Provider Revalidation Page

The Provider Revalidation Demographic page enables you to view and edit the revalidation information of individual and group providers.

The Revalidation Demographic page has the following panels:

Demographic
License/Specialty
Financial
Medicare Crossover
Identifiers
Exclusion/Sanction
Ownership Information
- Individual Ownership
  Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this option will not be available.
- Group Ownership
Authorized Representatives
Authorized Validator
Risk Level and Screening Requirements
Signature
Reval Confirmation

Demographic Fields

Field	Description
General Information To edit the general information, select the Edit Information check box.
Last Name	The legal last name of the provider. Examples: Stone, Smith, Jones, Apple
First Name	The legal first name of the provider. Example: Ida
Middle Initial	Middle initial of the provider.
Suffix	Letters that appear at the end of a person's last name. Used when one or more relatives in the same family have the same name to indicate relationship to one another. Examples: I, II, III, IV, V, Jr., Sr.
Title	The provider's title.
Date of Birth	The date the person was born; the person's date of birth. Format: MM/DD/YYYY Example: 05/23/1935
Legal Name as it appears on W9	The provider’s legal name as it appears on the W9.
Doing Business As (DBA) Name Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this field will not be available.	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.
Former DBA Name Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this field will not be available.	The provider's former Doing Business As (DBA) name.
Other State Medicaid Program Information
Have you revalidated with another state Medicaid program within the last 5 years?	Select Yes or No. If yes is selected, an additional field is displayed for entry.
Please identify the state	The state in which the last Medicaid program was revalidated.
Have you paid the application fee?	If you have paid the application fee, select Yes. If not, select No.
Service Location/Billing Address/Mailing Address Information Note: For a Non-Billing ORP or Non-Billing Rendering provider, Billing Address section will be disabled.
Street Address	The mailing address for the provider. Note: When you are editing the Street Address, you need to provide the Line 1 and Line 2 address.
City	City where the provider is located.
State	State where the provider resides.
Zip Code	The zip code and extension of the provider's address.
Location Numbers To add information in the Location Number fields, click Add Numbers. Note: Only for newly added record the Delete button is enabled.
Phone #	Phone number of the provider's work place. Note: You can edit the phone number of the provider by clicking the Phone# link.
Fax #	Fax number of the provider's work place.
Location Contact Person(s) To add information in the Location Contact Person(s) fields, click Add Contact Person. To edit the fields in this section, select the Edit Information check box. Note: Only for newly added record the Delete button is enabled.
Last Name	Last name of the contact at provider's office. Note: You can edit the last name of the contact person by clicking the Last Name link.
First Name	First name of the contact person.
Middle Name	The middle initial or name of the contact person.
Position	Position of the contact person in the organization.
Phone #	Phone number of the contact person in the organization.
Ext	The phone extension of the contact person in the organization.
Cell Phone #	Cell phone number of the contact person.
Fax #	Fax number of the contact person.
Email	Email address of the contact person

