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Trading Partner Enrollment (Identifying Information) Page

You use the Identifying Information page to add or edit a trading partner's identifying information to an enrollment application.

The Identifying Information page for Trading Partner Enrollment contains the following panels:

 

Classification Fields

Field Description
Billing Agent Select if you are classified as a billing agent and want to send or receive transactions electronically.
Clearing House

Select if you are classified as a clearing house and want to send or receive transactions electronically.
Switch Vendor

Select if you are classified as a switch vendor and want to send or receive transactions electronically.
Are you using software from a vendor?

Select Yes or Not to indicate if you are using vendor software to submit transactions.

If you choose Yes, the Software Vendor Details panel is displayed with additional fields.

 

Software Vendor Details

Field Description
These fields are displayed if you indicate that you are using software from a vendor to submit your transactions.
Software Vendor Name The name of the software vendor.
Vendor Contact First Name The first name of the software vendor contact.
Vendor Contact Last Name The last name of the software vendor contact.
Vendor Street Address The street address of the software vendor contact.
Vendor PO Box, Building, Suite #, etc. The post office box, building number, suite number, etc. of the software vendor contact.
Vendor City The city of the software vendor contact.
Vendor State The state of the software vendor contact.
Vendor Zip The zip code of the software vendor contact.
Vendor Zip 4 The zip code extension of the software vendor contact.

 

Demographic Fields

Field Description
The fields in this panel change according to what classification you choose. Each classification contains specific information. Fields for all classifications are listed in this table.
Billing Agent Option Fields
Individual Indicates the billing agent is an individual. Shown only if classification is Billing Agent.
Business Indicates the billing agent is a business. Shown only if classification is Billing Agent.
Depending on which option is selected, additional fields are displayed for you to enter the individual or business billing agent information. Field descriptions for both options are listed below.
Individual Billing Agent
Last Name Last name of the individual billing agent.
First Name First name of the individual billing agent.
Middle Initial Middle initial of the individual billing agent.
SSN The Social Security number of the individual billing agent.
Business Billing Agent
Business Name The organization's official business name.
FEIN The organization's Federal Employer Identification number.
Alaska Medical Assistance ID The provider number the individual was previously assigned by Alaska to use when submitting Medicaid claims.

 

Address Information Fields

Field Description
To validate an address, click Validate Address.
Street Address Trading Partner's physical street address. PO box numbers are not accepted as physical addresses.
PO Box, Building, Suite #, etc. More specific address information.
City Location's city.
State Location's state.
Zip Location's zip code.

 

Location Numbers Fields

Field Description
To add location numbers, click Add Numbers. To view or edit, in the Location Number table, click the appropriate row.
Phone # The trading partner's phone number.
Fax # The trading partner's fax number.

 

Location Contact Person(s) Fields

Field Description
To add a location contact person, click Add Contact Person. To view or edit, in the Location Contact Person table, click the appropriate row.
Last Name The contact person's last name.
First Name The contact person's first name.
Phone # The contact person's phone number.
Ext The contact person's phone extension.
Fax # The contact person's fax number.
E-mail The contact person's e-mail address.
Position The contact person's position in the organization.

 

Version as of 6/30/2015.

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