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Individual Provider Enrollment (Service) Page

You use the Service page to add or edit an individual provider's primary service location, mailing, and billing information to the enrollment application.

The Service page for Individual Provider Enrollment page contains the following panels:

You can open or close certain panels. Click (the plus sign) beside a panel to open the panel. Click (the minus sign) to close the panel.

 

Service Location Information- Section 4 Fields

Field Description
These fields contain information about the provider's primary service location for this application. Additional locations may be added on the Submit Application - Step 2 page or after the provider's application has been approved.
Physical Address (P.O. Box not accepted) Provider's physical street address. PO box numbers are not accepted as physical addresses. Up to 64 alphanumeric characters can be entered.
Building, Suite #, etc. More specific address information. Up to 64 alphanumeric characters can be entered.
City Location's city.
State

Location's state.

Default: ND

Zip Location's zip code and extension.
County Location's county. Automatically completed after the address is validated.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Location Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Location Phone Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save.
Phone Type The type of number associated with this location.
Contact Number The number associated with this phone type.

Service Location Contact Person Fields

To add a new contact person, click Add Service Location Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Service Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Service Location Contact Person action bar, click Save.
Service Location Name A descriptive identifier for the primary service location.
Last Name Last name of this location's contact person.
First Name First name of this location's contact person.
MI or Middle Initial Middle initial of this location’s contact person.
Phone or Phone Number Phone number of this location’s contact person.
Ext Extension of this location’s contact person.
Fax Fax number of this location’s contact person.
Cell The mobile phone number of this location's contact person.
Email E-mail address of this location’s contact person.
Position Position in the organization of this location’s contact person.

 

Service- Section 4 Fields

Field Description
Gender Served
 Select each gender the provider serves.
Age Range Served Select each age range the provider serves.
Languages Supported

Languages supported by the provider.

  • To move an item from the Available list to the Selected list, select the item, and then click Right pointing arrow (the right arrow).
  • To move an item from the Selected list to the Available list, select the item, and then click Left pointing arrow (the left arrow).
  • To select or clear multiple items, press CTRL and click the items.
Other Language If Other was selected in the Languages Supported list, enter the other language the provider supports that is not already listed.
Please define your services area by counties served, or by distance from your location.

The area served by this location. Select Counties or Distance From, depending on how you want to define your service area.

To select the counties served:

  • To move an item from the Available list to the Selected list, select the item, and then click Right pointing arrow (the right arrow).
  • To move an item from the Selected list to the Available list, select the item, and then click Left pointing arrow (the left arrow).
  • To select or clear multiple items, press CTRL and click the items.
Is this location wheelchair accessible? Select Yes or No to indicate if the location has wheelchair access.
Is this location TDD/TTY Equipped? Select Yes or No to indicate if the location is equipped for the hearing impaired. If Yes is selected, an additional field is displayed to enter the phone number.
TDD/TTY Phone # The TDD/TYY phone number for the hearing impaired, if the location has one.
Does this location provide after hours services? Select Yes or No to indicate if the location provides emergency services after standard business hours. If Yes is selected, an additional field is displayed to provide the phone number.
After Hours Contact Phone # If the location does have after-hours services, the phone number to be used.
Do you wish to be excluded from public provider searches? Select Yes if you wish to be excluded, or No if wish to be included.
Are you a 340b Provider? Select Yes or No if you participate in the 340B Drug Pricing Program and are affiliated with a pharmacy or are a pharmacy that provides prescription drugs at a reduced rate.

Hours of Operation Fields

To add hours, click Add Hours of Operation. To edit, in the Hours of Operation table, click the appropriate row.
Day of Week The day the facility is open.
Open The time the facility opens.
Close The time the facility closes.

Interpretive Services Available Field

To add existing interpretive services, click Add Interpretive Service. To edit, in the Interpretive Services Available table, click the appropriate row.
Interpretive Service Available/Interpretive Service

Type of interpretive service that the provider can provide.

Examples: Braille, Oral, Sign, TDD-TTY, Other
Special Needs Field
Special Needs Check box indicating the location is equipped to service a particular special need, such as mental health disabilities or deaf/hearing impaired disabilities. Select all the special needs that this location is equipped to serve.

