How to become Medicaid Provider?

  • Posted On: October 24, 2021

How to become Medicaid Provider?

The simplest approach to become a Medicaid provider is to apply online. When you apply online, you have a lower chance of committing mistakes that will result in your application being denied and returned to you for rectification. If you do not enter all of the required information, you will be prompted to do so.

How to enroll as a Medicaid Provider?

Step 1:

  • Get a National Provider ID (NPI)
  • This step should be printed.
  • The National Plan and Provider Enumeration System must issue an NPI to the majority of providers (NPPES).
  • Choose your provider type: On the HIPAA FAQs website, you can find a list of provider types that do not require an NPI: PR05
  • If you need an NPI, go to the NPPES website at https://nppes.cms.hhs.gov.

Step 2:

Fill out an Enrollment Form for Your Provider Type.

Prospective providers must file a NYS Medicaid Enrollment Application. Navigate to this website’s Provider Index page. Each Provider enrollment form includes the following information:

  • A distinct instruction document for field-specific instructions, forms, and/or documentation.
  • The enrollment form that must be completed
  • Links to all additional forms that can be submitted based on the type of provider

Applications that do not meet one or more of the requirements will be returned to the enrollee for completion.

Step 3:

Application Review

The NYS Department of Health will assess completed applications. If additional information is required to process the application, the provider will be advised as to what information is required and where it should be sent.

Step 4:

Notification of Determination 

The provider will be notified in writing of the approval or denial of the filed application.If the application is granted, the enrollee will get a letter including the provider’s MMIS ID Number, the effective date when services may be offered to an enrolled client, and other enrollment-related information.

Application for Provider Enrollment

The following is a checklist of provider qualifications and requirements.

  • Only after enrolling as a Medicaid or Health Choice provider must providers deliver services
  • Providers must include a genuine email address in their submissions
  • Receipts of applications will be acknowledged via email or mail
  • If Medicaid requires missing or additional information from providers, it will notify them through email.

Medicaid will accept specific petitions for retroactive effective dates if and only if the following conditions are met:

  • Retroactive eligibility has been granted to a consumer
  • There was an emergency service available
  • Medically essential services were provided, and the provider’s credentials, licensure, certifications, and so on were current and in good standing as of the earliest effective date of service.

Medicaid cannot give preferential treatment to enrollment applications that are delayed owing to provider error, missing information, or a delay in getting credentialing, endorsement, or licensure information from another agency.

Enrollment of Providers Re-credentialing

Re-credentialing is an assessment of a provider’s continuous eligibility for Medicaid participation. The terms re-credentialing, reverification, and revalidation are used interchangeably.

The Affordable Care Act requires providers to be recertified every five years. The provider’s credentials and qualifications are examined as part of the process to verify they satisfy programme standards and are in good standing. A criminal background check on all owners is also performed as part of the re-credentialing process, as is the management of relationships linked with the provider record.

The message center mailbox in the Tracks secure provider portal notifies providers of their upcoming re-credentialing due date.

Re-credentialing of Active Providers

Providers who do not complete the re-credentialing process on time will be barred from participating in the Medicaid programme. If the re-credentialing application is not submitted, reminders will be given 50 days, 20 days, and 5 days before the due date for provider re-credentialing. If a provider’s re-credentialing application is not filed before the re-credentialing due date, they will be suspended. Following a 50-day suspension, the provider will be removed from the Medicaid and Health Choice programmes.

It should be noted that re-credentialing does not apply to enrolled providers who have a term constraint, such as out-of-state providers. Every 365 days, out-of-state (OOS) providers must complete the enrollment process. For more information, please see the Tracks Provider Portal’s Provider Re-credentialing/Re-verification page.

Out-of-State Provider Enrollment

Out-of-state providers may submit either a full application for a five-year enrollment period or a lite-enrollment application for a 12-month enrollment period.

If an OOS provider chooses to use the lite-enrollment application, the following rules will apply:

  • The provider will fill out a shortened application
  • Enrollment is only available for one year
  • Background checks and credentials will be necessary
  • Criminal background checks based on fingerprints, if appropriate
  • For lite-enrollment, there is no application fee

If an OOS provider chooses to use the full-enrollment application, the following rules will apply:

  • A full-enrollment application will be completed by the provider
  • Every five years, the supplier must perform re-verification
  • Background checks and credentials will be necessary
  • Criminal background checks based on fingerprints, if appropriate

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