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Individual Provider Enrollment (Service) Page

You use the Service page to add or edit an individual provider's primary service location, mailing, and billing information to the enrollment application.

The Service page for Individual Provider Enrollment page contains the following panels:

You can open or close certain panels. Click (the plus sign) beside a panel to open the panel. Click (the minus sign) to close the panel.

 

Service Location Information- Section 4 Fields

Field Description
These fields contain information about the provider's primary service location for this application. Additional locations may be added on the Submit Application - Part 2 page or after your application has been approved.
Physical Address (P.O. Box not accepted) Provider's physical street address. PO box numbers are not accepted as physical addresses. Up to 64 alphanumeric characters can be entered.
Building, Suite #, etc. More specific address information. Up to 64 alphanumeric characters can be entered.
City Location's city.
State

Location's state.

Default: AK

Zip Location's zip code and extension.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Service Location Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save.
Phone # Phone number associated with this location.
Fax # Fax number associated with this location.

Service Location Contact Person Fields

To add a new contact person, click Add Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.
Last Name Last name of this location's contact person.
First Name First name of this location's contact person.
MI or Middle Initial Middle initial of this location’s contact person.
Phone or Phone Number Phone number of this location’s contact person.
Ext Extension of this location’s contact person.
Fax Fax number of this location’s contact person.
Email E-mail address of this location’s contact person.
Position Position in the organization of this location’s contact person.

 

Out-of-State Medicaid Enrollment Fields

Field Description

This panel is only displayed if you select a state other than Alaska for your service location. A provider may treat an Alaska Medicaid member but the services are rendered in another state other than Alaska.

Are you enrolled in the Medicaid program in the state in which you practice? Select Yes or No to indicate if you are enrolled in the Medicaid program in your practicing state. If Yes is selected, additional fields are displayed to provide information.
State-assigned Medicaid Provider ID Number The out-of-state identification number assigned to the provider, so the provider can treat an Alaska Medicaid member.
Enrollment date Date the provider enrolled in the Medicaid program.
Fiscal Agent Address Mailing address for the fiscal agent.
Building, Suite #, etc. The fiscal agent's building and suite number (part of mailing address).
City The fiscal agent's city.
State The fiscal agent's state.
Zip The fiscal agent's zip code.
Fiscal Agent Phone # The fiscal agent's telephone number.
State Medicaid Agency Phone # The telephone number for the out-of-state Medicaid agency.

 

Service- Section 4 Fields

Field Description
Does this location have drive-thru accessibility? If the location provides pharmacy services, select Yes or No to indicate if the pharmacy has drive-thru accessibility.
Do you provide delivery service? If the location provides pharmacy services, select Yes or No to indicate if the location provides delivery services.
Gender Served
 Select each gender the provider serves.
Age Range Served Select each age range the provider serves.
Languages Supported

Languages supported by the provider.

  • To move an item from the Available list to the Selected list, select the item, and then click Right arrow (the right arrow).

  • To move an item from the Selected list to the Available list, select the item, and then click Left arrow (the left arrow).
  • To select or clear multiple items, press CTRL and click the items.
Other Language If Other was selected in the Languages Supported list, enter the other language the provider supports that is not already listed.
Is this location wheelchair accessible? Select Yes or No to indicate if the location has wheelchair access.
Is this location TDD/TTY Equipped? Select Yes or No to indicate if the location is equipped for the hearing impaired. If Yes is selected, an additional field is displayed to enter the phone number.
TDD/TTY Phone # The TDD/TYY phone number for the hearing impaired, if the location has one.
Is this location open 24 hours? Select Yes or No to indicate if the location is open 24 hours per day.
Are the office hours the same Monday- Friday?

Select Yes or No to indicate if the office hours are the same for each weekday from Monday through Friday.

Note: If hours are not the same, then the day of the week, From, and To fields are displayed for the user to enter the office hours.

Monday - Friday The days of the week field displays if the answer is "No" to the "Are the office hours the same Monday - Friday?" field. For each day, select the hours that the location is open.
From / To Indicates the starting and ending hour times that the location is open. This field only displays if the answer is "No" to the "Are the office hours the same Monday - Friday?" field.
Does this location provide emergency services after standard business hours? Select Yes or No to indicate if the location provides after-hours services. If Yes is selected, an additional field is displayed to provide the phone number.
After Hours Contact Phone # If the location does have after-hours services, the phone number to be used.

 

Clinical Laboratory Improvement Amendments (CLIA) Fields

Field Description
If the application is for an independent laboratory or physician’s office that performs non-waiver laboratory services, a current CLIA certificate is required. To add new CLIA information, click Add CLIA. Existing CLIA information, if any, is displayed in a table. To edit, in the CLIA table, click the appropriate row. After you edit or add information, on the CLIA action bar, click Save. You must provide photocopies of all certificates listed.
CLIA # The CLIA certificate number.
Effective Date The beginning date of this certification.
Expiration Date The date the certification expires.