License/Specialty Fields

Field	Description
License/Certification To edit the fields in this section, select the Edit Information check box.
Are you adding license or certification information?	Select License or Certification depending on which you are adding or editing. If you select License, additional fields are displayed for you to enter specific license information.
License #	The provider's license number. Note: You can edit the license number of the provider by clicking the License# link.
Licensing Agency	The name of agency that issued the license.
Certification #	Provider's certification number. Note: You can edit the certification number of the provider by clicking the Certification# link.
Certifying Agency	The name of agency that issued the certification.
State	The state that issued the certification number.
Effective Date	Date when the certification became effective. Format: MM/DD/YYYY
Expiration Date	Date when the certification expires. Format: MM/DD/YYYY
Certification To edit the fields in this section, select the Edit Information check box.
Are you adding License or Certification information?	Select License or Certification depending on which you are adding or editing. If you select Certification, additional fields are displayed for you to enter specific certification information.
Certification #	Provider's certification number.
Certifying Agency	Name of the agency who issued the certification.
Certification Verified	Indicates whether you have verified the certification information. You verify that it was received, signed, and current.
Effective Date	Date when the certification became effective. Format: MM/DD/YYYY
Expiration Date	Date when the certification expires. Format: MM/DD/YYYY
State	State that issued the certification number.
Provider Specialty To add the provider specialty information, click the Add Provider Specialty button. To edit the fields in this section, select the Edit Information check box.
Provider Specialty	The provider's specialty type. A specialty requires completion of the appropriate residency program and board certification or eligibility. Examples: OB/GYN, Internal Medicine
Certification #	The provider's certification number.
Effective Date	Date when the certification became effective. Format: MM/DD/YYYY
Expiration Date	Date when the certification expires. Format: MM/DD/YYYY
State	State that issued the specialty certification number. Example: NH
Certifying Agency	Name of the agency that issued the certification.
Taxonomy To add the taxonomy information, click the Add Taxonomy button. To edit the fields in this section, select the Edit Information check box.
Taxonomy	The 10-digit/alpha taxonomy code of the provider's group. CMS defines the Taxonomy Codes as an administrative code set for identifying the provider type and the area of specialization for all health care providers. The code set is used in X12-278 Referral Certification and Authorization and the X12 837 Claim transactions. It is maintained by the National Uniform Claim Committee (NUCC).
Begin Date	Date the taxonomy became effective. Format: MM/DD/YYYY
End Date	Date the taxonomy expires. Format: MM/DD/YYYY

Financial Fields

Field	Description
SSN/FEIN You are only allowed to view your SSN/FEIN number and not edit it.
SSN/FEIN	Social Security Number or Organization's Federal Employer Identification Number.
Tax ID Type	The type of tax identification number.
Please confirm TAX ID Information is valid	Select Yes or No to confirm if the Tax ID is valid.

Medicare Crossover Fields

Field	Description
Medicare Crossover To add the Medicare information, click the Add Medicare Crossover Data button. To edit the fields in this section, select the Edit Information check box. Note: The Delete button is enabled only for the newly added request.
Medicare #	Medicare number of the provider. Note:You can edit the Medicare number of the provider by clicking the Medicare # link.
Medicare Program	Type of Medicare program. Examples: A, B, C, D
Begin Date	Begin date of the Medicare program. Format: MM/DD/YYYY
End Date	End date of the Medicare program. Format: MM/DD/YYYY

Identifier Fields

Field	Description
Alternate Provider ID To edit the fields in this section, select the Edit Information check box.
Alternate ID Type	The source member's alternate identification type. Example: MID
Alternate ID	The source member's alternate identification number.
Begin Date	The date when the Alternate ID number became effective. Format: MM/DD/YYYY
End Date	The date when the Alternate ID will expire. Format: MM/DD/YYYY

