LM unisCoverLtr certificationelectronicremittance

							Dear Early Intervention Manager:

Enclosed are the “Certification Statement for Provider Billing Medicaid” and the “Electronic Remittance
835/820 Request” forms. These forms must be completed and submitted to CSC (Medicaid) prior to your
first scheduled training class in preparation for your New York Early Intervention System (NYEIS)
launch.

The “Certification Statement for Provider Billing Medicaid” informs Medicaid that NYEIS can claim to
Medicaid under your municipality’s Early Intervention NPI numbers. You will need to submit two
notarized “Certification Statement for Provider Billing Medicaid” forms-one for the Early Intervention
(EI) Service Coordination NPI and one for the Other EI services NPI. These forms must be signed and
notarized before they are submitted to CSC. Additional instructions for the “Certification Statement
for Provider Billing Medicaid” form is included at the end of this memorandum.

The “Electronic Remittance 835/820 Request” Form tells Medicaid that, for claims submitted with the
NYEIS ETIN, 00AJ, and your municipality’s Early Intervention NPI number, an electronic remittance
advice should be sent back to your municipality, instead of a paper remittance advice. You will need to
attach to this form a list of your municipality’s two EI NPIs (one for EI service coordination, one
for Other EI services). The NPIs must be for the municipality’s EI Program only - DO NOT include
any IDs for rendering providers.

Below are the NPIs on file for your municipality. If these numbers do not match what you have on file,
please contact the Rate Based Provider Bureau at 518-474-8161 immediately.

        Service Coordination:
        All Other Services:

Once you submit both forms to CSC please send an email to beidataunit@health.state.ny.us to
confirm the numbers registered.

If you have any questions about the content of these forms, please contact the Shannon Proper at 518-473-
7016 or sap03@health.state.ny.us.

                                                Sincerely,


                                                Candace Adams Grossjohann, Ph.D.
                                                Bureau of Early Intervention
 Clarification to Instructions for the “Certification Statement for Provider Billing Medicaid” form

Field 4 (Provider Name):
        This is the official name registered to the Medicaid Provider Number requested in field 5.

        The official name can be verified several ways:
            If you are enrolled in ePaces your official provider name can be viewed in the Change
                Provider drop down list near the top of the page in ePaces
            Contact the eMedNY Call Center (1-800-343-9000). You will have to give them your
                municipality’s name and the Medicaid Provider ID and they will verify whether it is
                correct.
            If the above methods of verification fail, then the Municipality may request this
                information by sending a letter requesting the official name for your Medicaid Provider
                IDs to the following address:

                         Computer Sciences Corporation
                         ATTN: Provider Enrollment
                         PO Box 4610
                         Rensselaer, NY 12144

Field 5 (Medicaid Provider Number):
        The 8 digit Medicaid Provider Number is no longer required as long as you include the 10 digit
        NPI numbers (see item 6).

Field 6 (National Provider ID (NPI)):
        This is required. Failure to include the NPI will result in processing delays.

        The National Provider ID (NPI) may be found in the KIDS System Adhoc 36.

        Logon to KIDS and select
            System
            KIDS Adhoc
            #36 – County Identification Information

        The last two lines contain the National Provider Identifier for Service Coordination and All
        Other Services
          Clarification to instructions for the “Electronic Remittance 835/820 Request” form


Field 2:
     Provider Medicaid ID is no longer required
     NPI – This information is required

Please attach a separate list of both your NPI numbers in ascending order to this form.



The National Provider ID (NPI) may be found in the KIDS System Adhoc 36.

        Logon to KIDS and select
            System
            KIDS Adhoc
            #36 – County Identification Information

        The last two lines contain the National Provider Identifier for Service Coordination and All
        Other Services