Add Basic Information
Adding basic information is the first step in enrolling a provider. You can add these details when starting a new enrollment.
To add basic information:
- Select the applicable radio button:
- Individual
- Group Practice
- Facility/Agency/Organization/Institution
- Billing Agent/Clearinghouse
- If you are already enrolled in the Medicaid Provider Enrollment, Chain, and Ownership System (PECOS) and want to populate enrollment data from PECOS, select the Yes radio button. If you want to manually enter the data, select the No radio button.
- Complete the Provider Type, NPI, and SSN or FEIN fields. If you selected Yes to populate data from PECOS, you must also select the Practice Location State and enter the Practice Location Zip.
- Select the Submit button.
- If there are any errors with the PECOS data, you will receive an error message that no matching provider information was found. Select Cancel to verify the details or Continue to manually enter the provider's information.
- If no errors are found, the System displays the Basic Information page.
- Select the Submit button.
The System displays the Basic Information page.
- Select a Provider Type.
Note: The Provider Type that you select may change which fields are required.
- Change the Program selection(s) as needed.
- Enter the required information based on your previous selections.
- Select the Submit button.
The System saves the new enrollment and displays the Basic Information page.
Important Note: The System displays a message providing the application number. Make note of this number since you will need it to track the enrollment application. Applications not submitted within 90 calendar days will be deleted.
- Select the OK button.
The System displays the Enroll Provider page for your provider type. If you need to update any of the basic information, select the Provider Basic Information hyperlink from the BPW.