Group Provider Enrollment (Electronic Transaction Submission) Page

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You use the Electronic Transaction Submission page when enrolling as a group provider to indicate what method you wish to use to HIPAA compliant transactions. You can chose to use a trading partner, to enroll as a trading partner yourself, or to do both. A third-party trading partner is required to apply for a trading partner ID (also known as a submitter ID) and must register for a Web User ID.

Electronic Transmission Fields

Field	Description
Indicate which of the following will be used to submit electronic transmissions.
Alaska Medical Assistance Portal	Select if you want to submit HIPAA compliant transactions electronically through the AK MMIS Health Enterprise Portal. This option does not require a trading partner ID or affiliation.
Point of Sale	Select if you want to submit HIPAA compliant transactions electronically through point of sale. If selected, additional fields are displayed.
Vendor Software	Select if you want to submit HIPAA compliant transactions electronically through vendor software. If selected, additional fields are displayed.
Billing Agent/Clearinghouse	Select if you want to submit HIPAA compliant transactions electronically through a billing agent or clearinghouse. If selected, additional fields are displayed.
Additional Fields:
Software Vendor Name	The name of the software vendor.
Software Name	The name of the software being used to create HIPAA compliant transactions.
Version #	The version number of the software package being used.
Vendor Address	The mailing address of the software vendor.
Street Address 2	Continuation of the physical street address where the vendor is located. Use only if needed.
City	The city where the software vendor is located.
State	The state where the software vendor is located.
Zip	The zip code of the software vendor.
Vendor Contact First Name	The software vendor contact's first name.
Vendor Contact Last Name	The software vendor contact's last name.
Vendor Contact Phone #	The software vendor contact's phone number.
Vendor Main Contact Phone #	The software vendor contact's main contact number.
Vendor Fax #	The software vendor contact's fax number.
Vendor Email Address	The software vendor contact's email address.
Add Billing Agent/Clearinghouse Fields To add a billing agent, click Add Billing Agent. Existing billing agents, if any, are listed in a table. To edit, in the Billing Agent table, click the appropriate row. After changing or adding information, on the Billing Agent action bar, click Save.
Billing Agent/Clearinghouse Business Name	The name of the agent or clearinghouse that is being used to submit HIPAA compliant transactions.
Street Address	The physical street address where the agent or clearinghouse is located.
Street Address 2	Continuation of the physical street address where the agent or clearinghouse is located. Use only if needed.
City:	City in which the agent or clearinghouse is located.
State	State in which the agent or clearinghouse is located.
Zip	Zip code and extension where the agent or clearinghouse is located.
Billing Agent/Clearinghouse Contact First Name	The first name of the person at the agent or clearinghouse.
Billing Agent/Clearinghouse Contact Last Name	The last name of the person at the agent or clearinghouse.
Billing Agent/Clearinghouse Contact Phone #	The phone number of the person at the agent or clearinghouse.
Billing Agent/Clearinghouse Main Contact Phone #	The main contact phone number of the person at the agent or clearinghouse.
Billing Agent/Clearinghouse Contact Fax #	The fax number of the person at the agent or clearinghouse.
Billing Agent/Clearinghouse Contact Email Address	The email address of the person at the agent or clearinghouse.
Submit Transactions	837I Institutional Claim 837P Professional Claim 837D Dental Claim 270 Eligibility Request 276 Claims Inquiry Request 278 Service Authorization Pharmacy (NCPDP v5.1)
Receive Transactions	835 Remittance Advice 271 Eligibility Response 277 Claim Inquiry Response 278 Service Authorization Response
Provider Contact Name Fields
Contact First Name	The provider contact's first name.
Contact Last Name	The provider contact's last name.
Street Address	Physical street address where the provider contact is located.
Street Address 2	Continuation of the physical street address where the provider contact is located. Use only if needed.
City	City where the provider contact is located.
State	State where the provider contact is located.
Zip	Zip code where the provider contact is located.
Contact Phone	The provider contact's telephone number.
Ext	The provider contact's telephone extension.
Email Address	The provider contact's email address.

Field

Description

Indicate which of the following will be used to submit electronic transmissions.

Alaska Medical Assistance Portal

Select if you want to submit HIPAA compliant transactions electronically through the AK MMIS Health Enterprise Portal. This option does not require a trading partner ID or affiliation.

Point of Sale

Select if you want to submit HIPAA compliant transactions electronically through point of sale. If selected, additional fields are displayed.

Vendor Software

Select if you want to submit HIPAA compliant transactions electronically through vendor software. If selected, additional fields are displayed.

Billing Agent/Clearinghouse

Select if you want to submit HIPAA compliant transactions electronically through a billing agent or clearinghouse. If selected, additional fields are displayed.

Additional Fields:

Software Vendor Name

The name of the software vendor.

Software Name

The name of the software being used to create HIPAA compliant transactions.

Version #

The version number of the software package being used.

Vendor Address

The mailing address of the software vendor.

Street Address 2

Continuation of the physical street address where the vendor is located. Use only if needed.

City

The city where the software vendor is located.

State

The state where the software vendor is located.

Zip

The zip code of the software vendor.

Vendor Contact First Name

The software vendor contact's first name.

Vendor Contact Last Name

The software vendor contact's last name.

Vendor Contact Phone #

The software vendor contact's phone number.

Vendor Main Contact Phone #

The software vendor contact's main contact number.

Vendor Fax #

The software vendor contact's fax number.

Vendor Email Address

The software vendor contact's email address.

Add Billing Agent/Clearinghouse Fields

To add a billing agent, click Add Billing Agent. Existing billing agents, if any, are listed in a table. To edit, in the Billing Agent table, click the appropriate row. After changing or adding information, on the Billing Agent action bar, click Save.

Billing Agent/Clearinghouse Business Name

The name of the agent or clearinghouse that is being used to submit HIPAA compliant transactions.

Street Address

The physical street address where the agent or clearinghouse is located.

Street Address 2

Continuation of the physical street address where the agent or clearinghouse is located. Use only if needed.

City:

City in which the agent or clearinghouse is located.

State

State in which the agent or clearinghouse is located.

Zip

Zip code and extension where the agent or clearinghouse is located.

Billing Agent/Clearinghouse Contact First Name

The first name of the person at the agent or clearinghouse.

Billing Agent/Clearinghouse Contact Last Name

The last name of the person at the agent or clearinghouse.

Billing Agent/Clearinghouse Contact Phone #

The phone number of the person at the agent or clearinghouse.

Billing Agent/Clearinghouse Main Contact Phone #

The main contact phone number of the person at the agent or clearinghouse.

Billing Agent/Clearinghouse Contact Fax #

The fax number of the person at the agent or clearinghouse.

Billing Agent/Clearinghouse Contact Email Address

The email address of the person at the agent or clearinghouse.

Submit Transactions

837I Institutional Claim

837P Professional Claim

837D Dental Claim

270 Eligibility Request

276 Claims Inquiry Request

278 Service Authorization

Pharmacy (NCPDP v5.1)

Receive Transactions

835 Remittance Advice

271 Eligibility Response

277 Claim Inquiry Response

278 Service Authorization Response

Provider Contact Name Fields

Contact First Name

The provider contact's first name.

Contact Last Name

The provider contact's last name.

Street Address

Physical street address where the provider contact is located.

Street Address 2

Continuation of the physical street address where the provider contact is located. Use only if needed.

City

City where the provider contact is located.

State

State where the provider contact is located.

Zip

Zip code where the provider contact is located.

Contact Phone

The provider contact's telephone number.

Ext

The provider contact's telephone extension.

Email Address

The provider contact's email address.