TO: All Providers
RE: Provider Enrollment
In order to streamline the process, Alabama Medicaid provider enrollment applicants should gather all needed materials before applying. Below are some of the most common reasons why applications are denied:
1. Provider Name Mismatch
The provider’s name submitted on the application must match the provider’s name on all required documents (licenses, certifications, etc.). For example, if a provider applies as, “Benjamin J. Smith,” and provides a license with the name, “James Smith,” the application will deny due to name mismatch.
2. Documents and/or Forms Missing
If a provider does not submit all the required attachments for the application, the application may deny. Documents can be attached to an application at the time of submission. All providers should review the required documentation according to their provider type. Please visit the Alabama Medicaid website to get a list of the required documents.
a. Documents and/or forms required for all applications include:
i. Civil Rights Forms (pages 4 and 17)
b. Documents and/or forms required for some provider types include:
i. CLIA Certificate
ii. DEA Certificate
iii. IV Sedation Certification (dental providers only)
iv. EPSDT Agreement
v. Plan First Agreement
vi. Telemedicine Service Agreement/Certification
vii. Mobile Dental Facilities Certification (dental providers only)
viii. Certification of Mammography Systems
ix. Civil Rights Compliance Policies if not enrolled with Medicare
c. Documents required for group or facility provider enrollments include:
i. W-9 Tax Form
ii. Disclosure Form(s) required for all owners, officers, directors, shareholders, and
managing employees
d. Documents required for some provider types include a Corporate Board of Directors Resolution for all
incorporated businesses to mail a notarized hardcopy.
3. Trading Partner Identification (ID) Incorrect
A valid Trading Partner ID is required on all group and/or facility applications.
To obtain a Trading Partner ID, visit the Alabama Medicaid website and select the ‘Providers’ tab, then go to ‘Provider Enrollment’ link, and select forms for provider enrollment and revalidation, then scroll to the bottom of the page and click “Provider Trading Partner ID Request Form.” The form must be submitted to alabamasystemsemc@gainwelltechnologies.com. Once the form is received, a Trading Partner PIN letter is generated and mailed to you containing your unique Trading Partner ID.
4. Invalid Signature
Each individual within Group applications must be signed by the individual provider. Group applications must be signed by an authorized representative. For example, managing employee who is also listed on the required Ownership Disclosure Form.
5. Collaborating Agreement Requirements
a. Independent Nurse Practitioners under group Provider Type CRNP. The collaborating physician is NOT
required to be enrolled with Alabama Medicaid.
b. Physician Employed Nurse Practitioners under group Provider Type Physician. The collaborating physician
MUST be actively enrolled with Alabama Medicaid within the same group.
c. All Nurse Practitioners and Physician Assistants are required to a have an active collaborating
physician listed on their license.
If you have any questions regarding your application, please contact Provider Enrollment at (888) 223-3630.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2023
American Medical Association and © 2023 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.