Instructions To Complete Enrollment Form For Transportation printable pdf download

INSTRUCTIONS FOR COMPLETING THE NY MEDICAID ENROLLMENT FORM FOR

TRANSPORTATION

1. General Instructions:

•

Complete ALL items on the form unless otherwise instructed below. Failure to complete all required fields will result in your enrollment form being

returned to you which may have an impact on the enrollment effective date.

•

Required document (see #3 below) MUST cover the application date and be continuous through the current date.

•

Completion of signature field is required and must be original. Initials or rubber stamped signatures will not be accepted.

•

Type or legibly print in black or blue ink. Do not use red ink, nor white-out. All attachments will be scanned so they must be legible and on standard 8 ½ x

11 paper in good condition.

•

Keep a copy of all documents submitted.

2. Additional Instructions and Definitions for Form Completion:

Category(s) of Service:

0602

- Ambulette/Invalid Coach

Enter the following 4-digit code on the Enrollment Form:

0603

- Taxi (Upstate Taxi only)

0605

– Livery (NYC Taxi only)

0606

- OPWDD

Choose ONE and check the corresponding box on the Enrollment Form:



Check New Enrollment if the NPI or Provider listed is not currently enrolled in NYS Medicaid

 Check Revalidation if the NPI or Provider is currently enrolled and you were notified that Revalidation is required

per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received

 Check Reinstatement/Reactivation if the provider was previously enrolled but is not currently active.

Please note: You will be at financial risk if you render services to Medicaid beneficiaries before

successfully completing the enrollment process.

NPI:

Leave Blank

DBA Name:

If appropriate

DEA Number & Dates:

Leave Blank

Association Types:

Enter the letter (B, F, H, M, P or U) which best corresponds to the individual’s role:

B: Board of Directors Member

F: Facility Administrator

H: Compliance Officer

M: Managing Employee

P: Supervising Pharmacist

U: Laboratory Director

3. ADDITIONAL REQUIREMENTS

OMIG Provider Compliance Certification –

Confirmation notice for the OMIG Provider Compliance Program may be required. Visit

to determine if the Applicant / Provider must comply. If yes, a copy of the confirmation notice (printed from the website)

must be included with this application.

42 CFR, Part 455.460

requires the collection of an application fee for a new enrollment, revalidation, change of ownership and

reinstatement/reactivation. Click

here

for more information.

REQUIRED DOCUMENTS TO BE SUBMITTED WITH THIS FORM:



IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form (W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4)

can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933.



Copy of Your Certificate(s), Registration(s), Permit(s), License(s) as determined by the attached chart



Transportation Information Request Form (EMEDNY-424601)



If located outside of NYS, include a copy of your participation letter with your State’s Medicaid Program



Application Fee



ETIN Certification Statement for New Enrollments Form (EMEDNY-490602) (not required for revalidation or

reinstatement/reactivation)



Electronic Funds Transfer (EFT) Authorization Form (EMEDNY-701101) (not required for revalidation if EFT is already in place and no change is requested).



Signed Attestation for Non-Medical Transportation Providers (see page 4 of these instructions)

EMEDNY-424402 (03/17)