PEU HOME WINDOW

The entire enrollment application must be completed on-line.
A partial Enrollment Application may be saved and retrieved. However, all fields on the page must be completed in order to utilize the "save" option for that page. A PIN is issued to retrieve the partial application. The PIN cannot be used to retrieve an application that has been finalized and submitted.
After finalizing an on-line application, ONLY the provider agreement "signature page" containing the provider's original (wet) signature and any program requirement attachments must be faxed. All pages must be in an upright position (not upside down or sideways).
The signature page and attachments must be submitted on separate pages in the same transmission, or the application will be denied. DO NOT SHRINK OR MINIMIZE PAGES to combine pages.
Fax the signature page and required attachments in one transmission to 573-634-3105. Faxed pages go directly to the Provider Enrollment database, not an actual fax machine. Only one signature page and it's attachments are accepted per transmission.
In order for the agreement and attachments to be submitted in one transmission, you must make sure that each time a transmission is completed, the fax machine you are using not only finishes moving the pages through the machine, but has also finished the transmission and has disconnected from the fax number dialed.
Providers are required to print each page of their enrollment application and maintain for their records. This includes the original (wet) signed provider agreement. However, ONLY the provider agreement page and required attachments are required to be faxed.
An altered agreement is automatically denied. Any enrollment form completed by typewriter or handwritten is not acceptable. Fields cannot be blacked out, whited out, or crossed out; writing information on the forms is not acceptable. The only writing permitted on the form is the provider's original (wet) signature on the agreement page.
If the application completed on-line needs changes, a new on-line application must be completed and submitted. If additional information needs to be submitted, a letter may be sent with the signed agreement page.
Do not submit documentation that is not required for your provider type. Refer to the "Requirements for Each Provider Type" section to determine required attachments.
Fax number 573-634-3105 is used exclusively for on-line enrollment. All other faxes to this number are disregarded without reply.
Applications for provider types requiring paper applications cannot be faxed; the original paper application must be sent to Provider Enrollment by postal mail along with the required attachments.

	State of Missouri Medicaid

SPECIAL NOTICE
If applicant is an individual who already has an active Missouri Medicaid provider number, a new application is NOT needed to add an additional practice location. If you have any questions submit them via e-mail to: providerenrollment@dss.mo.gov .
Please read instructions below before clicking Continue
Provider Enrollment Information and Requirements for new applicants and existing providers
This Provider Enrollment Application site requires the latest version of Internet Explorer or Netscape Navigator. Paper applications are no longer available nor accepted for the provider types available on-line.
Instructions for each field of the Medicaid Enrollment Application are listed on the bottom bar of the screen, click the HELP link at the bottom of each part of the application for more detailed instructions. Click on the link Provider Enrollment Information at the top of this page for program requirements and attachments.
The entire enrollment application must be completed on-line. A partial Enrollment Application may be saved and retrieved. However, all fields on the page must be completed in order to utilize the "save" option for that page. A PIN is issued to retrieve the partial application. The PIN cannot be used to retrieve an application that has been finalized and submitted. After finalizing an on-line application, ONLY the provider agreement "signature page" containing the provider's original (wet) signature and any program requirement attachments must be faxed. All pages must be in an upright position (not upside down or sideways). The signature page and attachments must be submitted on separate pages in the same transmission, or the application will be denied. DO NOT SHRINK OR MINIMIZE PAGES to combine pages. Fax the signature page and required attachments in one transmission to 573-634-3105. Faxed pages go directly to the Provider Enrollment database, not an actual fax machine. Only one signature page and it's attachments are accepted per transmission. In order for the agreement and attachments to be submitted in one transmission, you must make sure that each time a transmission is completed, the fax machine you are using not only finishes moving the pages through the machine, but has also finished the transmission and has disconnected from the fax number dialed. Providers are required to print each page of their enrollment application and maintain for their records. This includes the original (wet) signed provider agreement. However, ONLY the provider agreement page and required attachments are required to be faxed. An altered agreement is automatically denied. Any enrollment form completed by typewriter or handwritten is not acceptable. Fields cannot be blacked out, whited out, or crossed out; writing information on the forms is not acceptable. The only writing permitted on the form is the provider's original (wet) signature on the agreement page. If the application completed on-line needs changes, a new on-line application must be completed and submitted. If additional information needs to be submitted, a letter may be sent with the signed agreement page. Do not submit documentation that is not required for your provider type. Refer to the "Requirements for Each Provider Type" section to determine required attachments. Fax number 573-634-3105 is used exclusively for on-line enrollment. All other faxes to this number are disregarded without reply. Applications for provider types requiring paper applications cannot be faxed; the original paper application must be sent to Provider Enrollment by postal mail along with the required attachments.
All questions regarding provider applications and general questions for Provider Enrollment must be communicated by e-mail to providerenrollment@dss.mo.gov. A valid e-mail address is required on your application. The contact person's e-mail address also should be completed on the Enrollment Application Part 2 along with the contact person's name. The contact person is notified of questions regarding the application.
If you have technical problems or problems faxing the documents, contact the Help Desk at 573-635-3559. Instructions on how to complete the application can be found by clicking the Help link at the bottom of each part of the application.

State of Missouri Medicaid