Enrolling with New York Medicaid as a practice. Every plan waits on the state's answer.

A New York practice enrolls in NYS Medicaid online, through the Provider Services Portal on eMedNY, the state's Medicaid system. Every provider in a Medicaid managed care plan's network has to be enrolled there too. A group enrolls as a group, each clinician enrolls and affiliates with it, and billing starts from the effective date on the state's approval letter.^AD

Why the plans need the state first.

Federal law requires every Medicaid managed care network provider to be enrolled with the state's Medicaid program. New York's guidance is blunt: a provider a plan flags as not enrolled must enroll or be removed from that plan's Medicaid network.^D

The state screens and enrolls. The plan then credentials on its own terms, and it may still decline a provider the state has enrolled.^G New York publishes a listing of every enrolled provider and a separate listing of applications still pending, and it tells plans to use them.^D

Step one: the NPI, before anything else.

New York treats an NPI from NPPES as a prerequisite, so each clinician's individual NPI and the group's own NPI come first.^AI Those records should match the application exactly.

Step two: pick the right category of service.

New York files each provider under a category of service. Physician groups, including those with nurse practitioners or physician assistants, use one group category. Groups mixing other licensed professionals, such as chiropractors or therapists, use another. A group of only optometrists or opticians files as an optical establishment instead.^B

Step three: build the file in the portal.

The application is built in the Provider Services Portal, now the only way to enroll, revalidate or report an ownership change.^EF It can be saved and finished later, within a set period.^B

A group uploads the IRS letter that assigned its tax ID. A PC, PLLC or LLP also shows its registration with the New York State Education Department.^B Add an electronic funds transfer form, the ETIN certification statement, license proof, and DEA or CLIA documents where they apply.^BC

Signing the certification statement also certifies that, where state law requires one, the practice runs an effective compliance program.^C

Step four: the state's review.

Department of Health staff review the file and send any questions electronically.^A Screening follows the provider's risk level. Moderate and high risk add a site visit, and high risk adds fingerprint background checks for every owner of 5% or more.^E

Step five: the letter, the ETIN, and then the plans.

The approval letter gives the Medicaid provider ID and the effective date of enrollment.^A Claims also need an ETIN, eMedNY's transmitter number, and New York says to wait for its confirmation before using it. A clinician joining an existing group affiliates with the group's ETIN on a separate form.^A

Then each Medicaid plan and commercial plan credentials the practice on its own terms. A plan that uses CAQH ProView (CAQH now operates as DataSpring) reads the clinician's profile there, and keeping that profile costs the provider nothing.^H

What sets the timing.

Three things set the pace: whether it went in complete, how fast each state question is answered, and whether the risk level adds a site visit or fingerprints. The state is also revalidating every enrolled provider in phases right now, on a federal directive.^E The pending listing is the plainest way to confirm a file is in process.^D

What trips practices up.

Two documents look right and are not. A W-9 is not accepted in place of the IRS assignment letter. A Department of State filing is not the Education Department registration the state asks for.^B

Silence costs a file outright. A started application left unsubmitted is deleted, and a submitted one whose state request goes unanswered is withdrawn. Either way the practice starts over.^BC

Claims can go out too early. Enrollment is approved, the ETIN is not confirmed yet, and the first claims have nowhere to go.^A

Some groups need Medicare first. New York requires Medicare enrollment for a group only when its members provide chiropractic, podiatry or physical therapy services.^B

Some provider classes cannot enroll at all for now. New York has a temporary moratorium on new labs, equipment suppliers, pharmacies, home care agencies, applied behavior analysis and some long-term care plans. Practitioner groups are not on the list, but a practice planning to supply equipment should check it first.^E

How we run a New York Medicaid file.

We read each NPI record, license, entity registration and ownership chart first, build the file complete, and answer each state request as it arrives. After that, each plan on your list is filed and followed to its effective date. We price New York Medicaid like any other payer: $350 for the practice's own application and $250 for each clinician.^J If we run your billing, each claim is followed to payment.

Questions practices ask.