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Category(s) of Service:
0269
Application Fee is
REQUIRED
.
Click here
for more information.
Provider Index
> OPWDD Waiver Provider
Provider Enrollment & Maintenance
This waiver allows NYS to use Medical Assistance reimbursement to support individuals with developmental disabilities in the community rather than in an Intermediate care facility.
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
,
or
Reporting an OWNERSHIP CHANGE
,
or
Reporting a RECEIVERSHIP
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
Choose only ONE of the following options & check the corresponding box on the top of the Enrollment Form
Check
Billing Provider
- If the applicant/provider intends on Billing NYS Medicaid
Check
Managed Care Only (Non Billing)
- If the applicant/provider is contracted with a Managed Care and is required to enroll with NYS Medicaid per the 21st Century Cures Act.
Category(s) of Service:
Enter the applicable 4-digit code(s) on the Enrollment Form
0269
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
Change of Ownership
to comply with 42 CFR, Part 455.104 - Proof that a Change of Ownership has occurred is required. See Requirements and Additional Forms (below).
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.
Check
Receivership
if the provider is enrolled and a Receiver has been appointed
Effective Date:
If your authorization was issued within the past 90 days AND has an effective date of more than 90 days ago, you may use the effective date of the authorization. Otherwise, the effective date must be less than or equal to 90 days ago.
FEIN:
Federal Employer Identification Number is required
LICENSE #:
Leave Blank
NY Medicaid ID:
Complete if either the Revalidation, Change of Ownership, Reinstatement/Reactivation or Receivership box was checked. NY Medicaid ID is 8-digits
DBA:
Optional
Control of Facility Code:
Click here for the list of codes
DEA or NYS Cont Subs Lic # & Dates:
These fields are NOT REQUIRED / Leave Blank.
# Of Beds:
Leave Blank
Service Address:
List all addresses where services will take place. These addresses must appear on your operating certificate or authorized by NYS Department of Health.
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
(NOT REQUIRED for revalidation if EFT is already in place and no change is requested or if you are enrolling as a Managed Care Only non-billing provider)
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
.
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.
Authorization from the NYS Office for People with Developmental Disabilities
Copy of your Provider Agreement with the State
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 is
REQUIRED
. By signing the
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID,
you (or the entity) certify that 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
INSTITUTION Enrollment Form
Maintenance Forms
Change of Address - form #610601
Disclosure Form for Institutions - form #380103
EFT Attestation Form - form #701102
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.
Status Change Form for Institutions - form #436602
Last Updated: 12/2021
Supplemental Information
Enrollment Application Fee
Home and Community Based Services Manual
Day Treatment Manual
NYS OMIG