Exclusion/Sanction Fields

Field	Description
Conviction Information in NH Medical Assistance Program Fields
1. Has any person who has ownership of, or a controlling interest in, the provider’s practice or business entity, or who is an agent, managing employee, contract employee, subcontractor, or employee of the provider’s practice or business entity, ever been convicted of a criminal offense related to New Hampshire’s Medical Assistance Programs, the Medicaid program in another state or territory, the Medicare program, or any other federally funded health or social service program?	Select Yes or No. If yes, additional fields are displayed for you to provide the conviction information.
To add a new conviction, click Add Name. To edit the conviction information, click the appropriate row.
Last Name	Last name of the person convicted of a criminal offense in NH Medical Assistance Program.
First Name	First name of the person convicted of a criminal offense in NH Medical Assistance Program.
Middle Name	Middle initial of the person convicted of a criminal offense in NH Medical Assistance Program.
Relationship	Relationship of the person convicted to the provider.
Type of Conviction	Type of conviction implied.
Date of Conviction	Date on which the person was convicted from the NH Medical Assistance Program.
Conviction City	City in which the person was convicted from the NH Medical Assistance Program.
Conviction State	State in which the person was convicted from the NH Medical Assistance Program.
Program Type	The program type of the conviction.
Conviction, Assessment or Exclusion Related to Federal Program Involvement Fields
2.Have you or any member of your immediate family ever been convicted, assessed, debarred, or excluded from the Medicaid, Medicare, or Title XVIII, Title XIX, Title XX Social security program or any other federal program due to fraud, obstruction of an investigation, or a controlled substance violation?	Select Yes or No. If yes, additional fields are displayed for you to provide the conviction, assessment or exclusion information.
To add a new conviction, assessment, or exclusion, click Add Name. To edit the conviction, assessment or exclusion information, click the appropriate row.
Last Name	Last name of the person convicted, assessed, debarred, or excluded from the Medicaid program.
First Name	First name of the person convicted, assessed, debarred, or excluded from the Medicaid program.
Middle Name	Middle initial of the person convicted, assessed, debarred, or excluded from the Medicaid program.
Relationship	Relationship of the person convicted to the provider.
Type of Conviction	Type of conviction implied.
Date of Conviction	Date on which the person was convicted from the Medicaid program.
Conviction City	City in which the person was convicted from the Medicaid program.
Conviction State	State in which the person was convicted from the Medicaid program.
Program Type	The program type of the Medicaid program.
Overpayment Information Fields
3. Do you, under any name or business identity, have any outstanding overpayment with any state or federal program?	Select Yes or No. If yes, additional fields are displayed for you to provide the overpayment information.
To add a new overpayment record, click Add Overpayment. To edit the overpayment information, click the appropriate row.
Last Name	Last name of the person who or the business name that has the outstanding overpayment.
First Name	First name of the person who or the business name that has the outstanding overpayment.
Middle Name	Middle name of the person who or the business name that has the outstanding overpayment.
Overpayment Amount	The total amount of outstanding overpayment.
Program Type	The program type of overpayment.
Disposition	The disposition of the overpayment.
Restitution Information Fields
4. Have you ever plead guilty, no contest or been sentenced for any felony crime and/or had a criminal fine or restitution order assessed or do you have a felony charge pending under Federal or State law?	Select Yes or No. If yes, additional fields are displayed for you to provide the restitution information.
To add a new restitution record, click Add Restitution. To edit the restitution information, click the appropriate row.
Last Name	Last name of the person with felony charge pending under Federal or State law.
First Name	First name of the person with felony charge pending under Federal or State law.
Middle Name	Middle name of the person with felony charge pending under Federal or State law.
Type of Conviction	Type of conviction implied.
Date of Conviction	Date on which the person was convicted of felony charge.
Conviction City	City in which the person was convicted of felony charge.
Conviction State	State in which the person was convicted of felony charge.
Program Type	The program type of the felony charge.
Sanction Information Fields
5. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been sanctioned by the Office of Inspector General (OIG), Medicare, Medicaid, or the Social Security Act, including a state Medicaid program.	Select Yes or No. If yes, additional fields are displayed for you to provide the sanction information.
To add a new sanction record, click Add Sanction. To edit the sanction information, click the appropriate row.
