Search   Monday, June 14, 2021 Skip to Provider Enrollment Subsystem Menu Home Publication Search Site Map Site Settings Language Selection |  Contact Information Contact Us Phone Numbers & Links |  Member Information Member Notices Find a Provider FAQ for Members Register for Secure Access |  Provider Information Provider Notices Provider Manuals Provider Messages Fee Schedules Forms for Providers Reports for Public Access FAQ for Providers Web Portal Training Provider Education |  Provider Enrollment Enrollment Application Status Enrollment Wizard Provider Contract Status EFT Agreement Enrollment Forms |  Nurse Aide/Medication Aide |  EDI Submitter Information Companion Guides Vendor List Registration Forms Software and Manuals FAQ for EDI |  Pharmacy Pharmacy Notices Pricing List Medicare Updates Other Documents Prior Approval Process |  HFRD HFRD Application Status HFRD Application Home Enrollment Application Status Enrollment Wizard Provider Contract Status EFT Agreement Enrollment Forms » User Information    Login/Manage Account Login/Manage Account Login Instructions>Search>Request Type>Provider>Contract>Specialty>Physician Specialty>ASL>Detail>Address>Bed>Pharmacy>Medicaid>Language>Special Need>Admit Privileges>License>Permit>Certification>Owner>Addtl Owner>Addtl Address>Fingerprint>Employee>Subcontractor>Rate>Sponsoring>Supervising>Payee>Hours>Access>Education>Training>Work>Insurance>Programs>Waiver>History>History CVO>Facility History>Doco>Autism Attest>ROI>SOP>Policy Attest>Attestation> » 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.    exit new application continue application    English | Español | Accessibility | Privacy | AMA & ADA Copyright © Copyright 2021 Gainwell Technologies