 

Clinical Laboratory Improvement Amendments (CLIA) Fields

Field Description
If the application is for an independent laboratory or physician’s office that performs non-waivered laboratory services, a current CLIA certificate is required. To add new CLIA information, click Add CLIA. Existing CLIA information, if any, is displayed in a table. To edit, in the CLIA table, click the appropriate row. After you edit or add information, on the CLIA action bar, click Save. You must provide photocopies of all certificates listed.
CLIA # The CLIA certificate number.
Begin Date The beginning date of this certification.
End Date The beginning date of this certification.

 

Mailing Address Fields

Field Description
Is this mailing address the same as service location?

Indicates if the mailing address is the same as the service location address. If Yes, then the service location address is automatically copied to the mailing address fields. If No, then additional fields are displayed for you to enter the mailing address.

Note: Mailing Address fields are the same address fields listed in the Service Location Information panel above.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Location Numbers Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Location Numbers table click the appropriate row. After you edit or add numbers, on the Numbers action bar, lick Save.

Note: The fields in the Mailing Location Numbers panel are the same as those found in the Service Location Numbers panel.

Mailing Location Contact Person Fields

To add a new number, click Add Mailing Location Contact Person. Existing numbers, if any, are displayed in a table. To edit, in the Mailing Location Contact Person(s) table, click the appropriate row. After you edit or add numbers, on the Mailing Location Contact Person action bar, lick Save.

Note: The fields in the Mailing Location Contact Person panel are the same as those found in the Service Location Contact Person panel.

 

Electronic Funds Transfer (EFT) Payment Fields

Field Description
Do you wish to participate in Electronic Funds Transfer Payments? Select Yes or No to indicate if you want to participate in Electronic Funds Transfer Payments. If Yes, then additional fields are displayed for you to enter banking information.
Bank Name Name of the provider’s financial institution where EFT payments are deposited. Up to 255 alphanumeric characters.
Bank Address The address of the provider's bank.
Address The continuation of the address for the provider's bank.
City The city where the provider's bank is located.
State The state where the provider's bank is located.
Zip The zip code and extension where the provider's bank is located.
Bank Routing Transit # Provider’s bank routing number for EFT. Up to 9 numeric characters.
Bank Account # Provider’s bank account number for EFT transactions. Up to 15 numeric characters.
Account Type

The type of account where EFT payments are deposited.

Default: Checking
Bank Phone # Bank phone number where the provider's account is held.
Account Holder Name The account holders full name.
Payee Name The provider's payee name.

 

Billing Address Fields

Field Description
The billing address is the location to which mailed payments will be sent (the Pay-To address). Billing Address fields are the same address fields listed in the Service Location Information panel above.
Is this billing address the same as the service location?

Select Yes or No to indicate if the billing address is the same as the service location. If Yes, then the service location address is automatically copied to the Billing Address fields. If No, then answer the second question.

Is this billing address the same as the mailing address? Select Yes or No to indicate if the billing address is the same as the mailing address. If Yes, then the mailing address is automatically copied to the Billing Address fields. If No, then additional fields are displayed for you to enter the billing address.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Location Numbers Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Location Numbers table click the appropriate row. After you edit or add numbers, on the Numbers action bar, lick Save.

Note: The fields in the Billing Location Numbers panel are the same as those found in the Service Location Numbers panel.

Billing Location Contact Person Fields

To add a new number, click Add Billing Location Contact Person. Existing numbers, if any, are displayed in a table. To edit, in the Billing Location Contact Person(s) table, click the appropriate row. After you edit or add numbers, on the Billing Location Contact Person action bar, lick Save.

Note: The fields in the Billing Location Contact Person panel are the same as those found in the Service Location Contact Person panel.
Does a third party billing agent submit your claims? Select Yes or No to indicate if a third party billing agent submits your claims. If Yes, then the Billing Agent agreement must be signed and sent in.
Does the Billing agent have access to make inquires on your behalf? Displayed if a third-party billing agent is submitting your claims. Select Yes or No to indicate if the billing agent can make inquires on your behalf.

 

Remittance Advice Fields

Field Description
Requested Delivery Media for Remittance Advices (RAs)

Select how you want to receive your remittance advice. If Web Portal Provider Inbox is chosen, then you must register for Web access.

Options are: Electronic (835), Web Portal Provider Inbox (Downloadable to paper), Paper (sent to your billing address)

 

Other Details

Field Description
Print Suspense Choose one of the options listed if you would like to include your suspended claims on your remittance advice.
RA Sort Ind Select how you would like your remittance advice sorted. If none is chosen, the RA will default to the member’s last name.
Bulletin Media Select how you would like to receive your bulletins.

 

Version as of 5/16/14.

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