Individual Billing Provider Enrollment (Electronic Transaction Submission) Page
You use the Electronic Claims Submission page when enrolling as an individual provider to indicate what method you wish to use to submit HIPAA compliant transactions. You can chose to use a trading partner, to enroll as a trading partner yourself, or to do both. A third-party trading partner is required to apply for a trading partner ID (also known as a submitter ID) and must register for a Web User ID.
Electronic Claims Submissions- Section 6 Fields
Field | Description |
---|---|
Indicate which of the following will be used to submit transactions electronically: | |
New Hampshire MMIS Health Enterprise System Web Portal | Select if you want to submit HIPAA compliant transactions electronically through the NH MMIS Health Enterprise Portal. This option does not require a trading partner ID or affiliation. |
Vendor Software |
Select if you want to submit HIPAA compliant transactions electronically through vendor software. If selected additional fields are displayed. Note: Only populate if you are doing your own billing electronically and not using a billing agent or clearing house. |
Software Vendor Name | The name of the software vendor. |
Software Name | The name of the software being used to create claims for submission. |
Version # | The version number of the software package being used. |
Protocol | The protocol for the software package being used. |
Billing Agent/Clearinghouse | Select if you want to submit HIPAA compliant transactions electronically through a billing agent or clearinghouse. |
Agent/Clearinghouse Name | The name of the agent or clearinghouse that is being used to submit HIPAA compliant transactions. |
Contact First Name | The first name of the person at the agent or clearinghouse. |
Contact Last Name | The last name of the person at the agent or clearinghouse. |
Contact Phone # | The phone number of the contact person. |
Street Address | The physical street address where the agent or clearinghouse is located. |
Street Address 2 | Continuation of the physical street address where the agent or clearinghouse is located. Use only if needed. |
City | City in which the agent or clearinghouse is located. |
State | State in which the agent or clearinghouse is located. |
Zip Code | Zip code and extension where the agent or clearinghouse is located. |
All | Select if you want to submit HIPAA compliant transactions electronically through all options above. If selected, additional fields are displayed. |
Please check transactions that you submit and/or receive: | |
Submit | Select all transactions that you want to submit electronically. |
Receive | Select all transactions that you want to receive electronically. |