Individual Billing Provider Enrollment (Service) Page

You use the Service page to add or edit an individual provider's primary service location, mailing, and billing information to the enrollment application.

The Service page for Individual Provider Enrollment page contains the following panels:

Note: The EFT and Remittance Advice panels will open new pop-up windows with additional fields, depending on the selections made.

You can open or close certain panels. Click The plus sign icon (the plus sign) beside a panel to open the panel. Click The minus sign icon (the minus sign) to close the panel.

Service Location Information- Section 4 Fields

Field Description
These fields contain information about the provider's primary service location for this application. Additional locations may be added on the Submit Application - Part 2 page or after your application has been approved.
Primary Physical Address (P.O. Box not accepted) Provider's physical street address. PO box numbers are not accepted as physical addresses. Up to 64 alphanumeric characters can be entered.
Building, Suite #, etc. More specific address information. Up to 64 alphanumeric characters can be entered.
City Location's city.
State

Location's state.

Default: NH
Zip Location's zip code and extension.
County Location's county. Automatically completed after the address is validated.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Service Location Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save.
Phone # Phone number associated with this location.
Fax # Fax number associated with this location.

Location Contact Person(s) Fields

To add a new contact person, click Add Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.
Last Name Last name of this location's contact person.
First Name First name of this location's contact person.
MI or Middle Initial Middle initial of this location’s contact person.
Phone or Phone Number Phone number of this location’s contact person.
Ext Extension of this location’s contact person.
Fax # Fax number of this location’s contact person.
Email E-mail address of this location’s contact person.
Position Position in the organization of this location’s contact person.

 

Service- Section 4 Fields

Field Description
Gender Served Select each gender the provider serves.
Age Range Served Select each age range the provider serves.
Languages Supported

Languages supported by the provider.

  • To move an item from the Available list to the Selected list, select the item, and then click Right arrow (the right arrow).

  • To move an item from the Selected list to the Available list, select the item, and then click Left arrow (the left arrow).

  • To select or clear multiple items, press CTRL and click the items.
Other Language If Other was selected in the Languages Supported list, enter the other language the provider supports that is not already listed.
Is this location wheelchair accessible? Select Yes or No to indicate if the location has wheelchair access.
Is this location TDD/TTY equipped for receiving calls for hearing impaired? Select Yes or No to indicate if the location is equipped for the hearing impaired. If Yes is selected, an additional field is displayed to enter the phone number.
TDD/TTY Phone # The TDD/TYY phone number for the hearing impaired, if the location has one.
Does this location provide emergency services after standard business hours? Select Yes or No to indicate if the location provides after-hours services. If Yes is selected, an additional field is displayed to provide the phone number.
After Hours Contact Phone # If the location does have after-hours services, the phone number to be used.

 

Clinical Laboratory Improvement Amendments (CLIA) Fields

Field Description
If the application is for an independent laboratory or physician’s office that performs non-waivered laboratory services, a current CLIA certificate is required. To add new CLIA information, click Add CLIA. Existing CLIA information, if any, is displayed in a table. To edit, in the CLIA table, click the appropriate row. After you edit or add information, on the CLIA action bar, click Save. You must provide photocopies of all certificates listed.
CLIA # The CLIA certificate number.
Effective Date The beginning date of this certification.
Expiration Date The date the certification expires.

 

Mailing Address Fields

Field Description
Is this mailing address the same as service location?

Indicates if the mailing address is the same as the service location address. If Yes, then the service location address is automatically copied to the mailing address fields. If No, then additional fields are displayed for you to enter the mailing address.

Note: Mailing Address fields are the same address fields listed in the Service Location Information panel above.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Mailing Address Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save.

Note: The fields in the Mailing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.

Mailing Address Contact Person Fields

To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.

Note: The fields in the Mailing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.

 

Electronic Funds Transfer (EFT) Payment Fields

Field Description
Do you wish to participate in Electronic Funds Transfer Payments?

Select Yes or No to indicate if you want to participate in Electronic Funds Transfer Payments.

If Yes, then additional fields for EFT enrollment are displayed and the provider must submit a completed and signed EFT Agreement with this application.

Note: You may also choose to enroll at a later time. To do this, use the EFT Enrollment link on your Provider home page after logging in.