Last Name	Last name of the person who has been sanctioned.
First Name	First name of the person who has been sanctioned.
Middle Name	Middle name of the person who has been sanctioned.
Relationship	Relationship of the person convicted to the provider.
Type of Sanction	The type of sanction issued.
Date of Sanction	Date on which the person was sanctioned.
Sanction City	City in which the person was sanctioned.
Sanction State	State in which the person was sanctioned.
Program Type	The program type of the sanction.
Detailed Information Fields
6. Have you or any of your employees, contract employees, or any person, or entity with ownership of your business, ever been denied malpractice insurance or ever voluntarily or in voluntarily agreed to any limitations, restrictions, or conditions to your license, certification, or permit including any formal or informal Professional Board Disciplinary Actions(s)?	Select Yes or No. If yes, additional fields are displayed for you to provide the detailed information.
To add a detailed record, click Add Additional. To edit the detailed information, click the appropriate row.
Last Name	Last name of the person convicted for formal or informal Professional Board Disciplinary Actions.
First Name	First name of the person convicted for formal or informal Professional Board Disciplinary Actions.
Middle Name	Middle name of the person convicted for formal or informal Professional Board Disciplinary Actions.
Relationship	Relationship of the person convicted to the provider.
Date of Occurrence	Date on which the person was convicted
State Occurred	City in which the person was conviction.
Description	Description about the conviction, if any.
Exclusion Information Fields
7. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever had any Program Exclusions from any federally funded program?	Select Yes or No. If yes, additional fields are displayed for you to provide the exclusion information.
To add a new exclusion record, click Add Exclusion. To edit the exclusion information, click the appropriate row.
Last Name	Last name of the person who had program exclusions from the federally funded program.
First Name	First name of the person who had program exclusions from the federally funded program.
Middle Name	Middle name of the person who had program exclusions from the federally funded program.
Relationship	Relationship of the person convicted to the provider.
Date of Occurrence	Date on which the person was excluded.
State Occurred	City in which the person was excluded.
Description	Description about the exclusion, if any.
Litigation Information Fields
8. Have you or any of your employees, contract employees, or any persons or entity with ownership of your business, been involved in any civil litigation whereby a judgment or settlement was entered into, or a Civil Monetary Penalty(s) was paid?	Select Yes or No. If yes, additional fields are displayed for you to provide the litigation information.
To add a new litigation, click Add Litigation. To edit the litigation information, click the appropriate row.
Last Name	Last name of the person who was involved in civil litigation.
First Name	First name of the person who was involved in civil litigation.
Middle Name	Middle name of the person who was involved in civil litigation.
Relationship	Relationship of the person convicted to the provider.
Date of Occurrence	Date on which the person was convicted.
State Occurred	City in which the person was convicted.
Description	Description about the conviction, if any.
Pending Action Information Fields
9. Do you or any of your employees, contract employees, or any person or entity with ownership of your business have any Judgment (s) or Pending Actions under the False Claims Act?	Select Yes or No. If yes, additional fields are displayed for you to provide the pending action information.
To add a pending action record, click Add Pending Actions. To edit the pending action information, click the appropriate row.
Last Name	Last name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
First Name	First name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
Middle Name	Middle name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
Relationship	Relationship of the person involved to the provider.
Date of Occurrence	Date on which the person was involved.
State Occurred	City in which the person was involved.
Description	Description about the involvement, if any.
Payment Suspension Information Fields
10. Have you, under any name or business identity, ever had payment suspended by any state or federal program?	Select Yes or No. If yes, additional fields are displayed for you to provide the payment suspension information.
To add a new payment suspension record, click Add Payment Suspension. To edit the payment suspension information, click the appropriate row.
Last Name	Last name of the person who was involved in payment suspension by the state or federal program.
First Name	First name of the person who was involved in payment suspension by the state or federal program.
Middle Name	Middle name of the person who was involved in payment suspension by the state or federal program.
Suspension Amount	The suspension amount payed by the person.
Program Type	The program type of payment suspension.
Disposition	The disposition of the payment suspension.

