NY Medicaid EHR Incentive Program. Eligible Professionals Step 3: Practitioner Enrollment Form

Transcription

1 Eligible Professionals Step 3: Practitioner Enrollment Form July 2015

2 2 NY Medicaid Enrollment Form Presentation and Enrollment Form Overview Locating the Practitioner Enrollment Form Review of Practitioner Enrollment Form

3 3 Enrollment Form Resources Scope of Presentation Presentation targeted at Eligible Professional (EP) types covered under the Overview and review of the Practitioner Enrollment Form Helpful Resources to Review Prior to Presentation Practitioner Enrollment Form: ID *Instructions to Complete the Enrollment Form* Physician: ID Dentist: ID Nurse Practitioner: ID Certified Nurse Midwife: ID Physician Assistant: ID

4 4 Enrollment Form and Provider Types Practitioner Enrollment Form*: ID The appropriate Category of Service code must be entered on the enrollment form. Provider Type Physician 0460 Certified Nurse Midwife 0525 Nurse Practitioner 0469 Physician Assistant 0462 Dentist 0200 *Please note that the enrollment form is the same for the above practitioner types, but the enrollment requirements will vary by practitioner type. Important: As of May 2015, Physician Enrollment Form is no longer accepted. Physicians must use Form Category of Service

5 5 NY Medicaid Enrollment Form Presentation and Enrollment Form Overview Locating the Practitioner Enrollment Form Review of Practitioner Enrollment Form

6 6 Locating the Enrollment Form Multiple ways to locate the NY Medicaid Enrollment Form: Option 1: emedny Search Utility Option 2: Provider Enrollment Webpage Quick Links: Provider Enrollment Webpages Physician Dentist Nurse Practitioner Certified Nurse Midwife Physician Assistant

7 7 Option 1: emedny Search Utility Navigate to Enter in the Search box.

8 8 Option 2a: Provider Enrollment Webpage Navigate to Click on Provider Enrollment tab.

9 9 Option 2b: Provider Enrollment Webpage Click on the Eligible Professional (EP) type you wish to enroll as.

10 10 Option 2c: Provider Enrollment Webpage Navigate to Option 1: Click here for the Enrollment Form. IMPORTANT: All EP types must enroll as Option 1. Option 2 (Order/Prescribe/Refer/Attend) enrollment does not meet the requirements of the.

11 11 Option 2c: Provider Enrollment Webpage Click on the Practitioner ENROLLMENT FORM Please also review the Instructions to Complete Enrollment Form.

12 12 NY Medicaid Enrollment Form Presentation and Enrollment Form Overview Locating the Practitioner Enrollment Form Review of Practitioner Enrollment Form Provider Information and Details Disclosure of Ownership and Control: Sections 1 6 Signature and Affirmation

13 13 New Enrollment Application Don t miss these steps! Enter the correct 4-digit code for Category of Service. New enrollment applicants select New Enrollment.

14 14 Provider Details Don t miss this step! Providers affiliated with a group must fill in the Group/Organization s Name and NPI.

15 15 Provider Contact Details Note: Correspondence, Pay To and Corporate Address may be the same address. All three sections must be completed.

16 16 Service Location Details Don t miss these steps! Include all service locations where care is rendered, excluding patient s address. Check only one for Type of Practice and Place of Service.

17 17 Disclosure of Ownership and Control Section 1: Disclosing Applicant Don t miss these steps! Disclosing Entity / Applicant is the applicant s information (Page 2). Ownership in Applicant is the applicant s information (Page 2). If the applicant has no ownership in the organization, enter 0%.

18 18 Section 2: Ownership in Other ODEs Don t miss this step! Enter the information for the entities that the applicant has an ownership or controlling interest in. This section may be left blank if not applicable to the provider.

19 19 Section 3: Ownership in Subcontractors Don t miss this step! Enter the information for subcontractors that the applicant has an ownership in. This section may be left blank if not applicable to the provider.

20 20 Section 4: Familial Relationship in Subcontrators Don t miss these steps! Only required if the applicant has ownership in a subcontractor (Section 3) AND there is a familial relationship. Record the subcontractor s information and familial relationships. This section may be left blank if not applicable to the provider.

21 21 Section 5: Managing Employees Don t miss these steps! Enter the information of the additional staff who will be managing the practice. If the provider does not have any managing employees, put "NONE" in the name box. Do not leave this section blank.

22 22 Section 6: Additional Questions Don t miss these steps! Please note that answers must be based on all entities identified in Sections 1-5. Make sure to answer all of the questions.

23 23 Signature and Affirmation Don t miss this step! Providers must read and understand the following agreements prior to signing.

24 24 Best Practices and Details Mark boxes with an X. Legibly print responses in blue or black ink. White-out will not be accepted. Sections 2, 3, and 4: Leave blank if there is no applicable information. Section 5: Enter NONE if there is no applicable information. Signature must be in blue or black ink. Questions? Contact emedny at for additional support.

25 25 Best Practices and Details Navigate to the specific provider enrollment webpage and complete the additional required forms. Review the form instructions to identify other documents that must be submitted (such as copy of license). Send the Provider Enrollment form together with the additional forms of the enrollment packet (such as EFT Authorization and ETIN certification). Questions? Contact emedny at for additional support.

26 emedny Provider Services phone: Provider Enrollment, Application Help, Enrollment Review Support Teams phone: Option 1: epaces, ETIN, MEIPASS, Enrollment, General Questions Option 2: Calculation, Eligibility, Reviews, Rejections Option 3: Public Health Registrations, Status Updates, Guidance Version