If the provider indicated Yes to enroll in EFT, the fields below are displayed and must be filled in.
Provider Information
Provider Name Complete legal name of institution, corporate entity, practice or individual provider.
Doing Business As (DBA) Name A legal term used in the United States meaning that the trade name, or fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it.
Provider Address 
Street The number and street name where a person or organization can be found.
City City associated with provider address field.
State/Province ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country.
Zip Code/Postal Code System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities.
Provider Identifiers Information
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity.
National Provider Identifier (NPI) A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Provider License Number The provider's license number.
License Issuer The issuer of provider's license.
Provider Type A proprietary health plan-specific indication of the type of provider being enrolled for EFT with specific provider type description included by the health plan in its instruction and guidance for EFT enrollment (e.g., hospital, laboratory, physician, pharmacy, pharmacist, etc.)
Provider Taxonomy Code A unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification and Area of Specialization.
Provider Contact Information
Provider Contact Name Name of a contact in provider office for handling EFT issues.
Title The provider's title.
Telephone Number The telephone number associated with contact person.
Telephone Number Extension The provider's telephone number extension, if applicable.
Email Address An electronic mail address at which the health plan might contact the provider.
Fax Number A number at which the provider can be sent facsimiles.
Financial Institution Information
Financial Institution Name Official name of the provider's financial institution.
Street Street address associated with receiving depository financial institution name field.
City City associated with receiving depository financial institution address field.
State/Province ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country.
Zip Code/Postal Code System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities.
Financial Institution Routing Number A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited.
Provider’s Account Number with Financial Institution Provider's account number at the financial institution to which EFT payments are to be deposited.
Type of Account at Financial Institution

The type of account the provider will use to receive EFT payments.

Examples: Checking, Saving
Financial Institution Telephone Number A contact telephone number at the provider's bank.
Account Number Linkage to Provider Identifier Provider preference for grouping (bulking) claim payments – must match preference for v5010 X12 835 remittance advice.
Submission Information
Reason for Submission The reason for submitting the EFT enrollment.
Authorized Signature The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. May be used with electronic and paper-based manual enrollment.

 

Billing Address Fields

Field Description
The billing address is the location to which mailed payments will be sent (the Pay-To address). Billing Address fields are the same address fields listed in the Service Location Information panel above.
Is this billing address the same as the service location? Select Yes or No to indicate if the billing address is the same as the service location. If Yes, then the service location address is automatically copied to the Billing Address fields. If No, then answer the second question.
Is this billing address the same as the mailing address? Select Yes or No to indicate if the billing address is the same as the mailing address. If Yes, then the mailing address is automatically copied to the Billing Address fields. If No, then additional fields are displayed for you to enter the billing address.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Billing Address Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the action bar, click Save.

Note: The fields in the Billing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.

Billing Address Contact Person Fields

To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.

Note: The fields in the Billing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.
Email E-mail address of this location’s contact person.
Does a third party billing agent submit your claims? Select Yes or No to indicate if a third party billing agent submits your claims. If Yes, then the Billing Agent agreement must be signed and sent in.
Does the Billing agent have access to make inquiries on your behalf? Displayed if a third-party billing agent is submitting your claims. Select Yes or No to indicate if the billing agent can make inquiries on your behalf.

 

Remittance Advice Field

Field Description
Requested Delivery Media for Remittance Advices (RAs)

Select how you want to receive your remittance advice. If Web Portal Provider Message Center is chosen, then you must register for Web access.

Note: If you select Both or Electronic, additional fields are displayed to complete for Electronic Remittance Advice (ERA) enrollment. You can also enroll later by using the ERA Enrollment link on the provider home page.

Options are: Electronic (835), Web Portal Provider - Message Center (Downloadable to paper), Electronic (820), Electronic Remittance Advice Report (820)

Electronic Remittance Advice Enrollment Fields

These fields are displayed if the provider selected the Electronic (835) option.
Provider Information
Provider Name Complete legal name of institution, corporate entity, practice or individual provider.
Doing Business As Name(DBA) A legal term used in the United States meaning that the trade name, or fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it.
Provider Address 
Street The number and street name where a person or organization can be found.
City City associated with provider address field.
State/Province ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country.
Zip Code/Postal Code System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities.
Provider Identifiers Information
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity.
National Provider Identifier (NPI) A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Provider License Number The provider's license number.
License Issuer The issuer of provider's license.
Provider Type A proprietary health plan-specific indication of the type of provider being enrolled for ERA with specific provider type description included by the health plan in its instruction and guidance for ERA enrollment (e.g., hospital, laboratory, physician, pharmacy, pharmacist, etc.)
Provider Taxonomy Code A unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification and Area of Specialization.
Provider Contact Information
Provider Contact Name Name of a contact in the provider office for handling ERA issues.
Title The provider's title.
Telephone Number The telephone number associated with the contact person.
Telephone Number Extension The provider's telephone number extension, if applicable.
Email Address An electronic mail address at which the health plan might contact the provider.
Fax Number A number at which the provider can be sent facsimiles.
Electronic Remittance Advice Information
Preference for Aggregation of Remittance Data (eg. Account Number Linkage to Provider Identifier) Provider preference for grouping (bulking) claim payment remittance advice – must match preference for EFT payment.
Submission Information
Reason for Submission The reason for submitting the ERA enrollment.
Authorized Signature The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. May be used with electronic and paper-based manual enrollment.