Individual or Group Provider Enrollment (Submit Application Step 2) Page

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You use the Submit Application Step 2 page to edit your individual or group application, to add another provider type to this location, to add or edit service locations, sign the application electronically, indicate the first date you would like to submit claims, save the application to complete at a later date, or submit your application.

Submit Application Step 2 Fields

Button	Description
Add Another Type	Allows you to add another type of provider for the current service location’s enrollment application. You are taken back to the Identifying Information or Demographic page to start entering information for the next provider type.
Add Another Service Location	Allows you to add another service location to your enrollment application. You are taken back to the Identifying Information or Demographic page to start entering information for the next service location. Information from the primary service location is entered into some of the fields for you to edit.
Edit Service Location	Allows you to change existing service location information on your enrollment application before it is submitted. In the Service Locations table that is displayed, select the appropriate row.
Edit Application	Allows you to review the application and make any necessary changes.
Electronic Signature	Select the applicable check box(es) to indicate your agreement.
Requested Claim Submission Effective Date	The date you would like to begin submitting claims. Format: MM/DD/YYYY, or click the calendar to select a date.
Save	Allows you to save the Provider Enrollment application. You can finish and submit the application later by Recalling a Provider Enrollment Application on the Provider Enrollment page.
Confirm Submit	Allows you to submit your web-based application. The Submit Complete page is displayed with your application tracking number and additional information regarding your enrollment.

Button

Description

Add Another Type

Allows you to add another type of provider for the current service location’s enrollment application. You are taken back to the Identifying Information or Demographic page to start entering information for the next provider type.

Add Another Service Location

Allows you to add another service location to your enrollment application. You are taken back to the Identifying Information or Demographic page to start entering information for the next service location. Information from the primary service location is entered into some of the fields for you to edit.

Edit Service Location

Allows you to change existing service location information on your enrollment application before it is submitted. In the Service Locations table that is displayed, select the appropriate row.

Edit Application

Allows you to review the application and make any necessary changes.

Electronic Signature

Select the applicable check box(es) to indicate your agreement.

Requested Claim Submission Effective Date

The date you would like to begin submitting claims.

Format: MM/DD/YYYY, or click the calendar to select a date.

Save

Allows you to save the Provider Enrollment application. You can finish and submit the application later by Recalling a Provider Enrollment Application on the Provider Enrollment page.

Confirm Submit

Allows you to submit your web-based application. The Submit Complete page is displayed with your application tracking number and additional information regarding your enrollment.

Service Location

Field	Description
The panel is displayed when Edit Service Location is clicked. To close, in the upper-right corner of the panel, click Close. To return to the Identifying Information or Demographic page to correct information for the service location, in the Service Locations table, click the appropriate row. You can then navigate to other pages to correct information as needed.
Street	The street address of the service location.
City	The city in which the service location is located.
State	The state in which the service location is located.
Zip	The zip code of the service location.
County	The county in which the service location is located.
Application Tracking Number	Number assigned to individual or group application for this service location.

Field

Description

The panel is displayed when Edit Service Location is clicked. To close, in the upper-right corner of the panel, click Close.

To return to the Identifying Information or Demographic page to correct information for the service location, in the Service Locations table, click the appropriate row. You can then navigate to other pages to correct information as needed.

Street

The street address of the service location.

City

The city in which the service location is located.

State

The state in which the service location is located.

Zip

The zip code of the service location.

County

The county in which the service location is located.

Application Tracking Number

Number assigned to individual or group application for this service location.