You use the Licensure/Certification page to add or edit a group provider's license, certification, and specialty information to an enrollment application.
The Licensure/Certification page for Group Provider Enrollment contains the following panels:
| Field | Description |
|---|---|
| Provider Type |
Type of provider you are. Examples: Physician, Dentist, etc. |
| Field | Description |
|---|---|
| To add new license or certification click Add Licensure and Certification. Existing license and certification, if any, is displayed in a table. To edit, in the Licensure and Certification List table, click the appropriate row. After changing or adding new licenses or certifications, on the License and Certification action bar, click Save. | |
| Are you adding license or certification information? | Select either License or Certification depending on which you are adding. Additional fields are displayed for you to enter specific license or certification information. |
| License Information Fields | |
| Provider Type |
Type of provider for which you are adding information. You may add license information for multiple provider types associated with this service location. Automatically displayed. |
| License Number | Provider license number. |
| Lic/Cert or Licensing Agency | Name of the agency who issued the license. |
| Effective Date |
Date when the license became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date on when the license expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| State |
The State that issued the license number. Example: ND |
| Certification Information Fields | |
| Provider Type |
Type of provider for which you are adding information. You may add license information for multiple provider types associated with this service location. Automatically displayed. |
| Certification # | Provider's certification number. |
| Certifying Agency | Certification agency's name. |
| Effective Date |
Date when the certification became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the certification expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| State |
State in which the license was issued. Example: ND |
| Field | Description |
|---|---|
| To add a new specialty, click Add Specialty. Existing specialties, if any, are displayed in a table. To edit, in the Specialty List table, click the appropriate row.After changing or adding new specialties, on the Specialty action bar, click Save. | |
| Specialty |
The Provider's specialty type. A specialty requires completion of the appropriate residency program and board certification or eligibility. Examples: OB/GYN, Internal Medicine, etc. |
| Provider Type |
Type of provider for which you are adding information. You may add license information for multiple provider types associated with this service location. Automatically displayed. |
| Begin Date |
Date when the specialty became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date when the specialty expires. Automatically displayed. |
| Cert # or Certification # | Provider certification number. |
| Board Name |
Name of the Medical board. Example: State Board of Medicine |
| State |
State in which the specialty certification was issued. Example: ND |
| Field | Description |
|---|---|
| To add a new taxonomy, click Add Taxonomy. Existing taxonomy codes, if any, are displayed in a table. To edit, in the Taxonomy table, click the appropriate row. After changing or adding new taxonomy codes, on the Taxonomy action bar, click Save. | |
| Taxonomy |
The 10 digits/alpha taxonomy code of the provider's group. |
| Begin Date |
Date when the taxonomy became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date when the taxonomy expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
Version as of 5/16/14.
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