Individual or Group Provider Enrollment (Submit Application Step 1) Page

You use the Submit Application Step 1 page to validate your application for individual and group enrollment. You can also use this page to register for Web access to check member eligibility, submit authorizations, submit claims electronically, perform claim or payment inquiries, create and maintain templates, receive messages, view and edit remittance advices, etc. When the Electronic Transaction Submission page is completed by individuals or group providers, they are required to register for a Web user ID.

Provider Enrollment - Submit Application Step 1 Fields

Field Description

Registering for Web access allows you to submit claims and other transactions electronically and creates an online message center where you can receive letters and remittance advices. It is required for providers submitting electronic transactions.

Web access allows you to access information for a single service location. If you have multiple service locations, you must add that location and provide a different user ID. You can add additional service locations on Submit Application Step 2 or using the NH MMIS Health Enterprise Portal after your application has been approved.
Would you like to register for Web access?

Select Yes or No to you indicate whether you want to register for Web access.

If Yes is selected, additional fields are displayed and required to be entered.
Legal Organization Name

Name of the practice or organization for which the Provider Organization Administrator works.

Examples: ABC Physicians Group, I. B. Doctor, MD
Organization Description

Short description of the practice or organization.

Examples: ABC Medical Care Group Facilities, I. B. Doctor General Practice
User ID

Enter the user ID the Provider Organization Administrator wants to use when logging on to the NH MMIS Health Enterprise Portal.

User IDs:

  • Are unique
  • Contain 6 to 16 alphanumeric characters
  • Contain no spaces

  • May contain one or more of the following special characters: hyphen (-), underscore (_), or period (.)

  • Conform to any other policies set by your organization
Prefix

Prefix of the person who is the Provider Organization Administrator.

Examples: Mr., Mrs., Ms., Dr.
Last Name Last name of the person who is the Provider Organization Administrator.
First Name First name of the person who is the Provider Organization Administrator.
MI Middle initial of the person who is the Provider Organization Administrator.
Suffix

Suffix of the person who is the Provider Organization Administrator.

Examples: Jr., Sr., II, III, etc.
Phone # The phone number of the person who is the Provider Organization Administrator.
Ext The extension of the phone number of the person who is the Provider Organization Administrator.
Email The e-mail address of the person who is the Provider Organization Administrator.
To check for errors on the application, click Validate Application. You must resolve any issues before submitting the application.