You use the Provider Identifier Number page to add or edit identification numbers to the individual provider's enrollment application.
The Provider Identifier Number page for Individual Provider Enrollment contains the following panels:
| Field | Description |
|---|---|
|
National Provider Identification (NPI) Fields To add a new NPI, click Add NPI. Existing NPIs, if any, are listed in a table. To edit, in the NPI table, click the appropriate row. After changing or adding an NPI number, on the NPI action bar, click Save. |
|
| NPI | Provider's National Provider Identifier number. |
|
Drug Enforcement Agency (DEA) Fields To add a new DEA, click Add DEA. Existing DEA numbers, if any, are displayed in a table. To edit, in the DEA table, click the appropriate row. After changing or adding a DEA number, on the DEA action bar, click Save. |
|
| DEA# | Provider's Drug Enforcement Agency number. |
| Medicaid Provider Fields | |
| Are you or have you been enrolled as a Medicaid Provider in another State? | Select Yes or No if you were previously enrolled as a Medicaid provider in another state. If you select Yes, select the state in which you were previously enrolled. |
| Other Medicaid State | State in which you were previously enrolled. |
| Field | Description |
|---|---|
|
Coordination of Benefits Agreement (COBA) claims, prior to NPI assignments, will not be paid unless a Medicare number is supplied. A Medicare number may only be placed on one provider file (group or individual). COBA claims will pay to the provider number to which the Medicare number is linked. Medicare may have issued a Medicare provider number for each facility where you provide services. Numbers assigned to you on behalf of an affiliated group should be added to the Medicare Numbers table. To add new Medicare information, click Add Medicare. Existing Medicare information, if any, is displayed in a table. To edit, in the Medicare Numbers table, click the appropriate row. After you edit or add Medicare information, on the Medicare # action bar, click Save. |
|
| Medicare # |
Provider's Medicare number. |
| Begin Date |
Date when the Medicare number became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date when the Medicare number expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Medicare Programs |
The Medicare payments you are currently authorized to receive. Examples: All, Medicare Program A, Medicare Program B |
|
Medicare History Fields To add new history information, click Add History. Existing Medicare history information, if any, is displayed in a table. To edit, in the Other Medicare Numbers table, click the appropriate row. After you edit or add history information, on the History action bar, click Save. |
|
| Medicare # | Any provider's Medicare number assigned to you in the past. |
| Carrier/Intermediary Name | Name of the Medicare carrier or intermediary. |
| Begin Date |
Date when the Medicare number became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date when the Medicare number expired. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Medicare Programs |
The Medicare payments you were authorized to receive. Examples: All, Medicare Program A, Medicare Program B |
Version as of 5/16/14.
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