Individual Billing Provider Enrollment (Identifying Information) Page
You use the Identifying Information page to add an individual billing provider's identifying information to the enrollment application.
If your services may be billed as a rendering provider through a group's FEIN, the group through whom you plan to bill should complete a separate application and list you as an affiliated member, which links you to their FEIN. You should also include this group in your list of group in your list of group affiliations when you enroll.
The Identifying Information page for Individual Billing Provider Enrollment contains the following panels:
SA Waiver Medium Fields
| Field | Description |
|---|---|
| Requested delivery media for SA letter |
Letter is sent to provider's email address if INBOX is selected or mailing address if Mail is selected. |
Identifying Information- Section 1 Fields
| Field | Description |
|---|---|
| Last Name |
Provider's last name. |
| First Name | Provider's first name. |
| MI | Provider's middle initial. |
| Suffix |
Provider's suffix. Examples: Sr., Jr., etc. |
| Title |
Provider's title. Examples: M.D., O.D. |
| Date of Birth | Provider's date of birth. |
| Doing Business As (DBA) Name |
The name the provider uses to conduct business. |
| Gender | Gender of the provider (male or female). |
| May gender information be shared with members? |
Select Yes or No to indicate if you want your gender information shared with Medicaid members or not. This question is answered No by default. you must select Yes if desired. |
| SSN |
The Social Security number for the individual provider. Your SSN is linked to provider's NH Medicaid provider number. All claims paid to the NH Medicaid provider number are submitted as income under provider's SSN to the Internal Revenue Service (IRS). You must provide a valid form of SSN verification. SSN is equivalent to the Provider Tax Identification Number (TIN). If the provider plans to bill using a 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 group's FEIN. Include the group in the provider's list of group affiliations. |
Current/Previous NH Medicaid Provider # Fields
| Field | Description |
|---|---|
| Were you previously enrolled as the Medicaid provider in NH? |
Yes or No indicates if you were previously enrolled as a Medicaid provider or not. Answering Yes requires you to enter your NH Medicaid provider number. |
| NH Medicaid Provider # | The provider number you were previously assigned by New Hampshire to use when submitting Medicaid claims. |