Individual Billing Provider Enrollment (Group Affiliation) Page

The Group Affiliation page is used to add or edit the group providers on whose behalf you perform services to the enrollment application.

If the provider's services may be billed as a rendering provider through a group's Federal Employer Identification Number (FEIN), the group through whom he or she plans to bill should complete a separate application and list the provider as an affiliated member, which links him or her to their enrollment application. Include this group in the provider's list of group affiliations.

Group Affiliation- Section 5 Fields

Field	Description
To add a new group, click Add Group. Existing group information, if any, is displayed in a table. To edit, in the Group Affiliation table, click the appropriate row. After changing or adding new group practices, on the Group action bar, click Save.
Name of Group Practice	Name of the group practice.
New Hampshire Title XIX Provider #	New Hampshire Medicaid provider number belonging to the group practice, specific to the service location on this application.
Effective Date of Affiliation	Date the group affiliation began. Format: MM/DD/YYYY, or click the calendar to select.