Individual Ownership Information Fields

Field	Description
Ownership - Other Providers Fields Note: If you are a Non-Billing ORP or Non-Billing Rendering provider, this page will not be available.
1. Have to ever had ownership in any organization that has billed, or is currently billed Medicare or NH Title XIX program services?	Select Yes or No. If yes, additional fields are displayed for you to provide the ownership information.
To add a new ownership record, click Add Ownership. To view or edit, in the Ownership - Other Providers table, click the appropriate row.
Business Name	Organization's legal business name as it appears in IRS forms. Note: You can edit the ownership information by clicking the Business Name link.
Effective Date	Date when ownership became effective.
End Date	Date when ownership ends.
Address	Physical street address of the organization.
City	City where the organization is located.
State	State where the organization is located.
Zip Code	Zip code and extension where the organization is located.
FEIN #	Organization's federal employer identification number.
Please enter a Medicare and/or NH Title XIX #	Select to indicate if the organization has either a current Medicare or Title XIX (Medicaid) number.
Current Medicare Number	The organization's current Medicare number.
Current NH Title XIX #	The organization's current Title XIX number.
Manager/Director - Other Providers Fields
2. Have you ever managed or directed any organization that has billed or is currently billing Medicare or NH Title XIX Program services? Complete the following for each organization this owner has managed or directed in the last 10 Years?	Select Yes or No. If yes, additional fields are displayed for you to enter the provider's information.
To add other provider's record, click Add Managing/Directing Information. To edit, in the Manager/Director - Other Providers table, click the appropriate row.
Business Name	The legal business name of the organization. Note: You can edit the manager/director information by clicking the Business Name link.
Effective Date	Date when ownership became effective.
End Date	Date when ownership ends.
Address	Physical street address of the organization.
City	City where the organization is located.
State	State where the organization is located.
Zip Code	Zip code and extension where the organization is located.
FEIN #	Organization's Federal Employer Identification Number.
Please enter a Medicare and/or NH Title XIX #	Select to indicate if the organization has either a current Medicare or Title XIX (Medicaid) number.
Current Medicare Number	The organization's current Medicare number.
Current NH Title XIX #	The organization's current Title XIX number.
Ownership of Subcontractor Fields
3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/Provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients?	Select Yes or No. If yes, additional fields are displayed for you to provide the subcontractor information.
To add new subcontractor record, click Add Subcontractor. To view or edit, in the Ownership of Subcontractors table, click the appropriate row.
Subcontractor Name	Name of the individual, agency, or organization to which the provider has contracted or delegated some of the management functions or responsibilities of providing medical care to the provider's patients.
Address	Physical street address of the subcontractor providing medical care to the provider's patients.
City	City where the subcontractor is located.
State	State where the subcontractor is located.
Zip	Zip code and extension where the subcontractor is located.
Relative Ownership of Subcontractors Fields
4. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice?	Select Yes or No. If yes, additional fields are displayed for you to provide the relative ownership information.
To add a relative ownership record, click Add Relative. To view or edit, in the Relative Ownership of Subcontractors table, click the appropriate row.
Last Name	Last name of the relative who has ownership in the subcontractor business or practice.
First Name	First name of the relative who has ownership in the subcontractor business or practice.
Middle Name	Middle initial of the relative who has ownership in the subcontractor business or practice.
Relationship	Relationship of relative to the owner of the subcontractor business or practice.
Subcontractor Name	Name of the individual, agency, or organization to which the provider has contracted or delegated some of the management functions or responsibilities of providing medical care to the provider's patients that is associated with the relative.
Address	Physical street address of the subcontractor associated with the relative.
City	City where the subcontractor associated with the relative is located.
State	State where the subcontractor associated with the relative is located.
Zip	Zip code and extension where the subcontractor associated with the relative is located.

Group Ownership Information Fields

Field	Description
Ownership Fields
1. How many owners of the applicant have a 5% or more direct or indirect ownership in the group?	Select the I affirm that this information is accurate check box.
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 the ownership became effective.
End date of Ownership	Date on which the ownership expires.
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
Business Name	Business name under which ownership is held.
Doing Business As (DBA) Name	Official name under which the organization is doing business as.
FEIN	The Federal Employee Identification Number used for tax purposes.
Effective Date of Ownership	Date the ownership became effective.
End Date of Ownership	Date on which the ownership ends.
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.
NH Title XIX Provider ID	The group's Medicaid provider identification number.
Direct Ownership or Indirect Ownership	Select if the group 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 group owner.
Relationship	Relationship of the group owner with another owner or person with controlling interest.
Controlling Interest Information
2. Please list all board members and executive officers that have a controlling interest in the corporation or partnership.	Select the I affirm that this information is accurate check box.
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.
City	City where the person is located.
State	State 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.
Owner and Subcontractor
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. If yes, additional fields are displayed for you to provide the owner and subcontractor information.
To add a new owner or subcontractor information, click Add Owner/Sub Owner. To edit the Owner and Subcontractor table, select 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.
Middle Initial	Middle initial of the owner or sub owner.
Subcontractor Legal Name	Legal name of the subcontractor.
Effective Date	Date when the Medicaid cover became effective.
End Date	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's or sub owner's location.
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.
Subcontractor Owner
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.	Select the I affirm that this information is accurate check box.
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.
Middle Initial	Middle initial of the subcontractor owner.
Subcontractor Legal Name	Legal name of the subcontractor.
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 transaction from 4b	List the business transactions that happened during the 5-years period ending on the date of the request.
Managing/Directing Employee Fields
5. What is the total number of managing/directing employees for the group?	The total number of managing/directing employees in the group.
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.
Middle Initial	Middle initial of the employee.
Title	Title of the employee.
Date of Birth	Date of birth of the employee.
SSN/FEIN	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's location.
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	The employee's business name.
Effective Date	Date 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 prior Title XIX Provider Number used by the employee.
State	State that issued the Title XIX Provider Number.

