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Individual Provider Enrollment (Ownership) Page

You use the individual Provider Enrollment pages to add paper applications received from providers. On the Ownership page, you add ownership information according to the paper application.

 

Ownership- Section 7 Fields

Field Description

Ownership Fields

1. Have you ever had ownership in any organization that has billed, or is currently billing Medicare or ND Program services?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed for you to add or edit the provider's ownership information.
To add new ownership information, click Add Ownership. To edit, in the Ownership table, click the appropriate row.
Organization’s Legal Business Name Organization's legal business name as it appears in IRS forms.
Effective Date Date when ownership became effective.
End Date Date when ownership ends.
Address Physical street address of organization.
City City where the organization is located.
State State where the organization is located.
Zip Zip code and extension where the organization is located.
EIN Organization's employer identification number.
Please enter your NPI and/or Medicaid numbers. Select to indicate if you have a current Medicare and/or Medicaid number.
NPI # The organization's National Provider ID number.
Current Medicare Number Organization's current Medicare number.
Current Provider # Organization's current Medicaid number.

Managing/Directing Fields

2. Have you ever managed or directed any organization that has billed or is currently billing Medicare or NDMedicaid Program services?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields display for you to complete information for each organization the owner has managed or directed in the last 10 years.

To add new managing/directing information, click Add Managing/Directing Information. To edit, in the Managing/Directing Information table, click the appropriate row.
Organization’s Legal Business Name The legal business name of the organization.
Effective Date Date when ownership became effective.
End Date Date when ownership ends.
Address Physical street address of organization.
City

City where the organization is located.
State

State where the organization is located.

Default: ND

Zip Zip code and extension where the organization is located.
EIN Organization's employer identification number.
Please enter your NPI and/or Medicaid numbers. Select to indicate if you have a current Medicare and/or Medicaid number.
NPI # The organization's National Provider ID number.
Medicare # Organization's Medicare number.
Medicaid Number Organization's current ND Medicaid number.

Subcontractor Information Fields

3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients.)

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit subcontractor information.
To add new subcontractor information, click Add Subcontractor. To edit, in the Subcontractor table, click the appropriate table row.
Subcontractor Name Name of the individual, agency, or organization to which the provider has contracted or delegated some of the management functions or responsibilities of providing medical care to the provider's patients.
Address Physical street address of the subcontractor providing medical care to the provider's patients.
City City where the subcontractor is located.
State State where the subcontractor is located.
Zip Zip code and extension where the subcontractor is located.

Subcontractor Relative Fields

4. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed for you to add or edit family information.
To add new family information, click Add Relative. To edit, in the Relative table, click the appropriate row.
Last Name Last name of the relative who has ownership in the subcontractor business or practice.
First Name First name of the relative who has ownership in the subcontractor business or practice.
MI Middle initial of the relative who has ownership in the subcontractor business or practice.
Suffix Suffix of the relative who has ownership in the subcontractor business or practice.
Relationship Relationship of relative to the owner of the subcontractor business or practice.
Subcontractor Name Name of the individual, agency, or organization to which the provider has contracted or delegated some of the management functions or responsibilities of providing medical care to the provider's patients that is associated with the relative.
Address Physical street address of the subcontractor associated with the relative.
City City where the subcontractor associated with the relative is located.
State State where the subcontractor associated with the relative is located.
Zip Zip code and extension where the subcontractor associated with the relative is located.

 

Version as of 5/16/14.

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