Trading Partner Enrollment (Identifying Information) Page

You use the Identifying Information page to add or edit a trading partner's identifying information to an enrollment application.

The Identifying Information page for Trading Partner Enrollment contains the following panels:

• Classification
• Software Vendor Details
• Demographic
• Address Information
  • Location Numbers
  • Location Contact Numbers

Classification Fields

Field	Description
Billing Agent	Select if you are classified as a billing agent and want to send or receive transactions electronically.
Other Payer	Select if you are classified as some other payer and want to send or receive transactions electronically.
Carrier	Select if you are classified as a carrier to send or receive transactions electronically.
Clearing House	Select if you are classified as a clearing house and want to send or receive transactions electronically.
Switch Vendor	Select if you are classified as a switch vendor and want to send or receive transactions electronically.
Are you using software from a vendor?	Select Yes or Not to indicate if you are using vendor software to submit transactions. If you choose Yes, the Software Vendor Details panel is displayed with additional fields.

 

Software Vendor Details Fields

Field	Description
These fields are displayed if you indicate that you are using software from a vendor to submit your transactions.
Software Vendor Name	The name of the software vendor.
Software Name	The name of the software being used to create HIPAA compliant transactions.
Version ID #	The version number of the software package being used.
Protocol	The protocol for the software being used.

 

Demographic Fields

Field	Description
The fields in this panel change according to what classification you choose. Each classification contains specific information. Fields for all classifications are listed in this table.
Billing Agent Option Fields
Individual	Indicates the billing agent is an individual. Shown only if classification is Billing Agent.
Business	Indicates the billing agent is a business. Shown only if classification is Billing Agent.
Depending on which option is selected, additional fields are displayed for you to enter the individual or business billing agent information. Field descriptions for both options are listed below.
Individual Billing Agent
Last Name	Last name of the individual billing agent.
First Name	First name of the individual billing agent.
Middle Initial	Middle initial of the individual billing agent.
SSN	The Social Security number of the individual billing agent.
Business Billing Agent
Business Name	The organization's official business name.
FEIN	The organization's Federal Employer Identification number.
Other Payer, Clearing House, or Switch Vendor Options Fields
Business Name	The organization's official business name.
SSN/FEIN	The organization's tax identification number.
Carrier Option Fields
Carrier ID	If you are a carrier and enrolling, this is your carrier identification number.
SSN/FEIN	The carrier's tax identification number.

 

Address Information Fields

Field	Description
Street Address	Trading Partner's physical street address. PO box numbers are not accepted as physical addresses.
PO Box, Building, Suite #, etc	More specific address information.
City	Location's city.
State	Location's state.
Zip	Location's zip code.
County	Location's county.

 

Location Numbers Fields

Field	Description
To add location numbers, click Add Location Number. To view or edit, in the Location Numbers table, click the appropriate row.
Phone #	The trading partner's phone number.
Fax #	The trading partner's fax number.

 

Location Contact Person(s) Fields

Field	Description
To add a location contact person, click Add Contact Person. To view or edit, in the Location Contact Person(s) table, click the appropriate row.
Last Name	The contact person's last name.
First Name	The contact person's first name.
Middle Initial	The contact person's middle initial.
Phone # or Phone Number	The contact person's phone number.
Ext	The contact person's phone extension.
Fax #	The contact person's fax number.
E-Mail	The contact person's e-mail address.
Position	The contact person's position in the organization.