Physician Enhancement Self-Attestation

Per 42 CFR 447.400, beginning January 1, 2013 and continuing through December 31, 2014 Medicaid is required to pay certain physicians up to the current Medicare rate.

In order to qualify for this enhanced rate, physicians must provide attestation that they are Board certified in family medicine, general internal medicine, pediatric medicine or a sub-specialty within one of these specialties.

Or, a provider may qualify for the enhanced payment if 60% or more of all Medicaid services they bill (including Medicaid managed care environments) are for the following codes: 99201 - 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474.

In the form below, please include the required provider information as well as an attestation under one of the above mentioned criteria.

Please note that certification to either of these criteria is subject to audit.

    Provider Information

    This is a required question
    This is a required question
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    This is a required question
    This is a required question
    This is a required question
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    This is a required question
    This is a required question
    This is a required question

    Attestation with Board Certification

    This is a required question
    This is a required question
    This is a required question

    Attestation without Board Certification

    This is a required question
    This is a required question

    Attestation to Information Provided

    This is a required question

    Providers qualifying under Board Certification or subspecialty option above must also fax a copy of their board certification and any subspecialty certifications to (801) 536-0484 in order to complete the self-attestation. The fax cover sheet should include the provider’s name, NPI, and a contact phone number.