New York Medicaid Provider Enrollment: eMedNY, Managed Care Plans and What to Expect

Layer one: enrolling with the state

Enrollment in New York State Medicaid is handled by eMedNY on behalf of the Department of Health. The application depends on your provider or practitioner type, and the eMedNY website publishes a specific enrollment packet for each. You will need the NPI (Type 1 for practitioners, Type 2 for groups and facilities), the state license, the practice address, ownership and control disclosures for groups, and a signed certification statement. Groups enroll the entity and then affiliate each practitioner with it.

Once enrolled you receive a Medicaid provider ID (MMIS ID) and can bill fee-for-service claims for members who are not in a managed care plan, such as certain carve-out services and members during the enrollment transition.

Layer two: Medicaid managed care plans

The majority of New York Medicaid members are enrolled in a managed care organization, and each plan credentials and contracts with providers separately. In New York City and surrounding counties, the plans a practice typically needs include Healthfirst, Fidelis Care, MetroPlusHealth, EmblemHealth’s Medicaid products, UnitedHealthcare Community Plan, Anthem (formerly Empire) BlueCross BlueShield HealthPlus, Molina and MVP Health Care, with the exact list depending on the county. Plans generally require you to be enrolled with the state first, then run their own credentialing (many through CAQH) and issue a participation agreement.

Being enrolled with eMedNY but not credentialed with the member’s plan means the claim denies. Being credentialed with the plan but not enrolled with the state means the plan cannot contract with you. You need both.

Who must enroll even without billing

Under federal rules New York requires ordering, prescribing, referring and attending (OPRA) providers to be enrolled in Medicaid. A claim for a prescription, a lab test or a referred service can deny if the ordering provider is not enrolled, so groups usually enroll every clinician, including those who do not bill Medicaid directly.

Specialty programs with their own rules

Several New York services carry additional designations beyond basic enrollment: behavioral health services under OMH and OASAS licenses, home and community-based services, Certified Home Health Agencies and Licensed Home Care Services Agencies, Adult Day Health Care, and Article 28 clinics. Each has its own licensure or certification prerequisite, and managed care plans ask for it during credentialing. If you are a home health agency or a behavioral health practice, confirm the program-level requirements before the plan applications go in.

Timelines

State enrollment and plan credentialing run in parallel once the state application is submitted, but plans usually will not complete credentialing without the Medicaid ID. Treat the full process as a quarter, longer for providers who need program-specific approvals.

Revalidation and maintenance

New York requires Medicaid providers to revalidate periodically, and plans re-credential on their own cycle (commonly every three years). Address, ownership and license changes must be reported to eMedNY and to each plan. A provider who moves and updates only the state record will find plan directories, and plan claims, pointing to the old address.

Common reasons applications come back

• Practice address on the application does not match the NPI record.
• Ownership disclosure incomplete for a group with more than one owner.
• Practitioner not yet affiliated with the group in eMedNY when the plan application is submitted.
• Missing program-specific license (OMH, OASAS, DOH) for the service type.
• Signed forms with a date that is now too old to be accepted.

Core MB is based in Brooklyn and enrolls New York providers with Medicaid and its managed care plans every week, alongside Medicare and the commercial payers. See credentialing and enrollment, or ask us about a specific plan.