How to Enroll Online as an Individual Provider

You can complete the AK MMIS Health Enterprise Portal online pages to enroll as an individual provider. An individual provider is a provider that reports income to the Internal Revenue Service through a Social Security number if you are already enrolled as a Alaska Medical Assistance provider, you also can complete the online pages to enroll another service location.

Optionally, you can:

• Delete information. To delete information from a record, in the table, click the appropriate row and on the panel's action bar, click Delete.
• Save the application. To complete the application at a later time, click Save.
• Exit the application. To exit the application without saving your changes, click Exit Application.
• Reset your entries. To clear the fields and remain on the page or panel, click Reset.
• Cancel your entries. To close the page or panel without saving your changes, click Cancel.

To enroll as an individual provider

1. Do one of the following:
   • On the Provider menu, click Enrollment.
   • On the Quick Links pod on the public Home page, click Provider Enrollment.

The Provider Enrollment page is displayed.

2. In the Become a Provider panel, click Individual Provider Enrollment.

   The Individual Provider Enrollment Instructions page is displayed.

3. Read the instructions, and click Continue.

   The Authorization page is displayed.

4. Read the authorization, and click Accept.

   Note: If you choose to decline, you cannot enroll as an Alaska provider. A message is displayed with a phone number to call, should you have questions or need assistance.

5. The first of several online enrollment pages is displayed. To page through and complete the following enrollment pages, click Continue:

Tip: To complete or submit an application at a later time, click Save. You can also save on each page to ensure the application is up to date.

• Identifying Information
• Licensure, Certification, Permit and Grant
• Provider Identifier Number
• Service Location Information
• Affiliation
• Electronic Claims Submission
• Ownership
• Exclusion/Sanction
  

All entered information is lost if you choose to exit the application before saving.


6. At the end of the application pages, on the Submit Application Step 1 page, read the instructions carefully and select Yes or No to indicate if you wish to have Web access. If Yes, enter your organization administrator's information.

Note: For individual and group applications, web access allows you to submit claims electronically, and creates an online message center where you can receive messages and remittance advice. In addition, you can submit a change of information application, submit service authorization request, and confirm member eligibility.

7. To check your application for errors, click Validate Application and resolve any issues.

   The Submit Application Step 2 page is displayed if there are no errors.

8. Optionally, to add another service location, on the Submit Application Step 2 page, do the following:

   1. Click Add Another Service Location.

   2. On the following pages, complete the fields, and then click Continue to proceed to the next page.

      • Identifying Information
      • Licensure, Certification, Permit and Grant
      • Provider Identifier Number
      • Service Location Information
      • Affiliation
   3. On the Submit Application Step 1 page, to check the service location application for error, click Validate Application and resolve any issues.

9. Optionally, to edit a service location, on the Submit Application Step 2 page, do the following:

   1. Click Edit Service Location.

   2. In the Service Locations table, click the appropriate row.

   3. On the Service page, complete the fields and navigate to any of the other pages as needed.

      • Service
      • Identifying Information
      • Licensure/Certification/Permit/Grant
      • Provider Identifier Number
      • Affiliation
   4. On the Submit Application Step 1 page, to check the service location application for error, click Validate Application and resolve any issues.

10. Optionally, to go back and edit the application before you submit it, on the Submit Application Step 2, do the following:

    1. Click Edit Application.
    2. Starting from Step 5, edit the application as needed.

11. To submit the application, on the Submit Application Step 2 page, click Confirm Submit. After you submit your application, you cannot recall it to change or add information at a later date. Your enrollment application information is submitted to Alaska for approval.

    The Submit Complete page is displayed.

12. If you submitted the application, on the Submit Complete page, you must also do the following:
    • Record your application tracking number, including the trading partner application number, if applicable.
    • Print the required documents.
    • Sign the required documents.
    • Upload or mail all signed and required additional documents to the address provided.
    • To print a copy of the enrollment application you just completed, click Print Application.
    • To exit the application form, click Exit Application.

What's Next?

Individual providers can optionally enroll as a group provider.

See Also

Version as of 6/30/2015.