Medicaid NY Form PDF Details

Embarking on the journey to enroll as a Medicaid provider in New York involves navigating through the comprehensive New York State Medicaid Enrollment Form, a crucial step for healthcare professionals aiming to extend their services to Medicaid beneficiaries. This form serves as a gateway to compliance and participation in the New York Medicaid Program, underscoring the importance of adhering to the extensive rules, regulations, and directives outlined by the Department of Health, particularly Part 504 of 18NYCRR. With the financial implication that services rendered to Medicaid beneficiaries will not be reimbursed if provided before the approval of the enrollment process, the urgency of a meticulous and informed completion of this form cannot be overstated. It encompasses mandatory disclosures including personal information under the New York State's Personal Privacy Protection Law, essential for the facilitation of proper payments pursuant to State and Federal Law and Regulations. Additionally, the form delves into specific instructions for physicians whether already enrolled in CAQH (Council for Affordable Quality Healthcare) or not, detailing the required documentation and verification processes, significantly impacting the onboarding timeline and overall compliance. This enrollment form, structured to collect essential information for the New York State Department of Health Office of Health Insurance Programs, mandates transparency about ownership and control, affiliations, and potentially, criminal background, aiming to safeguard the integrity of the Medicaid Program and ensure the provision of quality healthcare services to its beneficiaries.

QuestionAnswer
Form NameMedicaid NY Form
Form Length5 pages
Fillable?Yes
Fillable fields119
Avg. time to fill out25 min 7 sec
Other namesnew york state medicaid forms printable, new york medicaid form printable, nys medicaid transportation u form, medicaid application form new york state

Form Preview Example

New York State Medicaid

Enrollment Form

Thank you for your interest in enrolling with the New York State Medicaid Program. As a Medicaid provider, you agree to comply with the rules, regulations and official directives of the Department including, but not limited to, Part 504 of 18NYCRR (i.e., Title 18). Title 18 can be found by choosing the Laws and Regulations link of the Department of Health’s website, www.health.ny.gov.

You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process. Payment will not be made for any claims submitted for services, care, or supplies furnished before the enrollment date authorized by the Department of Health. If you have any questions, contact the eMedNY Call Center at (800) 343-9000.

New York State’s Personal Privacy Protection Law requires us to inform every person from whom we request personal information why we are requesting information and how we will use it. The information requested will permit proper payments to you as a Medicaid provider, according to the provisions of applicable State and Federal Law and Regulations. Collection of this information is authorized by Section 367-b of the Social Services Law. This information will be used as one element of various reviews before payment is made for the goods or services furnished and/or for any post payment audits required by the State or Federal authorities. This information will also be used to satisfy the reporting requirement imposed upon us by State and Federal Regulations (e.g., by IRS for payment information reporting purposes). Failure to provide us with the information will prevent establishing the records necessary to enroll you as a Medicaid provider. The information will be maintained by the New York State Department of Health, Office of Health Insurance Programs, Division of OHIP Operations, Bureau of Provider Enrollment, 150 Broadway, Albany, NY 12204

Physicians Enrolled in CAQH:

1. Complete this form in its entirety. Type/print legibly. Enrollment is not guaranteed.

2. Mail completed form to

Computer Sciences Corporation

 

PO Box 4603

 

Rensselaer, NY 12144-4603

Physicians Not Yet Enrolled in CAQH:

 

1.Go to www.CAQH.org and complete a CAQH Registration Kit and CAQH Provider ID. This will allow you to complete the on-line application in the Universal Provider Datasource (UPD).

2.To complete the CAQH application you will need:

•CAQH Provider ID (included in the registration kit sent from CAQH)

•Previously completed credentialing application (for reference)

•List of all previous practice locations

•Copies of:

Curriculum vitae (resume)

 IRS Form W-9

Current Medical License

Malpractice insurance face sheet

Current DEA certification (if applicable)

Summary of any pending settled malpractice cases

3.Verify your data entry and Attest.

4.Fax supporting documents to (866) 293-0414

5.For help completing the CAQH application, please contact the CAQH Help Desk at 1-888-599-1771 or by e-mail: caqh.updhelp@acsgs.com.

6.Once your CAQH enrollment is complete, follow the instructions above for “Physicians Enrolled in CAQH”.

