New York Medicaid: eMedNY

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. Security Packet B

3. Billing Agency ETIN Application (Billing Services Only) 

4. Trading Partner Agreement

5. 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 choose your line of business, then choose 1 then 4.

 

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.

 

Provider Electronic Transmitter Identification Number (ETIN) Application

  • Please enter Provider Name and Address

  • Please the name of the Administrator in your office

  • Enter the Main Contact Person’s Name and Phone

  • Enter the Provider’s NPI

  • Enter Your Medicaid Provider number

  • Print Name and Title, Sign and Date

Page 3:

  • New applicant’s please leave the ETIN field blank

  • If using a Billing Service, Enter Billing Service’s Name

  • Enter the date

  • Please enter the Provider’s name

  • Please enter the NPI number

  • Please enter the Medicaid Provider Number if applicable

  • Sign

  • Date

  • Print Name and Title

  • Phone

  • Email

  • 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 to request a “FTP Logon User ID and Password”***

 

Security Packet B

Page 2

  • Please enter your NPI/Medicaid Provider Number

  • Please print your Name and Sign

  • Enter the Provider or Billing Service Name

  • Please enter the Adress, your Title, and todays Date

Page 5

  • Please fill out Section 1, User information box, with your information

    • Name, Title, Address, Phone, Provider ID, and check the Box for Medical Provider

  • Pleast check the box for FTP Batch Submission in Section 2

  • Please enter the Requestor information in Section 3 (Entity requesting the Submitter ID, which will either be the Provider or 3rd Party Billing Service)

  • Please skip Sections 4 and 5

Page 7

  • You must assign a Unique Identifier which will be used to identify you when calling them

    • Please make sure this is something only you will know and you keep it for your records

  • Please enter your Unique Identifier

  • Please enter your NPI/Medicaid Provider Number

  • Please print and sign your name

  • Enter your demographic information please

  • Please enter your title and today's date

 

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)

Section A:

  • Enter your ETIN (Submitter ID)

  • Check either “Group” or “Individual” then enter the NPI

  • Enter your Medicaid Provider Number

  • Enter the Provider/Organization Name

  • Fill in your demographic information

  • Enter the Name, Phone, Email, and Fax for the main Contact person in your office

Section B:

  • Check the Box for FTP and enter the FTP User ID # you were assigned

Section C:

  • Skip this section

Section D:

  • 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 5.

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 ClaimShuttle Support Team and set an appointment for a Mailbox setup. ( No Test Transmission is required for EMedNY.)