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Application Submitted
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Application Submitted
Thank you for applying for enrollment with the Connecticut Medical Assistance Program. The information on your submitted application will now be reviewed by Gainwell Technologies. If any information is missing, invalid, or Gainwell Technologies is unable to process the application, you will receive written notification of the missing or invalid information from Gainwell Technologies. Providers will not be able to correct or modify completed applications using the Wizard but will need to submit paper corrections to the following address:
Gainwell Technologies
Provider Enrollment Unit
P.O. Box 5007
Hartford, CT 06102-5007
Application Tracking Number (ATN)
Your tracking number is
Notification of Enrollment Decision
If all information has been provided and is correct, Gainwell Technologies will submit a completed application to the Department of Social Services Quality Assurance Unit for review.
If an
approval
is received from the Department of Social Services, the Gainwell Technologies Provider Enrollment Unit completes the enrollment process in the interChange system and sends a Provider Enrollment Approval Notice to the provider. New providers are encouraged to view the Medical Assistance Program Provider Manual on the www.ctdssmap.com Web site located by clicking on Information then Publications from the Home Page.
Important:
In order to avoid future claim denials, newly approved provider groups, clinics, hospital outpatient clinics and FQHC providers must also ensure that each performing provider is enrolled in the Connecticut Medical Assistance Program as an individual member of the organization. If the member is not already enrolled, they must utilize this online Web portal enrollment Wizard to do so. If the member is already enrolled but simply needs to be associated to the organization, the organization, once approved, may do this on the Secure Web portal via Demographic Maintenance.
If a
denial
is received from the Department of Social Services, Gainwell Technologies sends a Provider Enrollment/Re-enrollment Rejection Notice to the provider. This letter outlines the reason(s) the application was denied. A provider receiving a denial from Department of Social Services' Quality Assurance Unit must follow the instructions for responding to the denial as outlined in the letter. In order to reapply to the Connecticut Medical Assistance Program, a provider must once again submit an application via this Enrollment Wizard.
Save a copy of the application
for your records only.
Do not send this application to the Connecticut Medical Assistance Program.
* If you are having problems opening PDF file. Please
click here
to download the file directly.
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