Explanation and Disclaimers Regarding the NYS Medicaid Exclusion List

Information about Excluded Individuals or Entities

The NYS Medicaid Exclusion List identifies individuals or entities who have been excluded from participating in the NYS Medicaid program under the provisions of 18 NYCRR § 515.3 and/or 18 NYCRR § 515.7.

An excluded individual or entity cannot be involved in any activity relating to furnishing medical care, services or supplies to recipients of medical assistance for which claims are submitted to the program, or relating to claiming or receiving payment for medical care, services or supplies during the period of exclusion. See 18 NYCRR § 515.5 for more information regarding the effect of exclusion.

Using the NYS Medicaid Exclusion List

Unless otherwise required by law or contract, it is recommended that providers check the NYS Medicaid Exclusion List at least every 30 days as a best practice.

Use of this list will help providers avoid submitting claims for medical care, services, and/or supplies that are ordered or prescribed by individuals or entities who are not authorized to submit such orders. Enrolled providers should verify that the orderer has not been excluded before filling an order or prescription. If the orderer's or prescriber's name appears on the NYS Medicaid Exclusion List, Medicaid should not be billed for the care, services, or supplies ordered, prescribed, or provided by that person or entity.

Any claim submitted for medical care, services, or supplies ordered/prescribed by any individuals or entities appearing on the NYS Medicaid Exclusion List may be denied, and the enrolled provider dispensing prescriptions or filling orders may be held responsible for repayment of any payments made by the Medicaid program under these circumstances.

For orders or prescriptions requiring prior approval or prior authorization, it should be noted that the receipt of an approval or authorization is not a guarantee of payment. Payment is subject to a patient's eligibility and compliance with all applicable statutes and policies.

Enrollment or Reinstatement into the Medicaid Program and/or Removal from the NYS Medicaid Exclusion List

If excluded, a party must submit an application for reinstatement if the party wishes to be enrolled/reinstated into the Medicaid program. OMIG has 90 days to complete its review and render a decision. (This timeframe may be extended if OMIG or the New York State Department of Health (DOH) requires more time to review the application and sends a letter for extension to the applicant, or if OMIG or DOH sends a letter requesting information to the applicant.) Decisions are based on information submitted with the application or letter. If the applicant is denied enrollment or reinstatement based upon prior conduct, the applicant cannot re-apply for enrollment or reinstatement for two years from the date of the denial (see 18 NYCRR §504.5(d)).

When submitting a reinstatement application, it is the applicant's responsibility to provide information and/or documentation detailing corrective steps taken to assure OMIG that the violations that led to the exclusion will not be repeated (see 18 NYCRR §515.10(e)). Reinstatement into the Medicaid program may be granted only if it is reasonably certain that the violations that led to the exclusion will not be repeated.

Any provider who has been terminated on or after January 1, 2011 from Medicare or from the Medicaid program or CHIP of any other state may not be enrolled or reinstated in the New York State Medicaid program (42 CFR 455.416 (c)).

Applications for enrollment or reinstatement may be obtained by accessing www.eMedny.org, and clicking on Provider Enrollment Forms (using the same form and process as initial enrollment). Applicants for reinstatement use the same application that new applicants use, but the box for "reinstatement" must be checked if an excluded provider wishes to be reinstated into the program.

Parties who do not want to enroll in the Medicaid program or are in a category that does not require enrollment in the Medicaid program (such as staff pharmacists or nurses who do not directly bill for home care), but seek removal from the NYS Medicaid Exclusion List may do so by sending a letter to OMIG's Enrollment and Reinstatement Unit at the address listed below.

NYS Office of the Medicaid Inspector General
Attn: ARTS – Exclusion Review
800 North Pearl Street
Albany, NY 12204

The letter must include the party's name, phone number, and license or provider number (if applicable), specifically state that that party is requesting only removal from the exclusion list and not reinstatement. The letter should also address the issue that led to exclusion, and may include documentation of any steps or actions that the party has taken as a result. Removal from a list without being enrolled or reinstated will not allow a party to bill Medicaid.

Disclaimer

The Office of the Medicaid Inspector General (OMIG) has attempted to ensure that all of the information contained in this document is as accurate as possible. However, OMIG makes no warranty or guarantee, either expressed or implied, concerning the accuracy of the content of the website. No posted information or materials provided are intended to constitute legal or medical advice.

Should you have a question regarding this notice or the status of the providers contained on the exclusion list, please contact the OMIG Administrative Remedies Unit at (518) 402-1816. If you would like additional information about the exclusion of any Medicaid provider, please submit a Freedom of Information Law (FOIL) request. Information about making a FOIL request can be found on our website