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New York Medicaid Program Application (Pharmacy Packet) 4090 - New York
| New York Medicaid Program Application (Pharmacy Packet) Form. This is a New York form and can be used in Department Of Health (EMEDNY) Statewide . |
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Dear Applicant: Thank you for your interest in enrolling in the New York State Medicaid Program. Participation in the New York State Medicaid Program is an important undertaking. Therefore, we want to make you aware of the following factors concerning your potential enrollment as a provider: x x x x An enrollment application does not guarantee enrollment in the Medicaid Program. At this time the Department does not enroll mail order pharmacies. Mail order pharmacies are defined as pharmacies which provide more than 15% mail order pharmacy services. If your application is approved, the effective date of your enrollment will be specified by the Department. You will be at financial risk if you render services to Medicaid patients before successfully completing the enrollment process. Payment will not be made for any claims submitted for service, care or supplies furnished before the enrollment date authorized by the Department. Services rendered to Medicaid beneficiaries at your service address may not be billed through any other provider number. If you provide services at your service location that are subsequently billed through another provider number, including a provider number issued to another location under the same ownership, your application will be denied and action will be taken against the billing provider. All of the information reported by you on the application will be verified by the Department before your acceptance into the Medicaid Program. Enrollments for New York City, Nassau, Rockland, Suffolk and Westchester Counties, out of state, ownership changes, previous terminations and sanctions are subject to further review. Subsequent requests for information concerning your application must receive a response within the time frames specified by the Department or your application is subject to termination. Enrollment may be denied for failure to accurately or completely disclose information during the application process and for any other factors the Department determines to be applicable. x x x x x American LegalNet, Inc. www.FormsWorkFlow.com x All enrolled pharmacies MUST participate in the mandatory Prospective Drug Utilization Program (ProDUR) to receive reimbursement. This important ProDUR information and certification requirements (separate from the enrollment requirement) can be accessed online at www.eMedNY.or g. Click on Provider Manuals and select the Pharmacy Manual. The ProDur/ECCA Provider Manual is contained in the Pharmacy Manual. First you will receive an inactive prereview letter advising you to use your National Provider Identifier (NPI)/Medicaid Provider #. Please note this letter does not constitute approval in the Medicaid Program. Until you are approved, your NPI/Medicaid Provider # may be used SOLELY to allow testing of your software so that you can comply with the mandatory on-line ProDUR. New York State Medicaid Regulations allow the Department 90 calendar days after receipt of a complete application to determine whether to enroll an applicant in the program. As a Medicaid provider you agree to comply with the rules, regulations and official directives of the Department, including but not limited to Part 504 of 18 NYCRR which can be found at the Department of Health's website, www.health.state.ny.us. In addition, pursuant to 42 CFR §455.105, by enrolling in the Medicaid Program, you are entering into an agreement with the NYS Department of Health by which you agree to and may be requested to provide the following information within 35 days upon request by the Department or the Secretary of Health and Human Services. 1. The ownership of any subcontractor with whom you have had business transactions totaling more than $25,000 during the 12 month period ending on the date of the request; and 2. Any significant business transactions between you and any wholly owned supplier, or between you and any subcontractor, during the 5 year period ending on the date of the request. If you have any questions, please contact the eMedNY Call Center at 1-800-343-9000. Sincerely, Bureau of Provider Enrollment Fee for Service Operations Group Division of OHIP Operations Pharmacy EMEDNY-409101 (10/11) American LegalNet, Inc. www.FormsWorkFlow.com MEDICAID PROVIDER ENROLLMENT PHARMACY/SUPERVISING PHARMACIST FORM CHECKLIST THE FOLLOWING INFORMATION MUST BE PROVIDED TO PROCESS YOUR ENROLLMENT APPLICATION. FAILURE TO SUBMIT REQUIRED INFORMATION MAY RESULT IN YOUR APPLICATION BEING RETURNED TO YOU AND WILL DELAY THE ENROLLMENT PROCESS. REQUIRED FIELDS TO BE COMPLETED ON THE ENROLLMENT FORM CATEGORY OF SERVICE (COS) APPLICATION TYPE APPLICANT NAME NATIONAL PROVIDER IDENTIFIER (NPI) FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) CORRESPONDENCE ADDRESS *IF REINSTATEMENT IS CHECKED PLEASE SEE REQUIRED DOCUMENTATION ON PAGE 2 OF 2 OF THIS CHECKLIST. **IF YES ANSWERED TO ANY OF THE FOUR QUESTIONS, YOU MUST COMPLETE THE "PRIOR CONDUCT QUESTIONNAIRE" AVAILABLE ON THE WWW.EMEDNY.ORG WEBSITE. YOU ARE REQUIRED TO PROVIDE DOCUMENTATION AND/OR DETAILS EXPLAINING THE CIRCUMSTANCES. REQUIRED DOCUMENTATION TO BE SUBMITTED MEDICAID PROVIDER ENROLLMENT: PHARMACY FORM COPY OF CURRENT LICENSE/REGISTRATION DISCLOSURE OF OWNERSHIP AND CONTROL BUSINESS ENTITY FORM PHARMACY INFORMATION REQUEST FORM BALANCE SHEET WITH SPECIFIC LINE ITEM ASSET INFORMATION HOSPITAL, NURSING HOME, CLINIC BASED PHARMACY QUESTIONNAIRE COPY OF DEPARTMENT OF TREASURY, INTERNAL REVENUE SERVICE LETTER ASSIGNING YOUR FEIN COPY OF THE LEASE COPY OF YOUR DEA CERTIFICATE IF YOU ARE DISPENSING CONTROLLED SUBSTANCES COPY OF MEDICARE AWARD LETTER PERSONAL IDENTIFICATION NUMBER (PIN) REQUEST FORM SUBMIT THE OFFICE OF MEDICAID INSPECTOR GENERAL (OMIG) PROVIDER COMPLIANCE CONFIRMATION (IF APPLICABLE). FOR MORE INFORMATION, GO TO THE OMIG WEBSITE, COMPLIANCE SECTION AT WWW.OMIG.NY.GOV. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com PAY TO ADDRESS SERVICE ADDRESS ALL YES/NO QUESTIONS MUST BE ANSWERED** DEA NUMBER IF DISPENSING CONTROLLED SUBSTANCES OWNER'S SIGNATURE EMEDNY-409202 (11/10) AFTER THE PROVIDER IS ENROLLED AND RECEIVES A PROVIDER ID, AN ELECTRONIC/PAPER TRANSMITTER IDENTIFICATION NUMBER APPLICATION AND A CERTIFICATION STATEMENT (LOCATED AT WWW.EMEDNY.ORG) MUST BE SUBMITTED FOR ELECTRONIC SUBMISSIONS. SUPERVISING PHARMACIST IF NOT CURRENTLY ENROLLED MEDICAID PROVIDER ENROLLMENT: SUPERVISING PHARMACIST FORM (EMEDNY4098) SUPERVISING PHARMACIST AGREEMENT FORM (EMEDNY-4099) COPY OF SUPERVISING PHARMACIST'S
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