Individual or Group Provider Enrollment (Submit Complete) Page

You receive the Submit Complete page when you have submitted your application successfully. It provides an application tracking number to be used when you are checking on the status of your application. You can print any required documents. All signed enrollment documents and additional information should be sent to the address indicated.

The Submit Complete page contains the following panels and options:

Application Tracking Number
Print, Sign, and Send in your application

Application Tracking Number Fields

Field	Description
Application Tracking Number	Number assigned to individual or group application. It is required when you check the status of your application either by phone or via the Web. It should also be written on all documents that are mailed in to support your application.
Trading Partner Application Number	Displayed only if vendor software information was completed on the Electronic Transaction Submission page. The number assigned to the trading partner application. It should also be written on all documents that are mailed in to support your application.

Print, Sign, and Send in Your Application Fields

Links	Description
Print Required Document Print, complete, and mail the document listed to the address indicated on the page. The list of documents depends on the type of application being submitted. Please put the Application Tracking Number on all documents that are being mailed in to support your application. The following are examples of some commonly required documents. Only original signatures are accepted. Note: Some of the fields below are for group provider enrollment only.
Provider Enrollment Signature Agreement	An agreement containing a list of signatures of person who are authorized to make inquiries and request data changes on behalf of the provider. The signatures imply agreement with all Federal and State rules and regulations for billing NH Medicaid.
Medicaid Provider Participation Agreement	Legal agreement indicating that you are participating in the NH Medicaid Program and agree to all terms listed in the agreement.
Document Requirements Checklist	A checklist of supplemental items by provider type and business model that are needed to finalize your application.
Billing Agent Agreement	An agreement authorizing the third-party Trading Partner identified on the application to submit/receive X12 transactions on behalf of the provider. This only displays if Billing Agent/Clearinghouse data is entered.
Trading Partner Enrollment Signature Page	Legal agreement that the organization (provider that is also a trading partner, or just trading partner) will abide by all federal regulations when sending/receiving electronic transactions to/from the NH MMIS. This field will only display if the Provider chooses Vendor Software on the Electronic Transaction Submission page and will need the Trading Partner Agreement Form to send in.
W-9	Request for Taxpayer Identification Number and Certification form which is used by third parties to file an informational return with the IRS on payments made to others. If the application includes W-9 as a specialty code the provider can select in the application, this field will not display as a link in this section.
Electronic Funds Transfer (EFT) Agreement	An agreement that authorizes the State of NH to directly deposit payments to that provider’s selected bank account. This must be accompanied by a voided check or bank statement copy to verify the bank routing number and bank account entered on the application. The agreement and its signature page are required if the Provider chooses to enroll in Electronic Funds Transfer.
Electronic Funds Transfer (EFT)Signature Page	A signature page that authorizes the State of NH to directly deposit payments to that provider’s selected bank account. The EFT Signature page is required if the Provider chooses to enroll in Electronic Funds Transfer.
Electronic Remittance Advice (ERA) Signature Page	A signature page that authorizes a specific type of remittance advice. The ERA Signature page is required if the Provider chooses to enroll for Electronic Remittance Advice (835).
To print a copy of the entire application you entered for your records, click Print Application. To exit the application and return to the Provider Enrollment Home page, click Exit Application.