This site is for newly enrolling MO HealthNet providers.
Effective July 1,2015, institutional providers will have
to submit an application fee and may require a site visit
before being approved as a new provider. Individual providers
such as physicians, dentists, advanced practice nurses and other
individual non-physician providers are not required to
pay the application fee. Click
here for more information.
If
you are already enrolled as a MO HealthNet provider and need to
make a change like adding a practice location or changing your
contact information, please complete a "Provider
Update Request" and fax it to (573) 634-3105. If you have any
questions submit them via e-mail to: MMAC.providerenrollment@dss.mo.gov
.
If
you are an existing MO HealthNet provider that is "Revalidating"
your enrollment because you received notice from MMAC, please go
to www.emomed.com
to complete and submit the revalidation application along with
any supporting documentation to avoid any interruption in
payments. If you do not have an eMOMED account, please go to www.emomed.com
and register for an account.
Click here for more information.
This Provider Enrollment Application
site requires the latest version of Microsoft Edge, Google Chrome
or Mozilla Firefox.
Instructions for each field of the MO HealthNet Enrollment
Application are listed on the bottom bar of the screen, click the
HELP link at the bottom of each part of the application for more
detailed instructions. Click on the link Provider
Enrollment Information at the top of this page for program
requirements and attachments.
The entire enrollment application must be
completed on-line.
A partial Enrollment Application may be saved and
retrieved. However, all fields on the page must be completed in
order to utilize the "save" option for that page. A PIN, NPI,
Email, and SSN, or EIN is issued to retrieve the partial
application. The PIN can be used to retrieve an application
that has been finalized and submitted.
After finalizing an on-line application, ONLY
the provider agreement "signature page" containing the
provider's original (wet) signature and/or electronic signature
from DocuSign, AdobeSign, or HelloSign and any program requirement
attachments must be faxed. All pages must be in an upright
position (not upside down or sideways).
The signature page and attachments must be
submitted on separate pages in the same transmission, or the
application will be denied. DO NOT SHRINK OR MINIMIZE PAGES to
combine pages.
Fax the signature page and required attachments in one
transmission to 573-634-3105. Faxed pages go directly to the
Provider Enrollment database, not an actual fax machine.
Only one signature page and its attachments are accepted per
transmission.
In order for the agreement and attachments to be
submitted in one transmission, you must make sure that each
time a transmission is completed, the fax machine you are using
not only finishes moving the pages through the machine, but has
also finished the transmission and has disconnected from the
fax number dialed.
Providers are required to print each page of their
enrollment application and maintain for their records. This
includes the original (wet) signed provider agreement and/or
electronic signature from DocuSign, AdobeSign, or HelloSign. However,
ONLY the provider agreement page and required
attachments are required to be faxed.
An altered agreement is automatically denied. Fields
cannot be blacked out, whited out, or crossed out; writing
information on the forms is not acceptable. The only writing
permitted on the form is the provider's original (wet)
signature on the agreement page.
If the application completed on-line needs changes, a
new on-line application must be completed and submitted. If
additional information needs to be submitted, a letter may be
sent with the signed agreement page.
Do not submit documentation that is not required
for your provider type. Refer to the "Requirements for
Each Provider Type" section to determine required
attachments.
Effective July 1, 2015, newly enrolling institutional
providers will be required to pay an application fee and may
require a site visit before being approved. Click
here for more information.
All questions regarding provider applications and general
questions for Provider Enrollment must be communicated by e-mail
to MMAC.providerenrollment@dss.mo.gov.
A valid e-mail address is required on your application. The
contact person's e-mail address also should be completed on the
Enrollment Application Part 2 along with the contact person's
name. The contact person is notified of questions regarding the
application.
If you have technical problems or problems
faxing the documents, contact the Help Desk at 573-635-3559.
Instructions on how to complete the application can be found by
clicking the Help link at the bottom of each part of the
application.
