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Medicaid revalidation Form: What You Should Know

Medicaid Provider Enrollment Renewal Form (WA.gov) Your application for Medicaid provider revalidation will be complete once your State Medicaid program has been notified that you are authorized to enroll and submit claims. In addition, your State Medicaid agency has been issued a Federal Revalidation Notice (Form 4868-F) to ensure that you are in compliance with its revalidation policy. If your State Medicaid agency does not have a renewal date on the form or doesn't receive one within a certain time period, it must send a revised Form 4868-F to us instead. In some states, Medicaid providers may have completed a revalidation process for previously enrolled patients, but you need to know, since your state's revalidation policy may have changed. Also, you will be informed of any change of State Medicaid agency by your State Medicaid agency. Please be aware that to be eligible for the revalidation, you must first update your information in Medicaid's Central Intake System and the other state systems that hold your Social Security Numbers and your billing records. To update this information, log into Medicaid's system using the login information that is assigned to you on your state of enrollment. Once your status as an active Medicaid provider has been validated, you are no longer eligible to submit claims for services under any program for which you were previously paying. In addition, you will no longer be charged for services that are no longer medically required. You are expected to file your renewal application and provide the necessary information and documentation on your renewal form to the State Medicaid agency, and any applicable federal health care programs, as soon as possible. You can submit your renewal information online to avoid having to fax, mail in, or wait for payment. Furthermore, you will need to sign and date the application, and the electronic form must be completed or electronically signed by your name and State of enrollment. Please note, Medicaid provider revalidation is not an initial certification of provider compliance. Your provider must submit their certification through their own administrative account, instead of through your state's administrative portal. For more information on verification, including a method to verify provider compliance by requesting and reviewing a revalidation audit report, please refer to the “Verification” section on page 29 of the Medicare and Medicaid Payment and Access Commission (MH PCA) “Revalidation Handbook”. A copy of your renewal application can be faxed to:. You can submit the renewal application online.

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