Enrollment Application

Thursday, December 11, 2025

Skip to Provider Enrollment Subsystem Menu

(click to hide) Alert Message posted 12/8/2025

Group Enrollment

Group Enrollment is now open!

Go to the Provider Enrollment Application under the Provider Enrollment menu option
Select the Group/Billing Application Type
Enter your group information, including affiliating your rendering providers
Enter your existing Payee Medicaid ID on the Payee panel

The deadline to enroll groups has been extended until late spring 2026. More training on Group Enrollment to come in early 2026.

Save Yourself Some Paperwork

If you have an existing payee, be sure to enter your existing payee’s Medicaid ID on the Payee panel.

This will save you from having to upload extra documentation when you submit your application.

You can find the existing payee’s Medicaid ID on your remittance advice on the top right corner listed as the PAYEE ID.

»	User Information



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»	Instructions

Welcome to the online Provider Enrollment application.

The enrollment application is a one source application for both fee-for-service Medicaid and CMO (Care Management Organization) enrollment.
You must complete each step in the Enrollment application. When you have completed all of the steps, including uploading all required supporting documentation, please click on the 'Submit' button to submit your application. The application is automatically saved after each step.
Fields marked with an asterisk (*) are required.
Please click the 'New Application' to start a new Provider Enrollment application or click 'Continue Application' to continue with an existing application.
Application Fee Information
42 CFR 455.460 requires that certain prospective (new), re-enrolling, or revalidating providers pay an application fee. Individual physicians or non-physician practitioners are exempt from the fee as well as those providers who have already paid the fee to a Medicare contractor or another State's Medicaid program. Section 105.3, Part I Policies and Procedures for Medicaid/Peachcare for Kids®, identifies the categories of service that are required to pay the application fee. Within thirty (30) days from the date of submission of an application, the Division may reject an enrollment application from a prospective (new) or re-enrolling individual or institutional provider that is not accompanied by the application fee or a letter requesting a hardship exception or waiver of the application fee.
Help is available by clicking the question mark (?) in the title bar.

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