Provider Enrollment Portal Quick Guide: Backdating a New Enrollment Application

Last updated: 05/5/2023

All providers are able to request an enrollment effective date up to 365 days 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.

For providers who are already enrolled and approved, a Backdate Enrollment Form (located on the Provider Forms web page under Provider Enrollment & Update Forms) must be completed.  Upload the completed form as an attachment from the Attachments and Submit page of the online Provider Maintenance tool in the Provider Web PortalPlease note: The backdate form is only for fee-for-service billing. Child Health Plan Plus (CHP+) and behavioral health providers need to contact their Managed Care Organization (MCO) or Regional Accountable Entity (RAE) to determine rules as they may have different restrictions.

  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 365 days 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 365 days 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.