
submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.).
Additional Instructions
for the Enrollment Form
Category(s) of Service:
Enter the applicable 4-digit code(s) on the Enrollment Form
0405
Choose ONE Application Type and check the corresponding box on the Enrollment Form:
Check
New Enrollment
if the NPI or Provider listed is not currently enrolled in NYS Medicaid
Check
Revalidation
if the NPI or Provider is currently enrolled and you were notified that Revalidation is required per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received
Check
Reinstatement/Reactivation
if the provider was previously enrolled but is not currently active.
Please note: You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process.
NPI:
This field is required.
DEA Number & Dates:
Leave Blank
Type of Practice:
Leave Blank
Place of Service:
Leave Blank
Association Types:
Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role.
Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member
F: Facility Administrator
H: Compliance Officer
I: Employee/Lifestyle Coach
M: Managing Employee
P: Supervising Pharmacist
U: Laboratory Director
Requirements & Additional Forms
Application Fee
($688)
Application Fee Exemption - form #520101
Electronic Funds Transfer (EFT) Authorization - form #701101
EXCEPT Optician - Salaried (0403) AND Optometrist - Salaried (0421). Use this link if you would like to submit your EFT Information to the NYS WEB site.
https://portal.emedny.org/provider/portal/eftRequest
-
NOTE for Optometrists only:
If you answered "No" to the Enrollment Form's Group question (Line 7 of page 2), EMEDNY-701101 is NOT required. Also not required for revalidation or reinstatement/reactivation.
ETIN Certification Statement for New Enrollments - form #490602
(Not required for revalidation, reinstatement, or reactivation). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601)
after you receive your Provider ID.
This form is available
here
.
Group Member Affiliation/Disaffiliation Request - form #610202
(If participating in more than one group, this form must be completed for each additional group).
Prior Conduct Questionnaire - form #431001
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.
Contact Lens Certificate
If applicable, a copy of your Contact Lens Certificate (to receive Specialty Code 715)
Low Vision Certificate
If applicable, a copy of your Low Vision Certificate (to receive Specialty Code 714)
Proof of current license / registration
Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
Provider Compliance Certification -
Certification of a Provider Compliance Program
may be
required. By signing the
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID,
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
.
Mailing Instructions
Keep a copy of all documents submitted, as requests for copies will not be honored.
Send the completed enrollment form, required documents and additional forms to:
STANDARD MAILING
EXPEDITED / PRIORITY MAILING
eMedNY
P.O. Box 4603
Rensselaer, NY 12144-4603
eMedNY
ATTN: Box 4603
327 Columbia Turnpike
Rensselaer, NY 12144
PRACTITIONER Enrollment Form
Maintenance Forms
Change of Address - form #610101
Complete on the
PE Portal
Disclosure Form for Practitioners - form #380104
Complete on the
PE Portal
EFT Attestation Form - form #701102
Complete on the
PE Portal
Group Member Affiliation/Disaffiliation Request - form #610202
Complete on the
PE Portal
(If participating in more than one group, this form must be completed for each additional group).
Optician/Optometrist COS Address Change - form #428901
Complete on the
PE Portal
Prior Conduct Questionnaire - form #431001
Complete on the
PE Portal
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.
Last Updated: 12/2021
Supplemental Information
Enrollment Application Fee
Vision Care Manual