Source: https://apps.omig.ny.gov/ssl/ssl_certification.aspx
Timestamp: 2020-07-11 11:58:50
Document Index: 725193439

Matched Legal Cases: ['§ 363', 'art 521', 'art 521', 'art 515', '§ 363', 'art 521', '§ 363', 'art 521', '§ 363', '§ 521']

SSL Certification Form
Social Services Law (SSL) Certification
Provider Name* Provider ID* Re-Enter
Provider ID* FEIN* Re-Enter
FEIN* NPI Re-Enter NPI
SSL Compliance Program Certification Form
SSL Compliance Program Certification FAQs
To be eligible to receive Medicaid payments or to submit claims, for or on behalf of another person, you are required to adopt and implement an effective compliance program.
A New York State Medicaid provider (Provider) must certify that its compliance program meets the requirements of NYS Social Services Law Section 363-d (SSL § 363-d) and 18 NYCRR Part 521 (Part 521).
New York State's Compliance Certification does not satisfy your filing requirements under the Federal Deficit Reduction Act of 2005 (DRA), which establishes requirements about the False Claims Act. For information on those requirements, see Deficit Reduction Act of 2005 (DRA) Certification Process and FAQs.
Certification Category (Choose one): *
Annual Certification You are an existing Provider who is subject to the mandatory compliance program obligation.
Enrolling Provider Certification You have an application pending with the New York State Department of Health (DOH) and you are subject to the mandatory compliance program obligations. You are not an enrollee if:
You enrolled in the Medicaid program prior to this calendar year
You have a Provider Identification Number (Provider ID)
Revalidating Provider Certification You are an existing Provider going through the revalidation enrollment process with the New York State Department of Health (DOH), and you are subject to the mandatory compliance program obligations. Refer to Compliance Guidance 2015-01 for directions on what compliance certification must be submitted to DOH.
Certification After Correcting Insufficiencies Identified in a Compliance Program Review You are a Medicaid Provider that has undergone a compliance program review by the New York State Office of the Medicaid Inspector General (OMIG). You were determined to have Insufficiencies cited in an OMIG Final Assessment that you were directed to correct. You have determined your compliance program now meets the requirements.
Certification After Receiving Notice of Regulatory Action for Failing to Complete Your Annual Certification You are a Medicaid Provider that has received a Notice that you are being considered for a sanction under 18 NYCRR Part 515.
Instructions to complete your SSL Compliance Program Certification:
It is each Provider's responsibility to determine if you have a compliance program obligation.
If you have a compliance program obligation, you must electronically certify your compliance program using this form on the Office of the Medicaid Inspector General's (OMIG) website.
If you are required to certify that you have a compliance program and do not have or will not have a program that meets the certification requirements, you must take immediate steps to implement and maintain a compliance program that meets the requirements. Failure to do so may result in further action against you by OMIG.
All fields containing a red asterisk (*) are required fields and must be completed.
For each Provider ID being certified, the Provider Name must be included.
If you wish to use one certification form to certify for multiple Provider IDs, click "Add Provider."
To use one certification form to certify for more than one Provider ID, you must meet all the requirements listed in Instruction 2 below.
There is a "Total" next to "*Required Field." This reflects the number of times that you have indicated you wish to add a Provider. Use the "Remove Provider" box to remove the last provider added or the extra box if you added more providers than you actually intend to certify.
Your Provider ID is required to complete the compliance program certification. Your Provider ID is the Medicaid Management Information Systems (MMIS) Provider ID assigned at your enrollment in the Medicaid program. Your Provider ID was assigned to you by the New York State Department of Health (DOH).
Include your Federal Employer Identification Number (FEIN) associated with the Provider ID(s) you are certifying.
It is possible that you may have more than one Provider ID associated with a single FEIN.
If you are certifying using multiple Provider IDs on one certification form (see Instruction 2 below), the FEIN field becomes a required field for all Provider IDs being certified on the form.
