Provider Enrollment Portal Quick Guide: Backdating a New Enrollment Application

Last updated: 03/11/2024

All providers are able to request an enrollment effective date up to ten months prior to the current date. This only applies to providers starting a new enrollment application and providers resuming an application that is still in process.

  1. Login to the Provider Enrollment Portal
  2. Request Information Panel

    The "Requesting Enrollment Effective Date" field is defaulted to the current date for new enrollment applications. Providers may enter a backdate up to ten months prior to the current date in the "Requesting Enrollment Effective Date" field.

    For providers resuming an enrollment application that is still in process, the "Requesting Enrollment Effective Date" field will be populated with the date entered when the application was last saved. That date must be within ten months prior to the current date.

    Providers should complete the remainder of their enrollment application. If the enrollment and backdate request are approved, the provider will receive a Welcome Letter which will contain the provider’s backdated contract effective date.

    Refer to the example below.

    Provider Enrollment Request Information

Need More Help?

Please visit the Provider Enrollment web page to find more resources on enrollment.