Provider Enrollment

Individuals, Organizations, Atypical Individuals, Atypical Organizations, Ordering/Referring providers as well as currently enrolled providers adding a new location can enroll into the system. A unique Reference ID is assigned to each application. Emails containing the Reference ID will be sent to both the authorized individual completing the application and the provider. The Reference ID is required to retrieve a saved application and to correct or update enrollment information after the application is approved. If the application is not completed and submitted at the time the Reference ID is issued, the provider has thirty (30) calendar days from the issuance date of the Reference ID in which to log back into the online application and complete the submission or the record will be deleted from the system.

Who Can Enroll

Individual Provider

-- An individual provider is a person enrolled directly who provides health services to health care members. 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 National Provider Identifier (NPI).

Individual/Sole Proprietor

-- An Individual/Sole proprietor is a person enrolled directly who provides health services to health care members. An individual may bill independently for services or may have an affiliation with an organization. An Individual/Sole proprietor enrolling in SCDHHS Medicaid program is required to submit their Social Security Number (SSN) and National Provider Identifier (NPI).

For SCDHHS individual Medicaid enrollment, type of ownership defaults to Individual/Sole Proprietor when an EIN is submitted on the application. As a sole proprietor, you would need to obtain an identification number if either of the following apply; (1) pay wages to one or more employees, or (2) you file pension or excise tax returns. If these conditions do not apply, your SSN is your taxpayer identification number.

Ordering/Referring Providers

-- All providers of health care services may be ordering/referring providers but not all ordering/referring providers are billing providers. In an effort to capture all providers who order services and/or refer Medicaid beneficiaries for services and who do not submit claims to SCDHHS for payment, ordering/referring providers are required to enroll. All ordering/referring providers are required to have an NPI and that NPI must be submitted on the claims as the ordering/referring provider. All claims will be subject to denial if the ordering/referring NPI is not on the claim and/or the ordering/referring provider is not enrolled in SCDHHS Medicaid program. Examples of ordering/referring providers are Physicians, a Licensed Nurse Practitioners, and Certified Midwives.

Organization

-- Any entity, agency, facility or institution that provides health services to health care members. 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 Employer Identification Number (EIN) and NPI.

Atypical Providers

-- CMS defines atypical providers as "providers that do not provide health care, as defined under HIPAA in Federal regulations at 45 CFR section 160.103." Providers who perform home and vehicle modifications, respite services, and attendants working in Community Long Term Care (CLTC) facilities are examples of atypical providers reimbursed by the Medicaid program. Even if these atypical providers submit HIPAA transactions, they still do not meet the HIPAA definition of health care and therefore cannot receive an NPI.

Atypical Individual

-- An Atypical Individual provider is a person enrolled directly who provides non-health related services to health care members. An atypical 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). The provider may or may not be eligible for an NPI and NPI is not required.

Atypical Organization

-- An Atypical Organization provider is a facility, agency, entity, institution, clinic or group of providers enrolled directly who provide non-health related services to health care members. An atypical organization may bill independently for services or may have an affiliation with an individual. Organizations enrolling in SCDHHS Medicaid program are required to submit their Employer Identification Number (EIN). The provider may or may not be eligible for an NPI and NPI is not required.

Add a Location

-- Organizations (facilities, agencies, groups, etc.) enrolled with a unique combination of an Employer Identification Number (EIN) and an NPI may add a location to a previously existing enrollment. The location being added must operate under the same EIN/NPI as the previously enrolled location. The location being added is subject to an enrollment application fee. When the EIN/NPI combination is not the same as a previously enrolled location, providers must complete a new enrollment for that location.

Change Request

-- Providers successfully enrolling as a SC Medicaid provider through the web application are able to submit changes to their enrollment information using the same web portal. Providers will not be able to make changes to submitted enrollment applications until after the application is approved and notification of such has been received by the provider.

 

 

Create a new application.
Modify an unsubmitted application
or a submitted application that was returned.
This functionality is currently unavailable.