Federal and state laws require all Medicaid Managed Care (MMC) network furnishing (pharmacy), ordering, prescribing, referring and/or attending (OPRA) providers to be enrolled with the New York State (NYS) Medicaid program. For more information, see the January 2018 issue of the Medicaid Update article titled Medicaid Managed Care and Children's Health Insurance Program Network Providers Must Enroll in the New York State Medicaid Program.
Beginning, Sept. 1, 2022, EmblemHealth will deny claims from non-enrolled providers. You must be enrolled either as a fee-for-service (FFS) billing provider or as an OPRA provider to continue receiving payment for services provided to EmblemHealth Medicaid members.
Enrollment of Physicians, Nurse Practitioners, Physician Assistants, Podiatrists, Dentists, Optometrists, Audiologists, and Certified Nurse Midwives
- Providers and practitioners who wish to receive payment for covered NYS Medicaid services should apply as an “Individual Billing Medicaid.” Information regarding how to enroll is available on the eMedNY “Provider Enrollment & Maintenance” web page.
- Providers who only wish to enroll as a non-billing provider may alternatively enroll as an OPRA provider on the eMedNY “Provider Enrollment & Maintenance” web page.
- Exceptions to the prescriber enrollment requirements for certain authorized prescribers are outlined in the March 2021 issue of the Medicaid Update article titled Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers.
Pharmacy Enrollment
Beginning Sept. 1, 2022, EmblemHealth will deny payment to pharmacies that are not enrolled as an FFS billing provider. Pharmacies are furnishing providers that must enroll in the NYS Medicaid program to continue receiving payment. Information on how to enroll is available on the eMedNY “Pharmacy Provider Enrollment” web page.
Criteria for NYS Medicaid Enrollment
Not all practitioner and pharmacy providers will meet criteria to qualify for enrollment. Providers can review the provider manuals available on the eMedNY “Provider Manuals” web page and on the eMedNY “Provider Enrollment & Maintenance” web page by selecting the appropriate provider type from the right-hand box titled “Provider List Filter.”
How to Check Provider Enrollment Status
Providers can check their enrollment status by using the tools available on the NYS Department of Health (DOH) “Medicaid Enrolled Provider Lookup” web page. Search by entering your Medicaid Provider ID or your National Provider Identifier (NPI). Use the table below to determine your current enrollment status and the corresponding action necessary as required from the “Medicaid Type” provided in the search result. Providers who have submitted enrollment applications may check the status of their application in the Medicaid Pending Provider Listing file, updated weekly on the eMedNY “Medicaid Managed Care Network Provider Enrollment” web page.
| Provider Type | "Medicaid Type" | Enrollment Status | Action Required |
|---|---|---|---|
| Pharmacy | FFS | Enrolled (qualified billing provider) | No action* |
| MMC | Not enrolled (MMC credentialed as a non-billing provider) | Enroll with Medicaid as a billing provider* | |
| No result | Not enrolled | Enroll with Medicaid as a billing provider* | |
| Practitioner/Prescriber | FFS | Enrolled (qualified billing provider) | No action** |
| MMC | Not enrolled (MMC credentialed as a non-billing provider) | Enroll with Medicaid as a billing or an OPRA provider** | |
| OPRA | Enrolled (qualified non-billing provider) | No action | |
| No result | Not enrolled | Enroll with Medicaid as billing provider** or if eligible as an OPRA provider |
*Pharmacy providers not enrolled in Medicare must enroll in Medicare as a participating provider.
**Some billing practitioners do not require Medicare enrollment. See enrollment index for your profession for more information.
Questions and Additional Information
- FFS coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at 518-486-3209or by email at PPNO@health.ny.gov.
- Enrollment questions may be directed to the Medicaid Enrollment Unit by telephone at 800-343-9000 or by email providerenrollment@health.ny.gov.
- MMC plan contact information can be found on the NYS DOH “New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center” homepage.
- For EmblemHealth network-related questions, sign in to emblemhealth.com/providers and use our Message Center to send us your inquiry.
JP 56547 6/2022