Authorized Representative Fields

Field	Description
Authorized Representatives To add a new authorized representatives, click Add Representatives. To view or edit, in the Authorized Representatives table, click the appropriate row. To delete a row of authorized representative information, click the Delete link.
Last Name	The authorized representative's last name.
First Name	The authorized representative's first name.
MI	The authorized representative's middle initial.
Begin Date	Authorized representative's beginning date.
End Date	Authorized representative's ending date.
Title	The authorized representative's title.
Suffix	The authorized representative's suffix.
Position	The authorized representative's position in the organization.
Pharmacist in Charge
First Name	The pharmacist's first name.
Last Name	The pharmacist's last name.
Middle Name	The pharmacist's middle initial.
Title	The pharmacist's title.

Authorized Validator Fields

Field	Description
Authorized Validator Information To add a new authorized validator, click Add Authorized Validator. To view or edit, in the Authorized Validator table, click the appropriate row. To delete a row of authorized validator's contact information, click the Delete link
Last Name	Last name of the authorized validator's number.
First Name	First name of the authorized validator's number.
Phone #	Phone number of the validator.
Email	Email address of the validator.

Risk Level and Screening Requirement Fields

Field	Description
Risk Level and Screening Requirement
NPPES Verified?	Select your option, if NPPES is verified. Examples: Yes, No, Not Applicable (NA) Note: You can select NA only for the provider for whom NPI do not apply.
Provider is Medicare Enrolled?	If the provider is Medicare enrolled, select Yes. If not, select No. Note: If you select 'Yes', additional fields are displayed.
Medicare Screen Date	The screening date of the Medicare site.
Medicare Enrolled Verified in PECOS?	If the Medicare enrolled is verified in PECOS, select Yes. If not, select No.
Medicare Site Visit Conducted?	If the Medicare site visit is conducted, select Yes. If not, select No.
Date Medicare Site Visit Conducted	Date on which the Medicare site visit was conducted.
Did Medicare Site Visit Pass?	If the Medicare site visit was passed, select Yes. If not, select No.
Risk Level Assigned	Type of risk level assigned to the Medicare site.
Date Risk Level Assigned	Date on which the risk level was assigned.

Signature Fields

Field	Description
Signature To print a copy of the signature page, click Print. Note: You need to print the signature page, and manually sign it before uploading it back in the Provider Revalidation Signature page.
Upload Signature Page To upload the signed copy of the signature page, click Add Signature Page. To edit the information in the section, click the row that needs to be edited. Note: To remove the copy of the uploaded signature page, select the row and then click Detach.
Date Added	Date on which the signed copy of the signature page was uploaded.
Added By	Name of the person who uploaded the copy of the signature page.
File Name	Name of the file that is been uploaded.
Description	Description for the uploaded file, if any. Note: You can provide a description that is limited to 50 characters.
Add Attachment To attach a file, click Browse. In the Choose File to Upload dialog box, browse to the location of the file and then click Open.
File	File that needs to be attached. Note: You cannot upload more than one file, and the uploaded file needs to be in one of the following formats: JPEG, PNG, and PDF. Also, the maximum file size that can be attached is 1 MB.
Attached	The status of the upload. Note: Displays Yes, if the copy of the page is successfully uploaded.