EMEDNY-408601 (07/14)

1

NY MEDICAID PROVIDER ENROLLMENT FORM

for

PHYSICIANS

Mail to:

Computer Sciences Corporation

PO Box 4603

Rensselaer, NY 12144-4603

Category of Service: _0460_

New Enrollment

(not currently enrolled)

Revalidation

(enrolled; required to revalidate)

NY Provider ID # ___________

(from Letter)

Reinstatement/Reactivation

If Applicant was previously excluded/terminated from the Medicaid Program, complete the Prior Conduct Questionnaire found at www.eMedNY.org and include it with this Enrollment Form

Applicant Name (exactly as it appears on your license/registration) Last, First, MI

 

Date of Birth (MM/DD/YYYY)

SSN

Are you enrolled in Medicare?

 

 

 

Yes

No

 

 

 

 

 

 

NPI (Individual)

NPI (Group-if affiliated with a Group)

If affiliated with a Group, do you have a

 

 

 

Private Practice as well?

 

 

 

 

Yes

No

N/A

 

Specialty

CAQH Provider ID - REQUIRED

 

 

 

 

 

 

 

 

 

License #

State of Licensure if not New York

Limited License?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT ADDRESS: (for questions during the Application Process)

 

 

 

 

Attention:

Street Address

Suite / Department / Floor

 

 

 

 

 

 

City

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

e-Mail Address - REQUIRED

Telephone Number (w/ extension)

Fax Number

 

 

 

 

 

 

 

 

CORRESPONDENCE ADDRESS: (where letters and claims forms, if any, should be sent) – PO Box not acceptable

PLEASE NOTE: This address will be used by NY Medicaid but may be replaced if CAQH provides a different address in the future

Attention:

Street Address

Suite / Department/ Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

FOR HOSPITALISTS AND EMERGENCY ROOM PHYSICIANS ONLY

CAQH does not request a “Pay to” Address for your enrollment. Please complete the following for your enrollment file with NY Medicaid:

PAY TO ADDRESS: (indicate where checks & remittance statements should be sent until EFT and e-Remits are in place):

Attention:

Street Address or PO Box

Suite / Department/ Floor

 

 

 

City

State

Zip Code (9 digit)

 

 

 

County (if in New York)

Telephone Number (w/ extension)

Fax Number

 

 

 

EMEDNY-408601 (07/14)

2

DISCLOSURE OF OWNERSHIP AND CONTROL

Completion is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be returned. Visit www.health.ny.gov to review definitions and policy found at 18NYCRR, Section 504.1 before completing this form. .

{If additional space is needed, copy form; all entries must be on the form}

SECTION 1:

Disclosing Entity / Applicant (Individual named on page 2 of this application)

Name

NPI

Home Address - Street

City & State

Zip Code (9 digits)

SSN

Date of Birth (MM/DD/YYYY)

Ownership in Applicant (if required by 18NYCRR, Section 504.1(d)(18)(iv)). Include familial relationship to the Applicant and other Owners (spouse, parent, child, sibling), if any. The address for corporate entities must include every business address. See 42 CFR Part 455.104(b)(1)(i) for more information).

Name of Individual or Entity

 

 

% of Ownership

 

NPI

 

 

 

 

 

 

Address (Home Address if individual)

City & State

Zip Code (9 digits)

 

 

 

 

 

 

SSN (if individual)

 

FEIN (if entity)

Date of Birth (if individual)

Familial Relationship (if individual, if any)

 

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

SECTION 2:

Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(b)(3)) - (Complete if any identified in Section 1 has an ownership or control interest in ODE)

Name (from Section 1)

Name of ODE

NPI or Medicaid ID of ODE

 

 

 

 

 

 

Name (from Section 1)

Name of ODE

NPI or Medicaid ID of ODE

 

 

 

SECTION 3:

Ownership in Subcontractors If the Applicant has an ownership or control interest of 5% or more in a subcontractor and an Owner of the Applicant also has an ownership or control interest in the subcontractor, complete the boxes below. If those identified in this Section have a familial relationship with a person with ownership or control interest in one of these subcontractors, complete Section 4).

