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Provider Enrollment & Maintenance

SD Medicaid has an online enrollment process for providers meeting the eligibility criteria referenced in General Enrollment Information below who are providing eligible services. Effective May 5, 2021 all enrollment activities are completed through the Provider Enrollment (PE) Portal.

Revalidation Due 6/7/2021

All actively enrolled providers must log into the PE Portal and verify that their enrollment record reflects accurate information both from a data conversion perspective as well as from a current operations perspective. The initial login and update for a given BNPI will be deemed their revalidation record.

Items of particular importance include:

  • Middle initials and names will be required for all occurrences where individual data is captured.
  • Managing employee data was converted but will require users to move and/or populate the middle and last names in the correct fields, populate SSNs, and populate the home address for the individual.
  • Contractual relationships between providers and parent organizations, managing contracts in the area of managerial, billing, consultative, and personnel staffing, and property arrangements must be populated.
  • PCP participation was not able to be converted. Update as appropriate.
  • End date relationships between individuals and entities where needed.
  • Review the new Disclosure form.
    • If any question is “Yes,” submit the form.
    • BNPIs must also submit a Disclosure form if there have been any entities or individuals added in the ownership, contractual relationship, or managing employee sections.

General Enrollment Information

  • New enrollments and updates to existing enrollment records are initiated online in the Provider Enrollment (PE) Portal.
  • Supporting documentation is sent via email sdmedxgeneral@state.sd.us.  Include the NPI, provider name, and whether it is a new enrollment or existing enrollment in the email body.
  • No application fee is charged.
  • Enrollment records and documentation must be completed and received within 30 days of starting data capture, or it will be denied/rejected.
  • Many attending, ordering, referring, and prescribing providers will be subject to the streamlined enrollment process upon claim submission and are not required to take enrollment action in the PE Portal.
  • Billing and Servicing providers must be a type of provider recognized by SD Medicaid on our provider enrollment chart and provide covered services in order to enroll.
  • Out-of-state providers must submit a claim for services that meets prior authorization and timely filing requirements with the enrollment documentation to be deemed eligible.
    • Timely filing requirements cannot be extended for failure to obtain prior authorization, provide documentation, or submit online enrollment records in a timely manner.
    • Providers should complete their actions at least 45 days prior to timely filing deadlines.
  • Providers are required to maintain their online enrollment records to accurately reflect business operations and eligibility to render and bill for services.
  • Enrollment record review is generally completed in the order received.
    • Exceptions may be made in the area of EDI and Payment Details. Refer to the User Guide.
    • New enrollments or new associations submitted by the provider that go beyond the timely filing requirements due to a delay in SD Medicaid’s review and approval may qualify for timely filing extensions. Special claim submission instructions will be included in the approval notices.

Entity NPI Enrollment

Entity NPI

  • Organizational (Type 2) NPI.
  • Requires a FEIN as the IRS tax identifier tied to the legal business name.  
  • Includes all incorporated entities (Inc, PC, LLC, etc.), non-profits, and not-for-profits
  • Found on claims as the billing NPI.
    • Some examples include groups, agencies, facilities, institutions, suppliers, and transportation.

Description of services and requirements by service.

  • Provider Enrollment Chart
  • Collectives of individual professionals who are going to be billing for the professional services should select a group taxonomy (193200000X or 193400000X) for the BNPI enrollment.

Required documentation

Individual NPI Enrollment

Individual NPI

  • Type 1 NPI.
  • Unincorporated individuals operating under their SSN.
  • Two types:
    • Billing NPI (BNPI)
      • Unincorporated sole proprietor/owner operating under and reporting taxes under their SSN
      • Uncommon; only available when all payers recognize provider as operating exclusively under their SSN and a single NPI
      • NPI in both servicing/treating and billing NPI fields on claims.
      • Amount BNPI receives for services is exactly what Medicaid paid
    • Servicing/Rendering NPI (SNPI)
      • Most common
      • Payment is directed to BNPI with a FEIN and not the individual’s SSN
      • Amount SNPI receives may be different than Medicaid payment (ex: salary, negotiated rate with employer, etc.)

Description of services and requirements by service.

  • Provider Enrollment Chart
    • Only one taxonomy code is permitted unless otherwise noted.
    • Individuals associated to multiple entities should advise the entities what taxonomy code to use as consistency amongst entities is required.
  • Required documentation
    • All Individuals
      • Provider Agreement
      • Disclosure
      • Copy of professional license/certification from requested enrollment date to current calendar date unless a date certain enrollment period is noted.
        • Note: MDs, DOs, PAs, CNPs, and ARNPs, temporarily practicing in SD under a license not issued by SD due to COVID-19 must specifically call this limitation out on their documentation email. Enrollment eligibility may not start prior to 3/1/2020 and will be terminated following the end of the emergency declaration.
    • Certain Individuals
      • Mental Health Services Addendum
      • PCP Addendum
        • Note: Only applies to a physician assistant, certified nurse practitioner, certified nurse midwife, DO or MD in the specializations noted on the form and whose physical servicing location is in SD, within 50 miles of SD, or in Bismarck, ND. In addition to the form, the information must be captured in the PE Portal record.
    • All BNPI
      • Letter from financial institution to support online payment details. All payments are made by electronic funds transfer.

Electronic Data Interchange (EDI)/Trading Partners

Electronic Data Interchange (EDI)

Trading Partners

  • Entities that send data directly to SD Medicaid from their computers or directly receives data from SD Medicaid
    • Must be known to SD Medicaid
    • Will be issued Trading Partner ID
  • Two eligible types
    • Self-submitters
      • Providers who send/receive data from their own computers without assistance from other trading partners
      • Enrolled using a billing NPI
    • Clearinghouses
      • Non-provider entity directly sending/receiving data on behalf of enrolled billing NPI
      • Enrolled as a Clearinghouse outside of the PE Portal
        • Contact SD Medicaid Provider Enrollment Response Team at sdmedxgeneral@state.sd.us for more info.
        • Will be issued Trading Partner ID upon approval that needs to be shared with provider clients for use in the provider’s enrollment record.

Provider Enrollment (PE) Portal

  • PE Portal Log-in
  • User Guide
    • Start here.  This captures the registration process, entry points, required fields, etc.
  • The Provider Enrollment (PE) Portal is the enrollment system of record and is used to complete both new enrollments and update existing records.
  • The PE Portal is also used to view the current status of items, such as whether the State is currently reviewing a submission.
  • Access requires registration and is authorized for Billing NPIs only. Providers who do not have credentials need to review the “Registration” process in the User Guide.
    • Note: The initial registration will be granted Provider Admin rights to the registered BNPI(s). This must be done by a provider staff member, not their external credentialing entity or other party.

Training

Disproportionate Share Hospital DSH 2021 Survey