Trading Partner Enrollment (Identifying Information) Page

You are here: Providers > Enrollment > Provider Enrollment Pages > Trading Partner Enrollment (Identifying Information) Page

You use the Identifying Information page to add or edit a trading partner's identifying information to an enrollment application.

The Identifying Information page for Trading Partner Enrollment contains the following panels:

Classification Fields

Field	Description
Billing Agent	Select if you are classified as a billing agent and want to send or receive transactions electronically.
Other Payer	Select if you are classified as some other payer and want to send or receive transactions electronically.
Carrier	Select if you are classified as a carrier to send or receive transactions electronically.
Clearing House	Select if you are classified as a clearing house and want to send or receive transactions electronically.
Switch Vendor	Select if you are classified as a switch vendor and want to send or receive transactions electronically.
Are you using software from a vendor?	Select Yes or Not to indicate if you are using vendor software to submit transactions. If you choose Yes, the Software Vendor Details panel is displayed with additional fields.

Field

Description

Billing Agent

Select if you are classified as a billing agent and want to send or receive transactions electronically.

Other Payer

Select if you are classified as some other payer and want to send or receive transactions electronically.

Carrier

Select if you are classified as a carrier to send or receive transactions electronically.

Clearing House

Select if you are classified as a clearing house and want to send or receive transactions electronically.

Switch Vendor

Select if you are classified as a switch vendor and want to send or receive transactions electronically.

Are you using software from a vendor?

Select Yes or Not to indicate if you are using vendor software to submit transactions.

If you choose Yes, the Software Vendor Details panel is displayed with additional fields.

Software Vendor Details Fields

Field	Description
These fields are displayed if you indicate that you are using software from a vendor to submit your transactions.
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 being used.

Field

Description

These fields are displayed if you indicate that you are using software from a vendor to submit your transactions.

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 being used.

Demographic Fields

Field	Description
The fields in this panel change according to what classification you choose. Each classification contains specific information. Fields for all classifications are listed in this table.
Billing Agent Option Fields
Individual	Indicates the billing agent is an individual. Shown only if classification is Billing Agent.
Business	Indicates the billing agent is a business. Shown only if classification is Billing Agent.
Depending on which option is selected, additional fields are displayed for you to enter the individual or business billing agent information. Field descriptions for both options are listed below.
Individual Billing Agent
Last Name	Last name of the individual billing agent.
First Name	First name of the individual billing agent.
Middle Initial	Middle initial of the individual billing agent.
SSN	The Social Security number of the individual billing agent.
Business Billing Agent
Business Name	The organization's official business name.
EIN	The organization's employer identification number.
Other Payer, Clearing House ,or Switch Vendor Option Fields
Business Name	The organization's official business name.
SSN/EIN	The organization's tax identification number.
Carrier Option Fields
Carrier ID	If you are a carrier and enrolling, this is your carrier identification number.
SSN/EIN	The carrier's tax identification number.

Field

Description

The fields in this panel change according to what classification you choose. Each classification contains specific information. Fields for all classifications are listed in this table.

Billing Agent Option Fields

Individual

Indicates the billing agent is an individual. Shown only if classification is Billing Agent.

Business

Indicates the billing agent is a business. Shown only if classification is Billing Agent.

Depending on which option is selected, additional fields are displayed for you to enter the individual or business billing agent information. Field descriptions for both options are listed below.

Individual Billing Agent

Last Name

Last name of the individual billing agent.

First Name

First name of the individual billing agent.

Middle Initial

Middle initial of the individual billing agent.

SSN

The Social Security number of the individual billing agent.

Business Billing Agent

Business Name

The organization's official business name.

EIN

The organization's employer identification number.

Other Payer, Clearing House ,or Switch Vendor Option Fields

Business Name

The organization's official business name.

SSN/EIN

The organization's tax identification number.

Carrier Option Fields

Carrier ID

If you are a carrier and enrolling, this is your carrier identification number.

SSN/EIN

The carrier's tax identification number.

Address Information Fields

Location Numbers Fields

Field	Description
To add location numbers, click Add Location Number. Existing numbers, if any, are displayed in a table. To edit, in the Location Numbers table, click the appropriate row. After changing or adding information, on the Numbers action bar, click Save.
Phone #	The trading partner's phone number.
Fax #	The trading partner's fax number.

Field

Description

To add location numbers, click Add Location Number. Existing numbers, if any, are displayed in a table. To edit, in the Location Numbers table, click the appropriate row. After changing or adding information, on the Numbers action bar, click Save.

Phone #

The trading partner's phone number.

Fax #

The trading partner's fax number.

Location Contact Person(s) Fields

Field	Description
To add a location contact person, click Add Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After changing or adding information, on the Contact action bar, click Save.
Last Name	The contact person's last name.
First Name	The contact person's first name.
Phone #	The contact person's phone number.
Ext	The contact person's phone extension.
Fax #	The contact person's fax number.
E-mail	The contact person's e-mail address.
Position	The contact person's position in the organization.

Field

Description

To add a location contact person, click Add Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After changing or adding information, on the Contact action bar, click Save.

Last Name

The contact person's last name.

First Name

The contact person's first name.

Phone #

The contact person's phone number.

Ext

The contact person's phone extension.

Fax #

The contact person's fax number.

E-mail

The contact person's e-mail address.

Position

The contact person's position in the organization.

Field	Description
Street Address	Trading Partner's physical street address. PO box numbers are not accepted as physical addresses.
PO Box, Building, Suite #, etc	More specific address information.
City	The city for this address.
State	The state for this address.
Zip	The zip code and extension for this address.
County	The county for this address.