Provider Enrollment Required Documentation
Provider Enrollment Application Instructions
New policy concerning Out of State enrollment and Effective Date of Provider Agreement is located in the Division of Medicaid's Admin Code Title 23, Part 200, Chapter 4, Rule 4.2 (B) and Rule 4.4 located at www.medicaid.ms.gov/providers/administrative-code.
Print out the Provider Enrollment Application and the Additional Enrollment Requirements Checklist forms from the list of links given below.
All enrolling providers are required to submit: A completed Mississippi Medicaid Enrollment Application A completed Mississippi Medicaid Provider Disclosure Form Electronic Funds Transfer (Direct Deposit Authorization Form) including verification of the bank account (preprinted voided check, deposit slip or letter from the bank verifying the account number and transit routing number Medical Assistance Participation Agreement Completed W-9 for the enrolling provider Completed Civil Rights Compliance Information Request Package Any additional specific required documentation for the provider type in which you are enrolling as noted on the Additional Enrollment Requirements Checklist Effective from 01/01/2020, all Out of State enrolling providers are also required to submit the Provider Application Cover Letter
After verifying your specific required documentation and completing the necessary forms, mail the signed signature page and all other required documents to: Mississippi Medicaid Program Provider Enrollment P.O. Box 23078 Jackson, MS 39225
Retain a copy of the completed application for your records.
This application will not be accepted if any portion has been filled out incorrectly, form(s) are not completed and/or missing.
Signatures
Original signatures are required on the signature page. Copied or stamped signatures are not acceptable. Correction fluid is not permissible on any portion of this application including signature pages.
Contact a Provider Enrollment Specialist
You may contact a Provider Enrollment Specialist by calling (800) 884-3222 for any questions concerning this application.
Change of Ownership Applicants
All applicants indicating a Change of Ownership: A Provider Enrollment Application must be submitted (see Links below). If you have questions, contact a Provider Enrollment Specialist at (800) 884-3222.
PDF Files
PDF Files are used throughout the application as a file type for additional information documents. To view PDF files you will need Adobe Acrobat Reader installed on your machine. For a free download please click the Acrobat Reader icon.
Links:
Additional Enrollment Requirements Checklist
Provider Risk Level Information
Provider Enrollment Application
Electronic Funds Transfer (Direct Deposit Authorization Form)
Medical Assistance Participation Agreement
W-9
Civil Rights Compliance Information Request for Medicaid Certification
CLIA Certification
EDI Provider Enrollment Form (Required if you intend to submit claims electronically)
EDI Trading Partner and Business Associate Agreement
EDI Gateway Services (Optional information about submitting EDI)
ERA Enrollment Application
NF Ventilator Dependent Care Services Addendum (For Nursing Facilities Only)
Provider Disclosure Form
Provider Application Cover Letter (For Out of State Providers Only)
Thank you for your interest in supporting the Mississippi Medicaid Program. If you have any questions, please contact Conduent at (800) 884-3222.