Ny Documents.) All fields must be completed or the application may be returned. If a field is Non-Applicable, the applicant should type or print NONE. SECTION A: PROVIDER Re-Enrollment 1. New Enrollment 3. Primary Office Address 5. City 7. State 2. Provider Type Reinstatement Request Provider Name 4. Name Change 6. County 8. Zip Code 9. Telephone: 10. Fax: 11. E-mail Address (3) Report Additional NPI's In Section D 13. FEIN 12. National Provider Identification # - NPI 14. SSN 1.
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How to fill out the Illinois Medicaid Provider Enrollment online
Filling out the Illinois Medicaid Provider Enrollment form is an essential step for providers seeking participation in the Medicaid program. This guide will lead you through the online process, ensuring that all components of the form are completed accurately and efficiently.
Follow the steps to complete your application online.
- Click ‘Get Form’ button to access the Illinois Medicaid Provider Enrollment form. This will enable you to open the document in an editor for completion.
- Begin filling out Section A by indicating your provider type, whether it is for new enrollment, re-enrollment, or another purpose. Ensure that you provide your provider name clearly.
- Complete your primary office address, including the city, state, county, and zip code. Provide accurate information to ensure proper correspondence.
- Enter your contact details including your telephone number, fax number, and email address. If you have multiple NPI numbers, note them in Section D.
- In Section B, specify your category of service and provider specialty, including primary and secondary specialties if applicable. Complete any other details requested regarding your medical qualifications.
- If applicable, address any details in Section C regarding former participation, such as a change of ownership or effective dates.
- Proceed to fill out Section E with the payee information. Include your tax identification number and any other pertinent billing details.
- Review Section F for certification and signature. You must certify the accuracy of the information provided and understand the implications of falsifying information.
- After completing all sections, ensure all fields are filled accurately. If any field does not apply to your situation, clearly write 'NONE'.
- Finish by saving changes, and download, print, or share the completed application as necessary.
Take the next step towards enrollment and complete your application online today.
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How do I verify my Medicaid provider eligibility in Illinois?
1-800-842-1461. To use the automated system, you must have the individual's Medicaid Recipient Identification Number (RIN) and the date of service for which you need eligibility information. If you do not know the individual's RIN, you need the individual's name, birthdate and SSN and must talk with hotline staff.
What is the number for Medicaid enrollment in Illinois?
Visit .EnrollHFS.Illinois.gov or call 1-877-912-8880 (TTY: 1-866-565-8576).
How do I change my Medicaid provider in Illinois?
An individual must call the Client Enrollment Broker Call Center at 1-877-912-8880 (TTY: 1-866-565-8576) or go online to the Enrollment Portal at .enrollhfs.illinois.gov to get more information about their HealthChoice Illinois plan choices and to make a plan switch.
What is the Medicaid of Illinois provider phone number for eligibility verification?
Eligibility Verification Use this link for information on the MEDI System. Use this link for information on the REV Eligibility System. AVRS eligibility system is available 24 hours a day at: 1-800-842-1461.
How to check claim status on Illinois Medicaid provider portal?
1. Login to MEDI https://medi.hfs.illinois.gov/ 2. Select Internet Electronic Claims (IEC) 3. Select Claim Status Inquiry 4.
What is the Illinois Medicaid number for providers?
Provider Help Line: 1-800-804-3833 · 1-877-434-1082 TTY.
How do I contact Medicaid in Illinois?
Call the DHS Customer Service Helpline for assistance at: (800) 843-6154 voice/(866) 324-5553 TTY, Monday through Friday, 8:00 a.m. to 5:30 p.m., except state holidays.
How do I check my Illinois Medicaid status?
If you aren't sure if your Medicaid coverage has been approved yet or if it is still active, you can check Manage My Case or call the state's Automated Voice Recognition System (AVRS) at 1-855-828-4995 with your Recipient Identification Number (RIN).
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