 

Mammography Fields

Field Description
To add new Mammography Certification, click Add Mammography Certification. Existing Mammography Certification information, if any, is displayed in a table. To edit, in the Mammography Certification table, click the appropriate row. After you edit or add information, on the Mammography Certification action bar, click Save. You must provide photocopies of all certificates listed.
Mammography Certification Certification number for the service location's mammography services.
Effective Date The date the certification for mammography become effective.
Expiration Date The date the certification for mammography expires.

 

Mailing Address Fields

Field Description
Is this mailing address the same as service location?

Indicates if the mailing address is the same as the service location address. If Yes, then the service location address is automatically copied to the mailing address fields. If No, then additional fields are displayed for you to enter the mailing address.

Note: Mailing Address fields are the same address fields listed in the Service Location Information panel above.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Mailing Address Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, lick Save.

Note: The fields in the Mailing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.

Mailing Address Contact Person Fields

To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.

Note: The fields in the Mailing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.

 

Publication Distribution Address

Field Description
Is this publication distribution address the same as service location?

Indicates if the publication distribution address is the same as the service location address. If Yes, then the service location address is automatically copied to the publication distribution address fields. If No, then additional fields are displayed for you to enter the publication distribution address.

Note: Publication Distribution Address fields are the same address fields listed in the Service Location Information panel above.
Is this publication distribution address the same as mailing location?

Indicates if the publication distribution address is the same as the mailing location address. If Yes, then the mailing address is automatically copied to the publication distribution address fields. If no, then additional fields are displayed for you to enter the publication distribution address.

Note: Publication Distribution Address fields are the same address fields listed in the Service Location Information panel above.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Mailing Address Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Add Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, lick Save.

Note: The fields in the Mailing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.

Mailing Address Contact Person Fields

To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.

Note: The fields in the Mailing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.

 

Electronic Funds Transfer (EFT) Payments Fields

Field Description
Do you wish to participate in Electronic Funds Transfer Payments? Select Yes or No to indicate if you want to participate in Electronic Funds Transfer Payments. If Yes, then additional fields are displayed for you to enter banking information and you must submit a completed and signed EFT Agreement form with this application.
Financial Institution Name Name of the provider’s financial institution where EFT payments are deposited.
Bank Address The address of the provider's bank.
Address The continuation of the address for the provider's bank.
City The city where the provider's bank is located.
State The state where the provider's bank is located.
Zip The zip code and extension where the provider's bank is located.
Bank Routing Transit # Provider’s bank routing number for EFT. Up to 9 numeric characters.
Bank Account # Provider’s bank account number for EFT transactions. Up to 15 numeric characters.
Account Type

The type of account where EFT payments are deposited.

Default: Checking
Bank Phone # Bank phone number where the provider's account is held.
Account Holder Name The account holders full name.
Payee Name The provider's payee name.

 

Billing Address Fields

Field Description
The billing address is the location to which mailed payments will be sent (the Pay-To address). Billing Address fields are the same address fields listed in the Service Location Information panel above.
Is this billing address the same as the service location?

Select Yes or No to indicate if the billing address is the same as the service location. If Yes, then the service location address is automatically copied to the Billing Address fields. If No, then answer the second question.
Is this billing address the same as the mailing address? Select Yes or No to indicate if the billing address is the same as the mailing address. If Yes, then the mailing address is automatically copied to the Billing Address fields. If No, then additional fields are displayed for you to enter the billing address.
Is this billing address the same as the publication distribution address? Select Yes or No to indicate if the billing address is the same as the publication distribution address. If Yes, then the publication distribution address is automatically copied to the Billing Address fields.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.

Billing Address Contact Number Fields

To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, lick Save.

Note: The fields in the Billing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.

Billing Address Contact Person Fields

To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.

Note: The fields in the Billing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.
Email E-mail address of this location’s contact person.
Does a third party billing agent submit your claims? Select Yes or No to indicate if a third party billing agent submits your claims. If Yes, then the Billing Agent agreement must be signed and sent in.
Does the Billing agent have access to make inquires on your behalf? Displayed if a third-party billing agent is submitting your claims. Select Yes or No to indicate if the billing agent can make inquires on your behalf.

 

Remittance Advice Fields

Field Description
Requested Delivery Media for Remittance Advices (RAs)

Select how you want to receive your remittance advice. If Web Portal Provider Message Center is chosen, then you must register for Web access.

Options are: All, Electronic (835), Web Portal Provider - Message Center (Downloadable to paper), Paper

 

Version as of 6/30/2015.

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