If you have a National Provider Identifier (NPI) associated with a Provider ID, include that number on the form.
Do not submit a certification for a Provider ID that does not have an obligation to implement and maintain a compliance program.
MULTIPLE PROVIDER IDs ON ONE CERTIFICATION FORM:
If you submit Medicaid claims, receive Medicaid payments, or order Medicaid services under more than one Provider ID that has a compliance program obligation, you may be able to submit one certification that includes all the Provider IDs, if all of the following conditions are met:
the same compliance program applies to all the Provider IDs listed on this certification form;
the Certification Category chosen is the same for all the Provider IDs listed on this certification form;
the Compliance Officer is the same for all the Provider IDs listed on this certification form;
the Certifying Official is the same for all the Provider IDs listed on this certification form; and
all Provider IDs reported on the certification have the same FEIN.
Please note: Certifying entities may enter up to 150 Provider IDs on a single certification form. Certifying entities that have additional Provider IDs to certify must complete and submit additional certification form(s) as needed to capture all Provider IDs subject to the certification requirement.
COMPLIANCE OFFICER INFORMATION:
The Compliance Officer is the employee who is vested with responsibility for the day-to-day operation of the compliance program. For Providers with multiple compliance staff, the single individual vested with responsibility for oversight of the whole compliance program should be listed as the Compliance Officer.
CERTIFYING OFFICIAL INFORMATION:
The Certifying Official should be someone other than the Compliance Officer. Additionally, the Certifying Official should be the person who completes and submits the certification on OMIG's website. Please see Compliance Guidance 2016-01 for more information.
After you submit the form, you will be taken to a Confirmation Page. OMIG recommends that you print and/or download the PDF of the Confirmation Page.
Instructions to complete your SSL Compliance Program Certification - Enrolling Provider:
Provider Name must be included.
Include the FEIN associated with your pending Medicaid application. You must certify separately for each FEIN. Certification may not be combined for multiple FEIN(s).
If you have a National Provider Identifier (NPI) associated with the FEIN, include that number on the form.
Do not submit a certification for an FEIN that does not have an obligation to implement and maintain a compliance program.
* Required Field Total:
***Click on the Add Provider button to add a new provider. →
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IMPORTANT: Making a false statement in this certification may subject you to criminal prosecution for a misdemeanor or felony under the New York State Penal Law.
The person selecting the button below declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:
I am the Certifying Official whose name and contact information appears above;
the Provider acknowledges and agrees that as the Certifying Official, I have authority to bind the Provider and to complete this certification on behalf of the Provider(s) listed on this form;
as the Certifying Official, I have undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and have sufficient knowledge to complete this form;
the Provider; all its operations that bill, order, or provide services under the NYS Medicaid program listed above have adopted, implemented and maintain a compliance program that meets the requirements of SSL § 363-d and Part 521 and shall remain in place until the next December certification period;
the Provider understands that adopting, implementing and maintaining an effective compliance program that meets the requirements of SSL § 363-d and Part 521 is a requirement for the Provider to be eligible to receive medical assistance payments for care, services, or supplies, or to be eligible to submit claims for care, services, or supplies for or on behalf of another person;
this certification remains in effect until the next December certification period; and
the Certifying Official and the Provider acknowledge that this certification is being made to comply with the requirements of SSL § 363-d subsection 3, or 18 NYCRR § 521.3(b), or both.
Click the Submit button to file your certification.
When you click the "Submit" button, a Confirmation Page will appear listing the information used to complete the certification. The Confirmation Page will include the information contained on your completed certification form. Print or save the Confirmation Page for your records.
After you submit the certification form, the Compliance Officer and the Certifying Official will each receive a confirmation email at the email addresses listed by the Provider on the certification form. Save the email for your records.
PLEASE NOTE: Do not submit your compliance plan, supporting documentation, or self-assessment forms and work papers to OMIG unless OMIG specifically asks you to do so.