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Category(s) of Service:
0401
- with Salaried Optometrist/Salaried Optician (must have at least one Optometrist)
,
AND/OR
0402
- with Salaried Opticians - No Optometrists
Application Fee is
REQUIRED
.
Click here
for more information.
Provider Index
> Optical Establishment
Provider Enrollment & Maintenance
The New York State Department of Health and the Department of Correctional Services (DOCS) have jointly implemented a program to provide eyeglass materials to Medicaid recipients whose county of fiscal responsibility is a county other than New York City. Under this program, if you become enrolled in the Medicaid Program as an eyeglass dispenser (i.e., optometrist, optician, or retail optical establishment) you would forward eyeglass prescriptions for Medicaid recipients to the DOCS/DOH Project so that the materials can be produced by DOCS at their Wallkill facility in Ulster County. The completed eyeglasses will be returned directly to you. Dispensing providers will continue to bill the Medicaid Program for their other professional services, i.e., examinations and dispensing fees. If you service recipients from counties other than New York City, youshould contact DOCS at (800) 836-2636 to receive an information package, sample frame kit and order forms.
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
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
0401
- with Salaried Optometrist/Salaried Optician (must have at least one Optometrist)
,
AND/OR
0402
- with Salaried Opticians - No Optometrists
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.
NPI:
This field is required.
DBA Name:
If appropriate
DEA Number & Dates:
Leave Blank
Disclosure of Ownership and Control, Section 1:
For Corporations & Optical Establishment are required to report all other business addresses (per 42CFR, Part 45.104(b)(1)(i))
Disclosure of Ownership and Control, Section 2:
The business owners is required to complete Ownership in Other Disclosing Entities (ODE) (per 42 CRF, Part 455.104(a)(3))
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
Business Providers: Disclosure of Other Businesses at Same Location - form #436702
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
.
Optical Employee List - form #428501
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.
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,
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
BUSINESS Enrollment Form
Maintenance Forms
Change of Address - form #610101
Disclosure Form for Businesses - form #380101
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 Businesses - form #436703
Last Updated: 12/2021
Supplemental Information
Enrollment Application Fee
Vision Care Manual