Owner’s Name (from Section 1)

Subcontractor Name

Tax Identification Number

 

 

 

 

 

 

Owner’s Name (from Section 1)

Subcontractor Name

Tax Identification Number

 

 

 

SECTION 4:

Familial Relationship in Subcontractors (Complete if those identified in Section 3 have a *familial relationship with a person with ownership or control interest in one of the subcontractors identified in Section 3).

*parent, child, sibling, spouse

Owner’s Name (from Section 1)

Subcontractor’s Name

 

Name & Familial Relationship

 

 

 

 

 

 

 

 

Owner’s Name (from Section 1)

Subcontractor’s Name

 

Name & Familial Relationship

 

 

 

 

EMEDNY-408601 (07/14)

 

3

 

SECTION 5:

Agents and Managing Employees (e.g. office manager, administrator, director or other individuals who exercise operational or managerial control over the day to day operations of the provider. Although unusual, if None, indicate NONE in the first "Name" field below. Include familial relationship to the Applicant (spouse, parent, child, sibling), if any. If additional space is needed, copy form; all entries must be on the form.

Name

 

 

Association Type (see instructions)

 

 

 

 

 

Home Address - Street

 

City & State

 

Zip Code (9 digits)

 

 

 

 

 

SSN

Date of Birth (MM/DD/YYYY)

Familial Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Association Type (see instructions)

 

 

 

 

 

Home Address - Street

 

City & State

 

Zip Code (9 digits)

 

 

 

 

 

SSN

Date of Birth (MM/DD/YYYY)

Familial Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Association Type (see instructions)

 

 

 

 

 

Home Address - Street

 

City & State

 

Zip Code (9 digits)

 

 

 

 

 

SSN

Date of Birth (MM/DD/YYYY)

Familial Relationship

 

 

 

 

 

SECTION 6:

Respond to these questions on behalf of: 1. the Applicant

2.all individuals and entities identified in Sections 1 & 5

3.any entity in which the Applicant has a 5% or more ownership

1.Have any of the individuals/entities (1, 2 and 3) been terminated, denied enrollment, suspended, restricted by Agreement or otherwise sanctioned by the Medicaid Program in New York or in any other State, Medicare, or any other governmental or private medical insurance program?

Yes

No

2.Have any of the individuals/entities (1, 2 and 3) ever been convicted of a crime related to the furnishing of, or billing for, medical care or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals in any State?

Yes

No

3.Have any of the individuals/entities (1, 2 and 3) ever had their business or professional license or certification, or the license of an entity in which they had an ownership interest over 5% ever been revoked, suspended, surrendered, or in any way restricted by probation or agreement by any licensing authority in any State?

Yes

No

4.Is there currently pending any proceedings that could result in the above stated sanctions for the individuals/ entities (1, 2 and 3)?

Yes

No

NOTE: If you answered “Yes” to any of the questions above, you must complete and submit the “Prior Conduct Questionnaire” available at www.emedny.org.

5. Do you, including any entity in which you have ownership, have any unpaid balances owed to the NY

Medicaid Program?

Yes No

If yes, indicate amount $_____

If yes, has payment been arranged? Yes

No If yes, attach verification of arrangement.

If no, this enrollment will be reviewed by the OMIG

EMEDNY-408601 (07/14)

4

SIGNATURE AND AFFIRMATION

By signing this enrollment form for participation in the New York State Medicaid Program, the Applicant/Provider understands and agrees to the following:

As a Medicaid Provider you agree to comply with the rules, regulations and official directives of the Department including, but not limited to Part 504 of 18NYCRR which can be found at the Department of Health’s website, www.health.ny.gov

In addition, pursuant to 42 CFR, Part 455.105, by enrolling in the Medicaid Program you agree to disclose the following regarding business transactions within the next 35 days upon request of the Department or the Secretary of Health and Human Services.

(1)Information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request, and

(2)Any significant business transactions between the provider and any wholly owned supplier, or between

the provider and any subcontractor during the 5-year period ending on the date of the request.

As a Medicaid Provider you agree to abide by all applicable Federal and State laws as well as the rules and regulations of other New York State agencies particular to the type of program covered by this enrollment application.

For those providers for whom the Mandatory Compliance Law applies (see www.OMIG.ny.gov), the Provider has certified via the Office of the Medicaid Inspector General’s web site referenced above that the provider and its affiliates have adopted, implemented and maintains an effective compliance program that meets the requirements of Social Service Law Section 363-d & 18NYCRR, Part 521. A copy of the certification confirmation is included with this enrollment.

