• 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.