Individual or Group Provider Enrollment (Submit Application Step 2) Page
You use the Submit Application Step 2 page to edit your individual or group application, add another service location to your application, save the application to complete at a later date, or submit your application.
Note: Before any submission actions are performed, NH MMIS checks that ALL required fields have been entered for ALL locations associated to this application. If this is not true, an error message is displayed to you with instructions to complete the missing data.
The Provider Enrollment - Submit Application Step 2 page contains two panels:
Provider Enrollment - Submit Application Step 2 Fields
| Button | Description |
|---|---|
| Add Another Service Location |
Allows you to add another service location to your enrollment application. You are taken back to the Identifying Information or Demographic page to start entering information for the next service location. Information from the primary service location is entered into some of the fields for you to edit. Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this option will not be available. |
| Edit Service Location |
Allows you to change existing service location information on your enrollment application before it is submitted. In the Service Locations table that is displayed, select the appropriate row. Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this option will not be available. |
| Edit Application |
Allows you to review the application and make any necessary changes. |
| Save |
Allows you to save the Provider Enrollment application. You can finish and submit the application later by Recalling a Provider Enrollment Application on the Provider Enrollment page. |
| Confirm Submit |
Allows you to submit your web based application. The Submit Complete page is displayed with your application tracking number and additional information regarding your enrollment. |
Service Location Fields
| Field | Description |
|---|---|
|
The panel is displayed when Edit Service Location is clicked. To close, in the upper-right corner of the panel, click Close. To return to the Identifying Information or Demographic page to correct information for the service location, in the Service Locations table, click the appropriate row. You can then navigate to other pages to correct information as needed. |
|
| Street | The street address of the service location. |
| City | The city in which the service location is located. |
| State | The state in which the service location is located. |
| Zip | The zip code of the service location. |
| County | The county in which the service location is located. |