Individual Billing Provider Enrollment (Ownership) Page

You use the Ownership page to add or edit an individual provider's ownership information to the enrollment application.

Ownership- Section 7 Fields

Field Description
1. How many owners of this application have a 5% or more ownership interest in the group?

The total number of owners with 5% or more ownership interest in the group in the field provided.

If you enter a number other than zero, additional fields are displayed for you to add or edit ownership information.

Ownership Fields

To add a new owner information, click Add Ownership. To view or edit, in the Ownership table, click the appropriate row.
Is the Owner an individual or group?

Indicates whether the owner is an individual or group.

Depending on which answer you select, additional fields appear for you to enter the provider's individual or group ownership information. Field descriptions for all options are listed below.

This field is only displayed when you add ownership information. If you must change ownership information from an individual to a group, you must delete the old record and add a new one.
Individual Selected As Owner
Last Name
 Last name of the owner.
First Name First name of the owner.
MI Middle initial of the owner.
Title Title of the owner.
Doing Business As (DBA) Name Owner's business name.
Effective Date of Ownership Date on which the ownership became effective.
Date of Birth Owner's date of birth.
Address Street address of the owner.
City City where the owner is located.
State State where the owner is located.
Zip Zip code and extension of the owner's location.
SSN Owner's Social Security Number.
NH Title XIX Provider ID Owner's assigned Medicaid ID, if applicable.
Direct Ownership or Indirect Ownership Select if the owner has direct ownership or indirect ownership.
Does this person have a familial relationship with another owner or person with controlling interest? Select Yes or No. If yes, provide the relationship of the owner.
Relationship Relationship of the owner with another owner or person with controlling interest.
Group Selected As Owner
Group Name Name of the group.
Doing Business As (DBA) Name Official name under which the organization is doing business as.
Effective Date of Ownership Date on which the ownership became effective.
End Date of Ownership Date on which the ownership ends.
Date of Birth Owner's date of birth.
Address Street address of the owner.
State State where the owner is located.
City City where the owner is located.
ZIp Zip code and extension of the owner's location.
SSN Owner's Social Security Number.
NH Title XIX Provider ID Owner's assigned Medicaid ID, if applicable.
Direct Ownership or Indirect Ownership Select if the owner has direct ownership or indirect ownership.
Does this person have a familial relationship with another owner or person with controlling interest? Select Yes or No. If yes, provide the relationship of the owner.
Relationship Relationship of the owner with another owner or person with controlling interest.
2. Please list all board members and executive officers that have a controlling interest in the corporation or partnership
Controlling Interest Details

To add a new controlling interest information, click Add Controlling Interest. To view or edit, in the Controlling Interest table, click the appropriate row.
Last Name
 Last name of the person with controlling interest.
First Name First name of the person with controlling interest.
MI Middle initial of the person with controlling interest.
Title Title of the person with controlling interest.
Doing Business As (DBA) Name Business name of the person with controlling interest.
Effective Date of Controlling Interest Date on which the person's controlling interest became effective.
End Date of Controlling Interest Date on which the person's controlling interest expires.
Date of Birth Date of birth of the person with controlling interest.
Address Street address of the person with controlling interest.
State State where the person is located.
City City where the person is located.
ZIp Zip code and extension of the person's location.
SSN Social Security Number of the person with controlling interest.
NH Title XIX Provider ID The person's Medicaid provider identification number.
Direct Ownership or Indirect Ownership Select if the person has direct ownership or indirect ownership.
Does this person have a familial relationship with another owner or person with controlling interest? Select Yes or No. If yes, provide the relationship of the person.
Relationship Relationship that the person has with another owner or person with controlling interest.
3. Do any of the owners, listed in question #1, have 5% or more ownership/controlling interest in a subcontractor to this provider? (A Subcontractor is an individual, agency, or organization to which a disclosing entity (i.e., the health plan) has contracted or delegated some of its management functions or responsibilities of providing Medicaid-covered services to its patients.)

Select Yes or No.
Owner/Subcontractor Details

To add a new owner/subcontractor information, click Add Owner/Subcontractor. To view or edit, in the Owner/Subcontractor Details table, click the appropriate row.
Owner Last Name Last name of the owner or sub owner.
Owner First Name First name of the owner or sub owner.
MI Middle initial of the owner or sub owner.
Subcontractor Legal Name Legal name of the subcontractor.
Effective Date The date when the Medicaid cover became effective.
End Date The date on which the Medicaid cover expires.
Address Street address of the owner or sub owner.
City City where the owner or sub owner is located.
State State where the owner or sub owner is located.
Zip Zip and extension of the owner or sub owner's located.
Does this person have a familial relationship with the owner of the subcontractor? Select Yes or No. If yes, provide the relationship of the person.
Relationship Relationship that the person has with another owner or person with controlling interest.

4a. Identify the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the past 12 months.

4b: List the significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

Subcontractor Owner Details

To add a new subcontractor information, click Add Subcontractor Owner. To edit the Subcontractor Owner table, select the appropriate row.
Owner Last Name Last name of the subcontractor owner.
Owner First Name First name of the subcontractor owner.
MI Middle initial of the subcontractor owner.
Address The subcontractor's street address.
City The subcontractor's city.
State The subcontractor's state.
Zip The subcontractor's zip code and extension.
List the significant business transactions from 4b. List the business transactions that happened during the 5-years period ending on the date of the request.
5. What is the total number of managing/directing employees for the group? The total number of managing/directing employees in the group.
Employee Details

To add a new managing or directing employee information, click Add Employee. To edit the Managing/Directing Employee table, select the appropriate row.
Last Name Last name of the employee.
First Name First name of the employee.
MI Middle initial of the employee.
Title Title of the employee.
Date of Birth Date of birth of the employee.
SSN Social Security Number of the employee.
Address Street address of the employee.
City City where the employee is located.
State State where the employee is located.
Zip Zip and extension of the employee located.
6. Has the managing/directing employee ever had a Title XIX provider number in this or any other state? Select Yes or No. If yes, additional fields are displayed for you to provide information on the Title XIX provider number.
Business Name Employee's business name.
Effective Date Date on which the Title XIX provider number became effective.
End Date Date on which the Title XIX provider expires.
SSN/FEIN Social Security Number or Organization's Federal Employer Identification Number of the employee.
Current Title XIX Provider # The current Title XIX provider number of the employee.
State State that issued the Title XIX provider number.
Prior Title XIX Provider # The Title XIX provider number used by the employee.
State State that issued the Title XIX provider number.