Healthcare providers can enroll in Medicaid in any state. In fact, they must enroll in each state’s Medicaid plan in which they are submitting a claim. This is not an easy process, because each state’s Medicaid provider enrollment requirements vary. State Medicaid provider requirements are dictated by complex and ever-changing rules. Navigating these changes and complexities requires watchdog legal and regulatory specialization.
Applying to be a provider in the Medicare program does not mean you have also applied to Medicaid, according to the Centers for Medicare & Medicaid Services (CMS), the federal oversight agency for all state Medicaid programs. In addition, enrollment approval in Medicare does not necessarily guarantee enrollment approval in Medicaid.
The Affordable Care Act, passed in 2010, mandates regulations and procedures governing providers who wish to enroll in their state Medicaid program or Children’s Health Insurance Program (CHIP). One purpose of the law is to reduce the number of improper Medicaid payments by screening providers as they enroll.
Can a Provider Be Denied Medicaid Enrollment?
Providers may be denied enrollment in a state’s Medicaid or CHIP program if they don’t meet various screening criteria. They can also be terminated for failure to meet specific criteria. But a provider whose enrollment is denied or terminated may contest that action if that state has appeal rights.
Medicaid Provider Enrollment Requirements
Medicaid provider enrollment requirements vary by state, so it’s essential for providers to consult their state’s Medicaid program for detailed guidelines. Providers must consider some common elements when enrolling in or revalidating their enrollment in Medicaid programs, according to CMS.
CMS issues federal regulations and sub-regulatory guidance that states must adhere to in implementing their Medicaid programs. The Affordable Care Act allows states to impose more stringent enrollment requirements than those found in the federal regulations, or additional ones.
To locate instructions for how to enroll in a specific state’s Medicaid Program or CHIP, CMS says, conduct a web search using the terms “state” + “Medicaid provider enrollment.” (Replace “state” with the name of the state where you seek to enroll). This will help you to locate information regarding a specific state’s enrollment process.
In general, providers enrolling in a state’s Medicaid program must:
- Complete the necessary enrollment forms and submit them to the state Medicaid agency in each state in which they are applying.
- Submit the required documents, which typically include a W-9 Tax Identification Number and Certification form, a copy of their license, and a Medicare/CCN CMS Certification Number, if applicable.
- Check to see if there are additional requirements specific to certain provider types in that state.
- Disclose information related to their ownership and control.
- Be willing to have a background check, including disclosure of healthcare-related criminal convictions.
- Allow for the typical 90 days for enrollment to be approved.
- Renew provider Medicaid enrollment every five years in each state.
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Schedule a ConsultationMedicaid Enrollment for Ordering, Prescribing, and Referring Providers
Many states require ordering, prescribing and/or referring (OPR) providers to be enrolled in Medicaid before their prescription will be filled and reimbursed for Medicaid patients. These providers do not have to be listed in Medicaid directories or submit claims to Medicaid for patients, but they do have to be enrolled. These rules for OPR providers apply only to Medicaid fee-for-service, not managed care plans.
This OPR enrollment requirement, issued under the Affordable Care Act, is intended to make sure providers are not under investigation for fraud and are properly licensed and allowed to order these services.
Several states, including Indiana, Georgia, and Connecticut, have a streamlined enrollment process for physicians and non-physician providers who want to become OPR providers only.
What You Need to Succeed at Medicaid Enrollment
The out-of-state Medicaid enrollment process can be very cumbersome and challenging, to say the least. Some states are trying to make enrollment easier, but there are still many pitfalls.
Most states require detailed confidential disclosure information for enrollment, such as Social Security numbers and addresses of board members, copies of provider driver’s licenses, etc. Many providers are understandably hesitant to provide these items. This is just one of the many challenges you will have to face to get your practice or your organization ready for participation in out-of-state Medicaid programs.
You’ll also need these to succeed:
- A well-designed system to manage initial enrollment and maintain provider numbers and associated credentialing
- A communication technique that helps the individuals involved understand why the enrollment process is critical. (In many cases, board members and physicians are more comfortable providing sensitive information to a trusted third party.)
- Updated provider numbers that are maintained with the states to reduce provider-related claim denials
- Complex claims expertise, data-driven analytics, managed care, and proprietary technology to achieve optimal results
Medicaid Enrollment Made Simple
Successful execution and measurable results from out-of-state Medicaid billing hinge on challenges surrounding state registration/enrollment and ever-changing regulatory nuances. When you make EnableComp your trusted partner, you can break through roadblocks and stay well-informed of continuous state-by-state changes. We operate as an extension of your business office by bringing our detailed and extensive knowledge of the regulations and requirements of 50 different state Medicaid programs.
We understand the challenges you face when attempting to enroll providers and how difficult it is to maintain that enrollment. We are experts at providing out-of-state Medicaid enrollment, billing, and collection services. Our process is designed to make it simple for you and your team, so you can keep your resources focused on other priorities.
