Payer List

Please follow the Enrollment Instructions below to become an electronic submitter for New York Medicaid.

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the EMedNY office prior to initiation of electronic claims submission or inquiry.

Note: You may be required to use Internet Explorer to open the links listed below.

1. Provider ETIN Application

2. Billing Agency ETIN Application (for Billing Services)

3. Trading Partner Agreement

4. Electronic or PDF Remittance Advice Request Form

(If you would rather fill out the Electronic Remittance Advice Form online, you can do so within the Provider Portal)

If the links listed above do not work properly, please download these forms from:
www.emedny.org
 

If you have any questions regarding any of the documents in this package, please phone the EMedNY EDI Technology Support Center at 1-800-343-9000 option 2.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Provider Electronic Transmitter Identification Number (ETIN) Application

1. Please Provider's Name and Address
2. Please the name of the Administrator in your office
3. Please enter the Main Contact Person’s Name and Phone
4. Enter the Provider’s NPI
5. Enter Your Medicaid Provider number
6. Print Name and Title, Sign and Date

Page 3:

1. New applicant’s please leave the ETIN field blank
2. If using a Billing Service, Enter Billing Service’s Name
3. Enter the date
4. Please enter the Provider’s name
5. Please enter the NPI number
6. Please enter the Medicaid Provider Number if applicable
7. Sign
8. Date
9. Print Name and Title
10. Phone
11. Email
12. This form must be Notarized, this section is for the notary public to fill out

Mail the Original completed application to:

Computer Sciences Corporation
ATTN: Enrollment Support
PO Box 4614
Rensselaer, NY 12144-8614

***Upon receipt of Submitter ID, Please call NY Medicaid at 1-800-343-9000 option 2 to request a “FTP Logon User ID and Password”***

Billing Agency ETIN Application

Page 2:

• Enter your Billing Agency's Name, Addres, Phone and Fax numbers
• Enter the Adminstrator and Contact information
• Sign and Date

Page 3:

• If you are using this form to obtain an ETIN, leave blank. If you wish to add a provider ID number to an existing ETIN, indicate the ETIN in the top left corner of the form
• Enter the name of the Billing Service
• Enter the Date
• Enter Provider Name, NPI, and Medicaid Provider ID number
• Provider must sign and date this form and enter their contact information
• This must be signed by a Notary Public

Trading Partner Agreement

Page 4

• Please enter the Provider/Business or Billing Service Name as the "Trading Partner"
• Please enter your name, title, and sign

(Please Note: Please include all pages when submitting this form)

ERA Request Form

(Please fill out this form after receiving your Submitter ID, FTP Logon User ID and Password)

 

• Enter your Provider Name
• Enter your Tax ID or EIN
• Enter the NPI
• Enter your Medicaid Provider Number if NPI exempt
• Enter your Trading Partner ID (ETIN)
• Enter the Name, Phone, Email, and Fax for the main Contact person in your office
• Check the box for 835
• Check the box for FTP
• Enter your FTP user ID # you were assigned
• Check the box for New Enrollment
• Sign, Date, Print Name and Title

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:

Mail the Original completed Documents to:

Computer Sciences Corporation
ATTN: Enrollment Support
PO Box 4614 Rensselaer, NY 12144-8614

Fax the ERA Request Form to: 518-257-4632

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the EMedNY EDI Technology Support Center at 1-800-343-9000 option 2.

Please be advised, ERA Request forms are processed Every Thursday at EMedNY.

Testing

Once you have received your Submitter ID and password from EMedNY, please call the SolAce Support Team and set an appointment for a Mailbox setup. ( No Test Transmission is required for EMedNY.)