Individual Billing Provider Enrollment (Licensure/Certification) Page
You use the Licensure/Certification page to add or update an individual provider's license, certification, specialty, and taxonomy information to the enrollment application.
The Licensure/Certification page for Individual Provider Enrollment contains the following panels:
Provider Type Fields
| Field | Description |
|---|---|
| Provider Type |
Type of provider you are. Examples: Dentist, Individual, Pharmacy, Optician, Hospice, Medical Service Supplier, etc. |
Licensure and Certification- Section 2 Fields
| Field | Description |
|---|---|
| To add a new license or certification, click Add Licensure/Certification. Existing license and certification information, if any, are listed in a table. To edit, in the Licensure and Certification List table, click the appropriate row. After changing or adding new licenses or certifications, on the License and Certification action bar, click Save. | |
| Are you adding license or certification information? | Select either License or Certification, depending on which you are adding. Additional fields are displayed for you to enter specific license or certification information. |
| License Information Fields | |
| License # | Provider license number. |
| Licensing Agency | Name of the agency who issued the license. |
| Effective Date |
Date when the license became effective. Format: MM/DD/YYYY, or click the calendar to select. |
| Expiration Date |
Date when the license expires. Format: MM/DD/YYYY, or click the calendar to select. |
| State | State in which the license was issued. |
| Certification Information Fields | |
| Cert # or Certification # | Provider's certification number. |
| Cert Agency or Certifying Agency | Certification agency's name. |
| Effective Date |
Date when the certification became effective. Format: MM/DD/YYYY, or click the calendar to select. |
| Expiration Date |
Date when the certification expires. Format: MM/DD/YYYY, or click the calendar to select. |
| State | State in which the certification was issued. |
Specialty Fields
| Field | Description |
|---|---|
| To add a new specialty, click Add Specialty. Existing specialties, if any, are displayed in a table. To edit, in the Specialty List table, click the appropriate row. After changing or adding new specialties, on the Specialty action bar, click Save. | |
| Specialty |
Provider's specialty type. A specialty requires completion of the appropriate residency program and board certification or eligibility. Examples: OB/GYN, Internal Medicine, etc. |
| Cert # or Certification # | Provider certification number. |
| Cert Agency or Certification Agency | Certification agency's name. |
| State | State in which specialty certification was issued. |
Taxonomy Fields
| Field | Description |
|---|---|
| To add a new taxonomy, click Add Taxonomy. Existing taxonomy codes, if any, are displayed in a table. To edit, in the Taxonomy table, click the appropriate row. After changing or adding new taxonomy codes, on the Taxonomy action bar, click Save. | |
| Taxonomy | The 10-digit/alpha taxonomy code of the provider. |
| Begin Date |
Date the taxonomy code became effective. Format: MM/DD/YYYY, or click the calendar to select. |
| End Date |
Date the taxonomy code expires. Format: MM/DD/YYYY, or click the calendar to select. |