Group Provider Enrollment (Licensure & Certification) Page
You use the Licensure & Certification page to add or edit a group provider's license, certification, specialty, and taxonomy information to an enrollment application.
The Licensure & Certification page for Group Provider Enrollment contains the following panels:
Provider Type Field
| 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 new license or certification click Add Licensure and Certification. Existing license and certification, if any, is displayed 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 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 Number | Provider license number. |
| Licensing Agency | Name of the agency who issued the license. |
| State |
The State that issued the license number. Example: NH |
| Effective Date |
Date when the license became effective. Format: MM/DD/YYYY, or click the calendar to select. |
| Expiration Date |
Date on when the license expires. Format: MM/DD/YYYY, or click the calendar to select. |
| Certification Information Fields | |
| Certification # | Provider's certification number. |
| Certifying Agency | Name of the agency who issued the certification number. |
| State |
The State that issued the certification number. Example: NH |
| 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. |
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 |
The Provider's specialty type. A specialty requires completion of the appropriate residency program and board certification or eligibility. Examples: OB/GYN, Internal Medicine, etc. |
| Certification # | The provider's certification number. |
| Certification Agency | Name of the agency who issued the certification. |
| State |
The State that issued the specialty certification number. Example: NH |
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's group. |
| Begin Date |
Date when the taxonomy became effective. Format: MM/DD/YYYY, or click the calendar to select. |
| End Date |
Date when the taxonomy expires. Format: MM/DD/YYYY, or click the calendar to select. |