Medicaid Payments Provider Certification

I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the state’s Title XIX plan and to furnish information regarding any payments claimed for providing such services, as the state agency or Department of Health and Human Services may request.

I further agree to accept as payment in full the amount paid by the Medicaid program for those claims submitted, including co-insurance, co-payment, or similar co-sharing charges.

Signature of Physician or Supplier

I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me, or by my employee under my personal direction.

Notice

This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of the claim will be from federal and state funds. I further understand that any false claims, statements, or documents, or the concealment of a material fact, may be prosecuted under applicable federal or state laws.

Payments

Thank you for your claim submission. If your claim is complete, you will receive payment at the next pay cycle. Payments are processed on the 1st and 3rd Mondays. If you have questions about your claim, email [email protected]. If you have questions about your payment, email [email protected]

Payment will come from Melio ACH to the account you designated. ACH takes 3-5 business days from the email notification. The client's ID on the payment is the insurance initials, the last 4 digits of the claim number, and the client's initials. Ex. OHSUx1234-IN. It can be found on the invoice number and the notes from the customer.

Payments