Group Provider Enrollment (Electronic Transaction Submission) Page

You use the Electronic Transaction Submission page when enrolling as a group provider to indicate what method you wish to use to 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.
Software Vendor Name	The name of the software vendor. Note: Only populate if you are doing your own billing electronically and not using a billing agent or clearing house.
Software Name	The name of the software being used to create HIPAA compliant transactions.
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. If selected, additional fields are displayed.
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 Address2	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.
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.