For Enrolling As A Medicaid Provider
The Medicaid program administered by the South Carolina Department of Health and Human Services (SCDHHS) is a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191.
Provider participation in the Medicaid program is voluntary; however, all rendering providers must be enrolled in the Medicaid program to receive reimbursement. To participate in the Medicaid program, a provider must meet strict requirements, including screening, licensure verification and site visits (if applicable), to ensure that all enrolling providers are in good standing and meet the standards for providing services to Medicaid beneficiaries.
- Obtain a National Provider Identification Number (NPI)
- Determine Enrollment and Provider Type
- Pay the $532 Application Fee
- Complete the Online Application
- Go Through The Screening Process
- Contact Managed Care Organizations Directly to Join Their Provider Network
STEP 1: OBTAIN A NATIONAL PROVIDER IDENTIFICATION NUMBER (NPI)
To obtain an NPI, please visit: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions
For general information and questions about the NPI, visit: https://nppes.cms.hhs.gov or contact:
Toll-free: (800) 465-3203
TTY: (800) 692-2326
E-mail: [email protected]
Mail: NPI Enumerator, P.O. Box 6059, Fargo, ND 58108-6059
If applying as an individual/sole proprietor, you should have the following information handy:
- Provider name
- SSN (or ITNI if not eligible for SSN)
- Provider date of birth
- Country of birth
- State of birth (if country of birth is U.S.)
- Provider gender
- Mailing address
- Practice location address and phone number
- State license information
- Contract person name, phone number and e-mail address
If applying as an organization:
- Organization Name
- Employer Identification Number (EIN)
- Name of authorized official for the organization
- Phone number of authorized official for the organization
- Organization mailing address
- Practice location address and phone number
- Contract person name, phone number and e-mail address
Enrolled providers are prohibited from allowing non-enrolled providers’ use of their NPI number in order for nonparticipating providers to be reimbursed for services. Claims for Medicaid reimbursement submitted under a NPI number other than that of the ordering, referring or rendering provider will be considered invalid and may result in a program integrity investigation and/or recoupment of the Medicaid payment. As required by 42 CFR 455.440, all claims submitted for payment for items and services that were ordered or referred must contain the NPI of the physician or other professional who ordered or referred such items or services.
A provider must immediately report any change in enrollment or contractual information (e.g., mailing or payment address, physical location, telephone number, specialty information, change in group affiliation, ownership, etc.) to SCDHHS Provider Service Center within 30 days of the change. Failure to report this change of information promptly could result in delay of payment and/or termination of enrollment. Submit updated changes via FAX: (803) 870-9022 or mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809
STEP 2: DETERMINE ENROLLMENT TYPE
To complete the appropriate application, it is critical to identify what type of application is being requested.
Enrollment types include:
Individual Provider is a person who provides health services to Medicaid beneficiaries. An individual may bill independently for services or may have an affiliation with an organization. Individuals enrolling in SCDHHS’ Medicaid program are required to submit their Social Security Number (SSN) and NPI upon enrollment.
Individual/Sole Proprietor Provider is a person who provides health services to Medicaid beneficiaries. An individual may bill independently for services or may have an affiliation with an organization. Individual/Sole Proprietors enrolling in SCDHHS’ Medicaid program are required to submit their Social Security Number (SSN), Employer Identification Number (EIN) and NPI upon enrollment.
Atypical Individual Provider is a person who provides non-health related services to Medicaid beneficiaries. An atypical individual provider may bill independently for services or may have an affiliation with an organization. Atypical Individuals enrolling in SCDHHS’ Medicaid program are required to submit their Social Security Number (SSN). Note: This person may or may not be eligible for an NPI and NPI is not required.
Organizations are any entities, agencies, facilities, institutions, clinics or group of providers that provide health services to Medicaid beneficiaries. An organization may bill independently for services performed or may be an affiliation of individual providers. Organizations enrolling in SCDHHS’ Medicaid program are required to submit their EIN and NPI.
Atypical Organizations are any entities, agencies, facilities, institutions, clinics or group of providers that provide non-health related services to Medicaid beneficiaries. An organization may bill independently for services performed or may be an affiliation of individual providers. Organizations enrolling in SCDHHS’ Medicaid program are required to submit their EIN and may or may not be eligible for an NPI and NPI is not required.
