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Formal
Enrollment as a Utah Medicaid Provider
Thank
you for your interest concerning participation in the Utah
Medicaid Program. The set of forms below outline procedures
to enroll as a Utah Medicaid provider. For more information,
please call Provider Enrollment at 1-801-538-6155,
or toll-free 1-800-662-9651
(option 3 then 4).
Providers
who wish to enroll as Utah Medicaid providers must fill
out each required document in its entirety and mail or fax
to the address below. You will be notified of the results
of your application.
-
Medicaid
Sanction Policy
- Utah
Medicaid Provider Application (please
retain a copy for your records)
- Instructions
for completing the provider application
-
Utah
Medicaid Provider Agreement (2011),
signed and dated.
Note: As a resource to help you comply with Section
II, page 5, paragraph 12 Criminal Disclosure, see the
List of
Excluded Individuals/Entities (LEIE).
- Ownership
Disclosure Form (Definitions)
- Civil
Rights Protections and Free Interpreter Services
- Direct
Deposit Authorization Form for Electronic Funds Transfers
(EFT) Electronic Funds Transfer is
mandatory for all new Utah Medicaid
providers.
-
Copy of Professional or Business License
(See page 2 of the instructions for completing the provider
application, item 2 of this list.)
-
Proof of Medicare Certification (See
page 2 of the instructions for completing the provider
application, item 2 of this list.) AND
one of the following to show current participation:
-
Current letter of accreditation (JCAHO or AOA)
-
Letter from HHS, CMS, or Medicare intermediary showing
current enrollment
- National
Supplier Clearinghouse letter with current service
address
-
Copy of IRS Form W-9 with current Taxpayer Identification
Number
(See Box 8 on page 2 of the instructions for completing
the provider application, item 2 of this list.)
- Additional
Dental Agreement
for urban dentists. For questions about the form or
the dental program policy, e-mail.
If
you are a mental health provider, please fill out the appropriate
form below in addition to the above required documents:
Mailing
Address:
Bureau of Medicaid Operations
Provider Enrollment
P.O.
Box 143106
Salt
Lake City UT 84114-3106
Fax: (801) 536-0471
Click here to access the online Utah
Medicaid Provider Manuals. The manuals contain information
on general policy, limitations of coverage, and reimbursement
policy for your specific type of service. The Provider Manuals
also include instructions for completing claim forms, an
example and explanation of the remittance statement, and
a description of Medicaid’s automated payment system.
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