(1) ETIN ______________ (2) BILLING SERVICE NAME (IF APPLICABLE) __________________________________
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
(3) As of (date) __________, all claims submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnished
(4) by (provider name) _______________________________ (5) (10-digit National Provider
ID (NPI) -- REQUIRED unless
exempted from NPI)
(6) (8-digit Medicaid Provider
Number -- If NPI exempt)
will be subject to the following certification.
I am (or the business entity named in this form of which I am a partner, officer, or director is) a qualified provider enrolled with and authorized to
participate in the New York State Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim; the
persons providing services, care and supplies have the necessary licensing, certification, training and experience to perform the claimed services; I
have reviewed these claims; I (or the entity) have furnished or caused to be furnished the care, services, and supplies itemized and done so in
accordance with applicable federal and state laws and regulations; I have read the eMedNY Provider Manual and all revisions thereto; all claims are
made in full compliance with the pertinent provisions of the Manual and revisions; all claims for care, services and supplies provided at the order of
another professional have to the best of my knowledge been ordered by that professional in bona fide compliance with the procedures set forth in the
manual and revisions. All care, services and supplies for which claim is made are medically necessary for the treatment of the named recipient, the
amounts listed are due and, except as noted, no part thereof has been paid by, or to the best of my knowledge is payable from any other source other
than the Medical Assistance Program; payment of fees made in accordance with established schedules is accepted as payment in full; other than a
claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitted or paid; ALL
STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE; NO
MATERIAL FACT HAS BEEN OMITTED; I UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL,
STATE AND LOCAL PUBLIC FUNDS AND THAT I MAY BE FINED AND/OR PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS
FOR ANY VIOLATION OF THE TERMS OF THIS CERTIFICATION, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTS OR
DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT; taxes from which the State is exempt are excluded; all records pertaining to the care,
services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to
individuals under the New York State Medical Assistance Program will be kept for a period of six years from the date of payment, and such records and
information regarding these claims and payment therefor shall be promptly furnished upon request to the local Department of Social Services, the State
Department of Health, the Office of the Medicaid Inspector General, the State Medicaid Fraud Control Unit or the Secretary of the Department of Health
and Human Services; there has been compliance with the Federal Civil Rights Act of 1964 and with section 504 of the Federal Rehabilitation Act of
1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap, age, sex and religion; I agree (or the entity agrees)
to comply with the requirement of 42 CFR Part 455 relating to disclosures by providers; I (or the entity) have adopted and implemented, where
applicable, an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title
18 of the New York Codes, Rules and Regulations Part 521; the State of New York through its fiscal agent or otherwise is hereby authorized to (1) make
administrative corrections to claims submitted under this agreement to enable its automated processing, subject to reversal by the provider, and (2)
accept the claim under this agreement as original evidence of care, services and supplies furnished.
In submitting claims under this agreement I understand and agree that I (or the entity) shall be subject to and bound by all rules, regulations, policies,
standards, fee codes and procedures of the New York State Department of Health and the Office of the Medicaid Inspector General as set forth in
statute or title 18 of the Official Compilation of Codes, Rules and Regulation of New York State and other publications of the Department, including
eMedNY Provider Manuals and other official bulletins of the Department. I understand and agree that I (or the entity) shall be subject to and shall
accept, subject to due process of the law, any determinations pursuant to said rules, regulations, policies, standards, fee codes and procedures,
including, but not limited to, any duly made determination affecting my (or my entity’s) past, present or future status in the Medicaid program and/or
imposing any duly considered sanction or penalty.
I UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILL
APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER, USING MY (OR
THE ENTITY'S) NPI OR MEDICAID PROVIDER IDENTIFICATION NUMBER. THIS
CERTIFICATION REMAINS IN EFFECT AND APPLIES TO ALL CLAIMS UNTIL
SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT.
PLEASE DO NOT
STAPLE OR
WRITE IN BAR
CODE AREA
(7) (Signature) ________________________________________________________ (8) (Date) __________________________
(9) (Print Name and Title) ___________________________________________________________________________________
(10) (Telephone #) __________________________ (11) (eMail, if available) __________________________________________
STATE OF _________________________________
COUNTY OF _______________________________ (12)
On this _____________ day of _________________, 20____, before me personally came
__________________________, to me know and known to me to the individual described in and who
executed the foregoing instrument, and (s)he acknowledge to me that (s)he executed the same.
(SEAL)
______________________________________________________
NOTARY PUBLIC .
EMEDNY-490601 (10/20)