Note: During the online enrollment process, organizations cannot affiliate individuals to their group. It is the responsibility of the individual provider to affiliate with a group. An affiliation cannot occur until the organization is enrolled.
Ordering/Referring Providers order services and/or refer Medicaid beneficiaries for services. Ordering/Referring only providers do not submit claims to SCDHHS for payment. However, the rendering provider will be required to include the ordering/referring NPI on all claims.
Add a Location is for entities, agencies, facilities, institutions, clinics or group of providers enrolled with a unique combination of an EIN and NPI and need to add a location to a previously existing enrollment. The location being added must operate under the same EIN/NPI as the previously enrolled location. When the EIN/NPI is not the same as the previously enrolled location, the provider must complete a new enrollment for that location.
STEP 3: PAY THE APPLICATION FEE
Fee per application: $532
Application fee can be paid at https://ssl.sc.gov/Checkout/DHHS/
This fee is required for every enrollment application submitted, including adding a new location to an existing enrollment. The South Carolina Department of Health and Human Services (SCDHHS) will collect the application fee via the SC.GOV Enterprise Payment System.
- The application fee increases each year based on the consumer price index for all urban consumers. The amount is calculated by CMS.
- The application fee is non-refundable, except under the following circumstances:
.. A request for hardship exception;
.. An application that is rejected prior to initiation of screening processes.
The application fee does NOT apply to:
- Individual Physicians
- Non-Physician Practitioner
- Providers who are enrolled in Medicare and/or enrolled in another state’s Medicaid Agency or Children’s Health Insurance Program (CHIP)
- Providers who have already paid the applicable application fee to Medicare and/or another State’s
TABLE 1: GUIDE FOR SPECIFIC PROVIDERS
|Who you are||Your enrollment type||Your provider type||Application fee?|
|Retail clinics||Organization||Retail Clinics||Yes (per location)|
|Hybrid clinics||Organization||1. Groups
3. Dentist, Group
|Yes (per location/provider type)|
For full list of provider types, please visit: https://www.scdhhs.gov/sites/default/files/Provider%20Type-Specialty%20
STEP 4: COMPLETE AN ONLINE APPLICATION
- Refer to http://provider.scdhhs.gov to access the Online Enrollment Application Introduction Video and the Online Enrollment Application Visual Guide and the web-based application itself. Submitting your application via this process ensures the security of providers’ information and is accessible from any computer that has internet access. The web-based application will enable you to:
• Initiate new enrollment for individuals and organizations;
• Add a new location to an existing enrollment.
Note: Once you have completed minimal required information, you will receive a Reference ID number. Use this Reference ID number to retrieve and complete an in-process application. The in-process application must be submitted within 30 days. After 30 days, the in-process application will be purged, and you will be required to begin the enrollment process again and be assigned another Reference ID number.
- Submit all necessary supporting documentation to Provider Enrollment via fax at (803) 870-9022. Indicate Reference ID number on all supporting documentation and/or communication in reference to the submitted application.
Note: Certain provider types, depending on the type of service provided, will be notified if the provider is required to sign a contractual agreement in addition to the provider enrollment agreement.
- Accept the terms and conditions of the online application by electronic signature, indicating the provider’s agreement to the contents of the participation agreement, the Electronic Funds Transfer Agreement, W-9 and Trading Partner Agreement.
STEP 5: SCREENING
In order to obtain payment, all providers who will be providing services to Medicaid patients must be properly screening according to the screening level as determined by the Secretary of the United States Department of Health and Human Services. The enrollment and screening process may take up to 35 days after an application has been submitted.
All SCDHHS providers, other than Durable Medical Equipment (DME) Providers, must have their enrollment information revalidated every five years regardless of their provider type.
All individuals and organizations will be screened upon submission of an application for:
- New enrollment for individuals and organizations;
- Adding a new location to an existing enrollment.
Once enrolled, you will receive an official notice of enrollment.
STEP 6: JOIN MANAGED CARE ORGANIZATION(S)
To Join a Managed Care Organization (MCO), you need to contact each plan individually to obtain the appropriate process on how to apply.
Absolute Total Care : (866) 433-6041
First Choice by Select Health : (888) 276-2020
Blue Choice Health Plan of SC : (800) 574-8864
Medicaid Provider Enrollment Guide – Download [Optimized PDF]
Medicaid Provider Enrollment Guide – Download