State Provider Enrollment - Frequently Asked Questions

Who needs to enroll in Mississippi Medicaid?

Any provider who would like to receive Medicaid reimbursement for services rendered to Mississippi Medicaid recipients. This includes rendering and billing providers, groups, and facilities.

How do I enroll?

To enroll as a Mississippi Medicaid provider, you have two submission options:

• Downloading the application and submitting hard copy signature pages/documents
• Enrolling online and submitting the hard copy signature pages and documentation

These application methods are located under “Provider” on the Envision website along with the enrollment requirements for each provider type

What information do I need?

• A completed Mississippi Medicaid Enrollment Application
• A completed Mississippi Medicaid Provider Disclosure Form
• Electronic Funds Transfer (Direct Deposit Authorization Form) including verification of the bank account (preprinted voided check, deposit slip or letter from the bank verifying the account number and transit routing number
• Medical Assistance Participation Agreement
• Completed W-9 for the enrolling provider
• Completed Civil Rights Compliance Information Request Package
• Any additional specific required documentation for the provider type in which you are enrolling as noted on the Additional Enrollment Requirements Checklist
• Effective from 01/01/2020, all Out of State enrolling providers are also required to submit the Provider Application Cover Letter

After verifying your specific required documentation and completing the necessary forms, mail the signed signature page and all other required documents to:

Mississippi Medicaid Program
Provider Enrollment
P.O. Box 23078
Jackson, MS 39225

How long does it take to hear back from enrollment?

Once the completed application is submitted, the enrollment process should be completed within six to eight weeks. The application form must be mailed and applications must contain original and not copies of signatures. Please call 1-800-884-3222 for questions concerning your application.

Who should I contact with further questions?

You may contact the Provider Enrollment Unit at 225-216-6370.

You may contact a Provider Enrollment Specialist by calling (800) 884-3222 for any questions concerning your application. For questions concerning why Envolve has requested you take action, please contact Customer Service at 1-888-241-0663.