Unannounced site visits by Medicaid, CMS or their agents/designated contractors may be a condition of initial and continued enrollment. In addition, the provider and/or owners (defined as at least a 5 % interest) may be required to consent to criminal background checks including fingerprinting.

As a Medicaid Provider you agree to notify this Department immediately of any changes supplied in this enrollment agreement, including impending ownership changes.

The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that executive compensation, bonuses, incentives and costs of administration exceed reasonable levels.

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR SECRETARY, AS APPROPRIATE.

__________________________________________________

_________________________

Applicant / Provider’s Signature (original; no stamps)

Date (MM/DD/YYYY)

______________________________________________________

 

Name & Telephone Number of Person who Prepared Application

 

EMEDNY-408601 (07/14)

5

How to Edit Medicaid NY Form Online for Free

Any time you want to fill out medicaid application new york, there's no need to download any kind of software - just make use of our online PDF editor. Our editor is consistently developing to give the best user experience achievable, and that is due to our commitment to continuous development and listening closely to customer feedback. In case you are looking to get going, here is what it takes:

Step 1: Simply hit the "Get Form Button" at the top of this webpage to launch our pdf editing tool. Here you will find everything that is required to fill out your file.

Step 2: Once you access the online editor, you will see the form all set to be filled out. In addition to filling out various blanks, you may also perform several other things with the form, specifically putting on custom text, changing the initial textual content, adding graphics, placing your signature to the PDF, and much more.

It will be straightforward to complete the form using this practical guide! Here's what you want to do:

1. Whenever filling out the medicaid application new york, make certain to complete all essential blanks in its relevant form section. It will help to expedite the work, allowing your details to be processed promptly and correctly.

Filling out segment 1 of nys medicaid application new york state

2. Once your current task is complete, take the next step – fill out all of these fields - not currently enrolled, Revalidation enrolled required to, If Applicant was previously, Applicant Name exactly as it, Date of Birth MMDDYYYY, SSN, NPI Individual, NPI Groupif affiliated with a Group, Are you enrolled in Medicare Yes, Specialty, License, CAQH Provider ID REQUIRED, State of Licensure if not New York, Limited License Yes No, and CONTACT ADDRESS for questions with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

not currently enrolled, Specialty, and Revalidation enrolled required to of nys medicaid application new york state

3. Throughout this step, have a look at If additional space is needed copy, Completion is required by CFR, NPI, Home Address Street, City State, Zip Code digits, SSN, Date of Birth MMDDYYYY, Ownership in Applicant if required, Name of Individual or Entity, of Ownership, NPI, Address Home Address if individual, City State, and Zip Code digits. All these need to be taken care of with highest accuracy.

Filling out section 3 of nys medicaid application new york state

4. This next section requires some additional information. Ensure you complete all the necessary fields - NOTE If you answered Yes to any of, Conduct Questionnaire available at, Do you including any entity in, Yes No If yes indicate amount, If no this enrollment will be, and EMEDNY - to proceed further in your process!

nys medicaid application new york state writing process described (portion 4)

Be extremely careful while filling out NOTE If you answered Yes to any of and If no this enrollment will be, since this is the section in which many people make a few mistakes.

5. Because you draw near to the completion of the file, you'll find a few extra requirements that need to be fulfilled. Notably, As a Medicaid Provider you agree, including but not limited to Part, In addition pursuant to CFR Part, following regarding business, As a Medicaid Provider you agree, regulations of other New York, For those providers for whom the, certified via the Office of the, Unannounced site visits by, As a Medicaid Provider you agree, enrollment agreement including, The Department may deny or, and executive compensation bonuses must all be done.

nys medicaid application new york state writing process detailed (portion 5)

Step 3: Immediately after going through the entries, hit "Done" and you are good to go! Join FormsPal today and instantly access medicaid application new york, set for downloading. All modifications you make are saved , enabling you to modify the pdf further if necessary. With FormsPal, you're able to fill out documents without worrying about personal information breaches or records being distributed. Our protected software makes sure that your private information is kept safe.

Medicaid NY Form isn’t the one you’re looking for?

Related Documents