UPDATED GUIDANCE: September 1st Deadline Approaching to Enroll in NYS Medicaid Program and Obtain Required MMIS
8/31/2022
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Posted by Provider Relations
The New York State (NYS) Medicaid program requires enrollment of licensed providers who serve Medicaid members, including prescribing practitioners identified on pharmacy claims per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. All Fidelis Care Medicaid Managed Care (MMC) network furnishing, ordering, prescribing, referring and attending (OPRA) providers must be enrolled with NYS Medicaid program by August 31, 2022.
Under the Medicaid Provider Enrollment Compendium (MPEC), there are two exceptions to the provider enrollment requirement:
Interns, Residents and Foreign Physicians in Training - Unlicensed Physicians
In accordance with NYS Education Law (NYSED), Article 131 §6526, unlicensed physicians who are residents, interns, and foreign physicians participating in training programs, are authorized to prescribe. NYS Medicaid recognizes the authority under which these unlicensed providers may prescribe; however, these physicians are not eligible for enrollment into the NYS Medicaid program without a license.
Out-of-State Licensed Prescribers
Under federal regulations, all ordering or referring physicians (ORPs), or other professionals, must be enrolled in the NYS Medicaid program. However, the MPEC allows for payment of prescription claims prescribed by out-of-state (OOS) licensed physicians or ORPs under limited circumstances. Please note: Federal regulations and NYS Medicaid policy require NYS Medicaid program enrollment for prescribers who do not meet the exceptions below, in order for their claims to be valid and enforceable against the NYS Medicaid program.
For further information, including billing and documentation guidance for the provider types listed above, please read The New York State Medicaid Update, Volume 38, Number 7.
Effective September 1, 2022, Fidelis Care will deny payment to unenrolled pharmacies, other unenrolled practitioners, and providers for services provided and/or prescribed.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist, or connect with our Call Center at 1-888-FIDELIS (1-888-343-3547).