Group Provider Enrollment (Electronic Transaction Submission) Page

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You use the Electronic Transaction Submission page when enrolling as a group provider to indicate what method you wish to use to HIPAA compliant transactions. You can chose to use a trading partner, to enroll as a trading partner yourself, or to do both. A third-party trading partner is required to apply for a trading partner ID (also known as a submitter ID) and must register for a Web User ID.

Electronic Transaction Submission - Section 6 Fields

Field	Description
Indicate which of the following will be used to submit claims electronically:
North Dakota MMIS Web Portal	Select if you want to submit HIPAA compliant transactions electronically through the North Dakota MMIS Web Portal. This option does not require a trading partner ID or affiliation.
Vendor Software	Select if you want to submit HIPAA compliant transactions electronically through vendor software. If selected additional fields are displayed.
Software Vendor Name	The name of the software vendor.
Software Name	The name of the software being used to create HIPAA compliant transactions.
Version #	The version number of the software package being used.
Protocol	The protocol for the software package being used.
Billing Agent/Clearinghouse	Select if you want to submit HIPAA compliant transactions electronically through a billing agent or clearinghouse. If selected additional fields are displayed.
Agent/Clearinghouse Name:	The name of the agent or clearinghouse that is being used to submit HIPAA compliant transactions.
Contact First Name	The first name of the person at the agent or clearinghouse.
Contact Last Name	The last name of the person at the agent or clearinghouse.
Contact Phone #	The phone number of the contact person.
Street Address	The physical street address where the agent or clearinghouse is located.
City:	City in which the agent or clearinghouse is located.
State	State in which the agent or clearinghouse is located.
Zip Code	Zip code and extension where the agent or clearinghouse is located.
Please check transactions that you submit and/or receive:
Submit	Select all transactions that you want to submit electronically.
Receive	Select all transactions that you want to receive electronically.

Field

Description

Indicate which of the following will be used to submit claims electronically:

North Dakota MMIS Web Portal

Select if you want to submit HIPAA compliant transactions electronically through the North Dakota MMIS Web Portal. This option does not require a trading partner ID or affiliation.

Vendor Software

Select if you want to submit HIPAA compliant transactions electronically through vendor software. If selected additional fields are displayed.

Software Vendor Name

The name of the software vendor.

Software Name

The name of the software being used to create HIPAA compliant transactions.

Version #

The version number of the software package being used.

Protocol

The protocol for the software package being used.

Billing Agent/Clearinghouse

Select if you want to submit HIPAA compliant transactions electronically through a billing agent or clearinghouse. If selected additional fields are displayed.

Agent/Clearinghouse Name:

The name of the agent or clearinghouse that is being used to submit HIPAA compliant transactions.

Contact First Name

The first name of the person at the agent or clearinghouse.

Contact Last Name

The last name of the person at the agent or clearinghouse.

Contact Phone #

The phone number of the contact person.

Street Address

The physical street address where the agent or clearinghouse is located.

City:

City in which the agent or clearinghouse is located.

State

State in which the agent or clearinghouse is located.

Zip Code

Zip code and extension where the agent or clearinghouse is located.

Please check transactions that you submit and/or receive:

Submit

Select all transactions that you want to submit electronically.

Receive

Select all transactions that you want to receive electronically.