Certification Statement for Provider Billing Medicaid (ETIN)

It is a requirement of The New York State Office of the Medical Inspector General (OMIG) that participating MCO providers supply a copy of their Certification Statement for Provider Billing Medicaid (ETIN) form to each MCO for which they are a participating provider upon signing the provider agreement with the MCO, and annually thereafter.

 

Submission Process:

Step 1

Obtain a copy of your completed “Certification Statement for Provider Billing Medicaid” form.

  • Ensure all twelve (12) spaces of required information are filled in
  • If a clean copy is needed, click this link and download the PDF

Step 2

Obtain a copy of Molina’s Attestation

  • Click this link and download the PDF
  • Ensure all seven (7) spaces of required information are filled in

Step 3

Attach the following documents to an email and send them to MNY.Compliance@molinahealthcare.com

  • Certification Statement for Provider Billing Medicaid form
  • Molina’s Attestation

 

Questions or concerns regarding Molina’s submission process can be directed to the Compliance Department at MNY.Compliance@MolinaHealthCare.Com.