Office of the Medicaid Inspector General
Compliance Certification
Social Services Law (SSL) Certification

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SSL Compliance Program Certification Form

SSL Compliance Program Certification FAQs

To be eligible to receive Medicaid payments or to submit claims, for or on behalf of another person, you are required to adopt and implement an effective compliance program.

A New York State Medicaid provider (Provider) must certify that its compliance program meets the requirements of NYS Social Services Law Section 363-d (SSL § 363-d) and 18 NYCRR Part 521 (Part 521).

New York State's Compliance Certification does not satisfy your filing requirements under the Federal Deficit Reduction Act of 2005 (DRA), which establishes requirements about the False Claims Act. For information on those requirements, see Deficit Reduction Act of 2005 (DRA) Certification Process and FAQs.


Certification Category (Choose one): *

* Required Field

Annual Certification You are an existing Provider who is subject to the mandatory compliance program obligation.
Enrolling Provider Certification You have an application pending with the New York State Department of Health (DOH) and you are subject to the mandatory compliance program obligations. You are not an enrollee if:
  • You enrolled in the Medicaid program prior to this calendar year
  • You have a Provider Identification Number (Provider ID)

Revalidating Provider Certification You are an existing Provider going through the revalidation enrollment process with the New York State Department of Health (DOH), and you are subject to the mandatory compliance program obligations. Refer to Compliance Guidance 2015-01 for directions on what compliance certification must be submitted to DOH.
Certification After Correcting Insufficiencies Identified in a Compliance Program Review You are a Medicaid Provider that has undergone a compliance program review by the New York State Office of the Medicaid Inspector General (OMIG). You were determined to have Insufficiencies cited in an OMIG Final Assessment that you were directed to correct. You have determined your compliance program now meets the requirements.
Certification After Receiving Notice of Regulatory Action for Failing to Complete Your Annual Certification You are a Medicaid Provider that has received a Notice that you are being considered for a sanction under 18 NYCRR Part 515.

Compliance Officer Information

* Required Field

First Name:* Middle Initial:
Last Name:* Suffix:
Title:*
Phone Number: (e.g.(123) 456-7890)*
Email Address:*
Re-Enter Email Address:*
Business Address Line 1:*
Business Address Line 2:
City:*
State:*
Zip Code:*

Certifying Official Information

* Required Field

First Name:* Middle Initial:
Last Name:* Suffix:
Title:*
Phone Number: (e.g.(123) 456-7890)*
Email Address:*
Re-Enter Email Address:*
Business Address Line 1:*
Business Address Line 2:
City:*
State:*
Zip Code:*

Certification

* Required Field

IMPORTANT: Making a false statement in this certification may subject you to criminal prosecution for a misdemeanor or felony under the New York State Penal Law.

The person selecting the button below declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:
  1. I am the Certifying Official whose name and contact information appears above;
  2. the Provider acknowledges and agrees that as the Certifying Official, I have authority to bind the Provider and to complete this certification on behalf of the Provider(s) listed on this form;
  3. as the Certifying Official, I have undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and have sufficient knowledge to complete this form;
  4. the Provider; all its operations that bill, order, or provide services under the NYS Medicaid program listed above have adopted, implemented and maintain a compliance program that meets the requirements of SSL § 363-d and Part 521 and shall remain in place until the next December certification period;
  5. the Provider understands that adopting, implementing and maintaining an effective compliance program that meets the requirements of SSL § 363-d and Part 521 is a requirement for the Provider to be eligible to receive medical assistance payments for care, services, or supplies, or to be eligible to submit claims for care, services, or supplies for or on behalf of another person;
  6. this certification remains in effect until the next December certification period; and
  7. the Certifying Official and the Provider acknowledge that this certification is being made to comply with the requirements of SSL § 363-d subsection 3, or 18 NYCRR § 521.3(b), or both.
*   I agree.

Captcha

 

Click the Submit button to file your certification.

When you click the "Submit" button, a Confirmation Page will appear listing the information used to complete the certification. The Confirmation Page will include the information contained on your completed certification form. Print or save the Confirmation Page for your records.

After you submit the certification form, the Compliance Officer and the Certifying Official will each receive a confirmation email at the email addresses listed by the Provider on the certification form. Save the email for your records.

     

PLEASE NOTE: Do not submit your compliance plan, supporting documentation, or self-assessment forms and work papers to OMIG unless OMIG specifically asks you to do so.