Medicaid Provider Enrollment for Individual Practitioners and Designated Agencies

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March 8, 2019

Subject: Medicaid Provider Enrollment for Individual Practitioners and Designated Agencies

To: Children and Family Treatment and Support Service (CFTSS) and Home and Community Based Services (HCBS) Providers

Purpose: This memo is to provide clarification regarding Medicaid provider enrollment requirements for designated provider agencies of CFTSS and HCBS.

Required: Medicaid Enrollment as a Provider Agency

Consistent with previous guidance and the State-issued designation letters, all designated agencies must be enrolled as a Medicaid provider agency to bill and be reimbursed for services. Agencies who were previously enrolled as Medicaid provider agencies prior to being designated for CFTSS and HCBS do not need to re-enroll. The State will add the appropriate Category of Service code (0268) to the agency file to allow for billing of designated services. Designated provider agencies who have not yet enrolled with Medicaid should apply under the "Children´s Health and Behavioral Health Transformation” and can access the paper forms electronically here.

Required: Medicaid Enrollment as an Individual Practitioner

The 21st Century Cures Act (Act), Section 5005(b)(2), now requires individual practitioners, who are an enrollable type and are providing services to children, to enroll in Medicaid and receive a Medicaid Management Information Systems (MMIS) Provider ID regardless of whether the practitioner is billing as an individual or as an agency. This means individual practitioners providing services through designated CFTSS or HCBS agencies must enroll as a Medicaid practitioner in the eMedNY system if they are an enrollable practitioner type.

Note: CFTSS and HCBS will NOT be billed by the individual practitioner, as these services must be billed through the designated agency. Individual practitioners who do not bill Medicaid directly should enroll as an Ordering, Prescribing, Referring, or Attending (OPRA) non-billing practitioner.

These individual practitioner types are enrollable types (see provider index link below):

  • Licensed Clinical Social Workers (LCSW)
  • Clinical Psychologists

Licensed Mental Health Counselors, Licensed Marriage and Family Therapists, Licensed Master Social Workers, Credentialed Alcohol and Substance Abuse Counsellors (CASAC), Peers, and Applied Behavioral Analysts are not enrollable types and cannot enroll in Medicaid or obtain a MMIS Provider ID as an individual practitioner. As noted above, the designated agency needs to enroll.

Required: National Provider Identification (NPI) Numbers

In addition to the MMIS Provider ID, providers who meet the definition of a Health Care Provider and conduct health care transactions under HIPPA in electronic form will need an NPI number. The NPI number is a 10-digit number that is required by MCOs for financial transactions and is necessary to obtain a Medicaid ID number. NPI numbers must be associated with the Medicaid Provider ID. Agencies and practitioners who have yet to apply for an NPI number can request an NPI electronically here.

Agencies:
All agencies submitting claims to NYS Medicaid and Medicaid Managed Care for Children and Family Treatment and Support Services (CFTSS) and Children´s Home and Community Based Services (HCBS) will need to obtain a NPI number. This must be obtained prior to applying for a MMIS Provider ID. A Healthcare Provider Taxonomy Code is required when applying for an NPI number. Agencies should choose the Taxonomy Code that most closely describes the agency´s type/classification/specialization. Examples are: Community/Behavioral Health - 251S00000X and Foster Care Agency - 253J00000X. Additional information and codes can be found here.

Individual Practitioners:
Any licensed individual practitioner who is required to obtain a MMIS Provider ID is also required to obtain a NPI number in order to become a Medicaid enrolled practitioner. This must be obtained prior to applying for a Medicaid ID number. A Healthcare Provider Taxonomy Code is required when applying for an NPI number. Individual practitioners should choose the Taxonomy Code for a licensed individual if you are licensed or for a non-licensed individual if you are not. Examples are: Social Worker-104100000X and Peer Specialist - 175T00000X. Additional information and codes can be found here.

Reporting NPI numbers on claim forms:
Individual practitioner NPI numbers are required on the claim form in the Attending Provider field. The NPI number of the individual practitioner who is providing the service should be included if they have an NPI number. If the individual practitioner does not have an NPI number, the OMH (02249154), OASAS (02249145), or OCFS (05448682) unlicensed practitioner ID may be used. If the individual practitioner is providing services at an agency that is licensed or certified by more than one agency above, it does not matter which of the unlicensed practitioner IDs are used.

In the Referring Practitioner field for CFTSS, the NPI number of the Licensed Practitioner of the Healing Arts (LPHA) who made the recommendation should be used. If the LPHA is a practitioner type that cannot be enrolled in Medicaid, the NPI number of the agency should be used.

In the Referring Practitioner field for Children´s HCBS, the NPI number of the agency should be used. Please refer to the MCTAC billing tool for more information on these required fields.

Additional information on billing CFTSS and HCBS can be found here.

Medicaid Managed Care Plans

The State is working with MCOs to ensure their participating providers are enrolled in Medicaid, as required by the Act. As such, the State has directed MCOs at this time to pend any provider terminations resulting from the provider´s failure to enroll in Medicaid. MCOs will engage with providers regarding compliance with the Act, specifically on providing contract amendments to enrollable providers; monitoring enrollment and compliance; identifying and reaching out to providers who have yet to apply for a MMIS Provider ID; and ensuring that non-enrollable provider types are appropriately withheld from this requirement.

Additional Resources