How to Enroll Online as an Individual Provider

You can complete the North Dakota MMIS Web Portal online pages to enroll as an individual provider. An individual provider is a provider that reports income to the Internal Revenue Service through a Social Security number. If you are already enrolled as a North Dakota Medicaid provider, you also can complete the online pages to enroll another service location or provider type.

Optionally, you can:

• Delete information. To delete information from a record, in the table, click the appropriate row and on the panel's action bar, click Delete.
• Save the application. To complete the application at a later time, click Save.
• Exit the application. To exit the application without saving your changes, click Exit Application.
• Reset your entries. To clear the fields and remain on the page or panel, click Reset.
• Cancel your entries. To close the page or panel without saving your changes, click Cancel.

To enroll as an individual provider

1. Do one of the following:
   • On the Provider menu, click Enrollment.
   • On the Quick Links pod on the public Home page, click Provider Enrollment.

The Provider Enrollment page is displayed.

2. In the Become a Provider panel, click Individual Provider Enrollment.

   The Individual Provider Enrollment Instructions page is displayed.

3. Read the instructions and click Continue.

   The Agreement page is displayed.

4. Read the participation agreement and click Accept or Decline, as appropriate.

   If the agreement is accepted, the first of several online enrollment pages is displayed. If it is declined, a message is displayed and the enrollment process is canceled.

5. To page through and complete the following enrollment pages that are applicable, click Continue:
• Identifying Information
• Licensure/Certification
• Provider Identifier Number
• Service
• Group Affiliation
• Electronic Transaction Submission
• Ownership
• Exclusion/Sanction
  
• Qualified Service Providers

Tip: To complete or submit an application at a later time, click Save.

All entered information is lost if you choose to exit the application before saving.


6. At the end of the application pages, on the Submit Application Step 1 page, read all the applicable agreements.
7. On the Submit Application Step 1 page, read the instructions carefully and click Yes or No to indicate if you wish to have Web access. If Yes, enter your administrator's information.

Note: Web access allows you to submit claims electronically, and creates an online message center where you can receive messages and remittance advice.

8. To check your application for errors, click Validate Application and resolve any issues.

   The Submit Application Step 2 page is displayed if there are no errors.

9. Optionally, to add another provider type, on the Submit Application Step 2 page, do the following:

   1. Click Add Another Type.

   2. On the following pages, complete the fields, and then click Continue to proceed to the next page.

      • Identifying Information
      • Licensure/Certification
      • Provider Identifier Number
      • Service
   3. On the Submit Application Step 1 page, click Validate Application and research and address any duplicate issues listed in the Duplicate Data table. Multiple provider types may appear in the table as possible duplicates and can be overridden.

10. Optionally, to add another service location, on the Submit Application Step 2 page, do the following:

    1. Click Add Another Service Location.

    2. On the following pages, complete the fields, and then click Continue to proceed to the next page.

       • Identifying Information
       • Licensure/Certification
       • Provider Identifier Number
       • Service
       • Group Affiliation
    3. On the Submit Application Step 1 page, click Yes or No to indicate whether you wish to have Web access for this service location. If Yes, enter the administrator's information.
    4. Click Validate Application and research and address any duplicate issues listed in the Duplicate Data table. Multiple service locations for a provider may appear in the table as possible duplicates and can be overridden.

11. Optionally, to edit a service location that has already been entered, on the Submit Application Step 2 page, do the following:

    1. Click Edit Service Location.

    2. In the Service Locations table, click the appropriate row.

    3. On the Service page, complete the fields and navigate to any of the other pages as needed.

       • Identifying Information
       • Licensure/Certification
       • Provider Identifier Number
       • Service
       • Group Affiliation
    4. If needed, on the Submit Application Step 1 page, edit the administrator's information for this service location.
    5. Click Validate Application and research and address any duplicate issues listed in the Duplicate Data table. Multiple service locations for a provider may appear in the table as possible duplicates and can be overridden.

12. Optionally, to go back and edit the application before you submit it, on the Submit Application Step 2 page, do the following:

    1. Click Edit Application.
    2. Starting from Step 4, edit the application as needed.
13. On the Submit Application Step 2 page, in the Electronic Signature section, if you agree with a statement, click the appropriate check box.
14. In the Requested Claim Submission Effective Date section, enter the date you would like to begin submitting claims.

15. To submit the application, click Confirm Submit. After you submit your application, you cannot recall it to change or add information. Your enrollment application information is submitted to North Dakota for approval.

    The Submit Complete page is displayed.

16. If you submitted the application, on the Submit Complete page, you must also do the following:
    • Record your application tracking number, including the trading partner application number, if applicable.
    • Review any listed documents.
    • Send in any required additional documents to the address provided.
    • To print a copy of the enrollment application you just completed, click Print Application.
    • To exit the application form, click Exit Application.

What's Next?

Individual providers can optionally enroll as a group provider.

See Also

Individual Provider Enrollment (Identifying Information) Page

Individual Provider Enrollment (Licensure/Certification) Page

Individual Provider Enrollment (Provider Identifier Number) Page

Individual Provider Enrollment (Service) Page

Individual Provider Enrollment (Group Affiliation) Page

Individual Provider Enrollment (Electronic Transaction Submission) Page

Individual Provider Enrollment (Ownership) Page

Individual Provider Enrollment (Authorized Representatives) Page

Individual Provider Enrollment (Exclusion/Sanction) Page

Individual Provider Enrollment (Qualified Service Providers) Page

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

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

Individual or Group Provider Enrollment (Submit Complete) Page

How to Download a PDF Provider Instructions

How to Download a PDF Provider Enrollment Package

How to Request a Provider Enrollment Package in the Mail

How to Recall a Provider Application

What Is Provider Enrollment?

About Provider Tasks

Version as of 5/16/14.