You can allow the user/submitter to attach additional documents for the provider enrollment record by searching corresponding provider information.
| Field | Description |
|---|---|
| Application Tracking# | 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. |
| Medicaid ID | A two-digit code attached to the procedure code to modify or clarify the description of the procedure. Up to four billing modifiers may be specified for the procedure code, if applicable.
This field cannot be changed after it is saved the first time. |
| Individual Code | An individual provider who reports income under a Social Security number but does not have a Federal Employer Identification Number (FEIN). This also includes sole proprietor providers who are individuals that may employ other individual healthcare providers. Sole proprietor providers must enroll with their SSN but may also choose to report income under their FEIN, if they have one. |
| Group code | A group organization provider that has a Federal Employer Identification Number (FEIN) under which income is reported. |
| Mailing address City | Provider's City. (If country of birth, USA) |
| Zip 5 + 4 | Provider’s Zip |
Validate: Validating the entered fields to allow the user to attach the additional documents for the provider enrollment records.
| Field | Description |
|---|---|
| To add an attachment, in the Attachments panel, click Add Attachment. Existing attachments are displayed in the table. To save all attachments, in the Attachments panel, click Save All Attachments. | |
| Date Added | The date the attachment was added. |
| Added by | The name of the person who added the attachment. |
| File Name | The file name of the attachment. |
| Description | The attachment description. |
Version as of 03/23/2024.
Copyright © 2017 Conduent, Inc. All rights reserved. Conduent and Conduent Agile Star are trademarks of Conduent, Inc. and/or its subsidiaries in the United States and/or other countries.