To submit the Medicaid Provider application, mail the signed form along with required documentation to Gainwell Technologies Provider Services at P.O. Box 4804, Trenton, NJ 08650. Alternatively, you can fax your completed application with credentials to 609-584-1192. For any questions or additional assistance, contact Gainwell Technologies Provider Services at 609-588-6036.

Important deadlines for the Medicaid provider application will vary based on enrollment cycles and state requirements. It's crucial to stay updated with the New Jersey Department of Human Services for specific submission dates in 2024 and 2025. Regularly check for announcements related to any changes in application processes or requirements.

The purpose of this form is to facilitate the enrollment of healthcare practitioners in the Medicaid program. This application is essential for physicians and other professionals who wish to provide services to Medicaid beneficiaries in New Jersey. Completing this form accurately ensures compliance with both state and federal healthcare regulations.

• 1. Practitioner Name: The full name of the applicant.
• 2. NPI Number: National Provider Identifier, a unique identification number.
• 3. Date of Birth: The date of birth of the practitioner.
• 4. Practitioner Address: The complete address of the practitioner.
• 5. SS#: Social Security number of the applicant.
• 6. Practitioner Contact Name: Contact person's name, if different from the practitioner.
• 7. Contact Phone #: The phone number for contacting the practitioner.
• 8. Email Address: Email address for communication.
• 9. Fax Number: Fax number for document submissions.
• 10. Type of Service: Type of medical service being applied for.
• 11. Tax ID: Tax Identification Number for the applicant.
• 12. Certification No.: Number assigned to certifications, if applicable.
• 13. Medicaid Provider #: Medicaid Provider number for existing providers.

Failing to submit this form can result in delays or denial of Medicaid provider enrollment. It is vital to ensure that all information is accurate and complete to prevent rejections. If there are issues with your application, you may face obstacles in billing or providing services to Medicaid beneficiaries.

• Denial of Medicaid Enrollment: Incomplete applications can lead to outright denials of enrollment.
• Delayed Processing: Errors in the application can cause significant delays in processing.
• Ineligibility for Services: Without successful submission, providers may be ineligible to bill for services rendered.

• 1. New Provider Enrollment: If you are a new provider needing to enroll in the Medicaid program.
• 2. Referring Medicaid Clients: If you are a practitioner who will be referring patients for Medicaid services.
• 3. Revalidation of Enrollment: When you need to update your existing Medicaid enrollment information.