Individual or Group Provider Enrollment (Submit Application Step 1) Page

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You use the Submit Application Step 1 page to read and acknowledge any required provider agreements and validate your application for individual and group enrollment. You can also use this page to register for Web access where you can check member eligibility, submit authorizations, submit claims electronically, perform claim or payment inquiries, create and maintain templates, receive messages, view and edit remittance advices, etc. When the Electronic Transaction Submission page is completed by individuals or group providers, they are required to register for a Web user ID.

Provider Enrollment - Submit Application Step 1

Field	Description
Provider Agreement
Agreement documents	To read required agreements, click the document links.
Register for Web Access Registering for Web access allows you to submit claims and other transactions electronically and creates an online message center where you can receive letters and remittance advices.It is required for providers submitting electronic transactions Web access allows you to access information for a single service location. If you have multiple service locations, you must add that location and provide a different user ID. You can add additional service locations on Submit Application Step 2 or using North Dakota MMIS Web Portal after your application has been approved.
Would you like to register for Web access?	Select Yes or No to indicate whether you want to register for Web access. If Yes is selected, additional fields are displayed and required to be entered.
Organization Name	Name of the practice or organization in which the Provider Organization Administrator resides. Examples: ABC Physicians Group, I. B. Doctor, MD
Organization Description	Short description of the practice or organization. Examples: ABC Medical Care Group Facilities, I. B. Doctor General Practice
User ID	Enter the user ID the Provider Organization Administrator wants to use when logging on to the North Dakota MMIS Web Portal. User IDs: Are unique Contain 6 to 16 alphanumeric characters. Letters are stored as upper-case. Contain no spaces May contain one or more of the following special characters : hyphen (-), underscore (_), or period (.) Conform to any other policies set by your organization
Prefix	Prefix of the person who is the Provider Organization Administrator. Examples: Mr., Mrs., Ms., Dr.
Last Name	Last name of the person who is the Provider Organization Administrator.
First Name	First name of the person who is the Provider Organization Administrator.
MI	Middle initial of the person who is the Provider Organization Administrator.
Suffix	Suffix of the person who is the Provider Organization Administrator. Examples: Jr., Sr., II, III, etc.
Phone #	The phone number of the person who is the Provider Organization Administrator.
Ext	The extension of the phone number of the person who is the Provider Organization Administrator.
Email	The e-mail address of the person who is the Provider Organization Administrator.
Validate Application To check for errors on the application, click Validate Application. You must resolve any issues before submitting the application.

Field

Description

Provider Agreement

Agreement documents

To read required agreements, click the document links.

Register for Web Access

Registering for Web access allows you to submit claims and other transactions electronically and creates an online message center where you can receive letters and remittance advices.It is required for providers submitting electronic transactions

Web access allows you to access information for a single service location. If you have multiple service locations, you must add that location and provide a different user ID. You can add additional service locations on Submit Application Step 2 or using North Dakota MMIS Web Portal after your application has been approved.

Would you like to register for Web access?

Select Yes or No to indicate whether you want to register for Web access.

If Yes is selected, additional fields are displayed and required to be entered.

Organization Name

Name of the practice or organization in which the Provider Organization Administrator resides.

Examples: ABC Physicians Group, I. B. Doctor, MD

Organization Description

Short description of the practice or organization.

Examples: ABC Medical Care Group Facilities, I. B. Doctor General Practice

User ID

Enter the user ID the Provider Organization Administrator wants to use when logging on to the North Dakota MMIS Web Portal.

User IDs:

Are unique
Contain 6 to 16 alphanumeric characters. Letters are stored as upper-case.
Contain no spaces
May contain one or more of the following special characters : hyphen (-), underscore (_), or period (.)
Conform to any other policies set by your organization

Prefix

Prefix of the person who is the Provider Organization Administrator.

Examples: Mr., Mrs., Ms., Dr.

Last Name

Last name of the person who is the Provider Organization Administrator.

First Name

First name of the person who is the Provider Organization Administrator.

Middle initial of the person who is the Provider Organization Administrator.

Suffix

Suffix of the person who is the Provider Organization Administrator.

Examples: Jr., Sr., II, III, etc.

Phone #

The phone number of the person who is the Provider Organization Administrator.

Ext

The extension of the phone number of the person who is the Provider Organization Administrator.

The e-mail address of the person who is the Provider Organization Administrator.

Validate Application

To check for errors on the application, click Validate Application. You must resolve any issues before submitting the application.