Medicaid provider application prep checklist
By Scott McKenzie, founder of Home Care Agency Blueprint · Updated
Gather what your state Medicaid agency is likely to ask for before you open its provider application. The federal rules require ownership and control disclosures, license verification and screening; your state’s form lists exactly what it needs and in what format. Use this checklist alongside the state’s own instructions.
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Find the right application
1. I have found my state Medicaid agency’s provider enrollment page for my provider type.
Source: Your state Medicaid agency (Medicaid.gov state contacts)
2. I know the exact provider type or service name the state uses for what my agency will do.
Source: Your state Medicaid agency (Medicaid.gov state contacts)
3. I have downloaded the current application instructions or checklist from the state.
Source: Your state Medicaid agency (Medicaid.gov state contacts)
Information and documents to gather
4. Legal business name, tax identification number, and entity documents.
Your own planning
5. Every business address the state asks for: primary business address, each business location, and any P.O. box.
Source: 42 CFR 455.104 (ownership and control disclosures)
6. Name, address, date of birth and Social Security number of each individual with an ownership or control interest, and the tax ID of any corporate owner.
Source: 42 CFR 455.104 (ownership and control disclosures)
8. Name, address, date of birth and Social Security number of each managing employee.
Source: 42 CFR 455.104 (ownership and control disclosures)
9. A copy of your current state license or certification, if your provider type needs one.
Source: 42 CFR 455.412 (license verification)
11. Any policies, insurance, training records or staffing documents the program’s provider qualifications list.
Source: Medicaid.gov, HCBS 1915(c) waivers
Screening steps to expect
12. Whether the state will charge an application fee for your provider type, and how to pay it.
Source: 42 CFR 455.460 (application fee)
13. Fingerprints or consent to a criminal background check, if state law or your provider type’s risk level requires them.
Source: 42 CFR 455.434 (background checks, fingerprints)
14. Availability for a site visit, if your provider type is screened at moderate or high risk.
Source: 42 CFR 455.432 and 455.450 (site visits, risk levels)
After you submit
15. A complete copy of everything you submitted, with the submission date.
Your own planning
16. A plan to answer state requests for more information quickly, with one person responsible.
Your own planning
17. Credentialing applications for each Medicaid managed care plan you want to work with, if your state uses managed care for your service.
Source: 42 CFR 438.214 (managed care credentialing)
18. A reminder to report ownership changes, and to revalidate when the state asks.
Source: 42 CFR 455.104 (ownership and control disclosures)
How to use this checklist
- Find your state Medicaid agency’s provider enrollment page and the provider type that matches your services.
- Download the current application instructions.
- Gather business, ownership, managing employee and license information.
- Check which screening steps apply to your risk level, such as a fee, fingerprints or a site visit.
- Submit, keep a complete copy, and answer follow-up requests quickly.
- Credential with managed care plans if your state uses them, and track ownership changes and revalidation.
Why the ownership details matter
A state must deny or end enrollment if the provider, or a person with an ownership or control interest, or an agent or managing employee, fails to submit timely or accurate information, unless the state documents that doing so is not in the program’s best interests. It may also deny or end enrollment if information on the application was falsified. Complete, consistent ownership information is the part of the application most worth getting right the first time.
Fingerprint requests
When a state requires fingerprints, a provider or any person with a five percent or greater ownership interest must submit them within 30 days of a request from CMS or the state. If they do not, the state must deny or end enrollment unless it documents that doing so is not in the program’s best interests.
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Your state sets the details. Federal rules set minimum screening steps. Each state Medicaid agency decides its own provider types, forms, fees, order of steps and payment rates. Confirm every requirement with your state Medicaid agency; Medicaid.gov lists contacts for each state.
Frequently asked questions
Where do I get the Medicaid provider application?
From your state Medicaid agency, usually on its provider enrollment pages. Medicaid.gov lists contacts for each state.
Is there an application fee?
Federal rules require states to collect an applicable fee before signing a provider agreement, with exceptions such as providers already enrolled in Medicare or another state’s Medicaid program. Ask your state whether it applies to you and how much it is.
Do I need an NPI to apply?
Often, but not always. Under federal HIPAA rules, a health care provider that conducts standard electronic transactions, such as electronic claims, must get an NPI. Some non-medical service providers are not health care providers under HIPAA, and states handle their identifiers differently. Ask your state Medicaid agency what it requires for your provider type. NPIs are issued through NPPES.
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