Enrollment Guide for NOPR Providers
Maine Integrated Health Management Solution
Enrollment Guide for
Non-Billing, Ordering, Prescribing, and Referring (NOPR) Providers
Version 6.0
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Revision History
|Version |Date |Author |Action/Summary of Changes |Status |
|0.1 |02/23/2016 |Kari Keller |Creation per ACA Provider Revalidation CR41423 |Draft |
|0.1 |03/10/2016 |Rebecca Labbe, Pam |Updates per State and Molina work stream review. |Draft |
| | |Foster |Additional updates per ACA changes. | |
|0.1 |09/26/2016 |Pam Foster |QA review and prep for formal submission |Draft |
|0.2 |11/04/2016 |Rebecca Labbe, Pam |Updates per State comment log v0.1 dated 10/21/2016|Draft |
| | |Foster | | |
|1.0 |12/28/2016 |Darcy Casey |Finalization per State approval email |Final |
|1.1 |04/27/2018 |Rebecca Labbe, |Updates to Sections 1 & 7, and Figures 6-4, 7-1 & |Draft |
| | |Pam Foster |12-2 per CR70672 | |
|1.1 |05/04/2018 |Ryan Albrecht |QA review and preparation for State submission |Draft |
|2.0 |05/17/2018 |Ryan Albrecht |Finalization per State acceptance email dated |Final |
| | | |05/17/2018 | |
|3.0 |11/16/2018 |Pam Foster |Updated references of Molina to DXC, as appropriate|Final |
|3.1 |10/22/2019 |Rebecca Labbe |Updates to section 9.2 Provider Type/Specialty per |Draft |
| | | |CR89115 | |
|3.1 |12/17/2019 |Mike Libby |QA review and prepare for State submission |Draft |
|4.0 |12/18/2019 |Mike Libby |Finalization per State acceptance email dated |Final |
| | | |12/18/2019 | |
|4.1 |12/07/2020 |Pam Foster |Updated email addresses in section 10.2 per |Draft |
| | | |CR95781 | |
|5.0 |12/07/2020 |Pam Foster |Finalization per State acceptance email dated |Final |
| | | |12/07/2020 | |
|5.1 |12/11/2020 |Rebecca Labbe, |Updates to section 9.3 per CR96831 |Draft |
| | |Pam Foster | | |
| | | |Replaced Figures 4-1 & 8-1, replaced coversheet | |
| | | |logo DXC with Gainwell Technologies | |
| | | |QA review and prep for formal submission | |
|6.0 |01/05/2021 |Pam Foster |Finalization per State acceptance email dated |Final |
| | | |01/05/2021 | |
Usage Information
Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The content of this document herein is subject to change without notice.
HIPAA Notice
The Maine HealthPAS Online Portal is for the use of authorized users only. Users of the Maine HealthPAS Online Portal may have access to protected and personally identifiable health data. As such, the Maine HealthPAS Online Portal and its data are subject to the Privacy and Security Regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).
By accessing the Maine HealthPAS Online Portal, all users agree to protect the privacy and security of the data contained within as required by law. Access to information on this site is only allowed for necessary business reasons, and is restricted to those persons with a valid user name and password.
Table of Contents
1. Introduction 1
2. Information Needed 1
3. System Requirements 1
4. Public Navigation 1
4.1 Home 2
4.1.1 Health PAS Online Banner 2
4.1.2 General Sub-Tab 3
4.1.3 Member Sub-Tab 3
4.1.4 Provider Sub-Tab 3
4.2 Contact Us 4
5. Provider Enrollment Application (PEA) Navigation 6
5.1 PEA Banner 6
5.2 Help Links and Guidance 6
5.3 Navigation Features 7
6. Trading Partner Login 8
7. Start the PEA 10
8. Provider Enumeration Information 11
9. Ordering/Referring Providers 12
9.1 Ordering/Referring Provider 12
9.2 Provider Type/Specialty 14
9.3 Ordering Provider Taxonomy 19
10. Documents 21
10.1 Additional Terms 21
10.2 Supporting Documents 22
11. Signature 24
11.1 Signature 24
11.2 Summary 26
12. Resuming an Enrollment 26
13. Provider Enrollment Application Statuses 28
List of Figures
Figure 4-1: Sign In Hyperlink 2
Figure 4-2: Health PAS Online Banner 3
Figure 4-3: General Sub-Tab 3
Figure 4-4: Member Sub-Tab 3
Figure 4-5: Provider Sub-Tab 4
Figure 4-6: Contact Us Screen 5
Figure 5-1: PEA Banner 6
Figure 5-2: Help Links & Guidance Section 7
Figure 5-3: Navigation Menu 7
Figure 5-4: Command Buttons Example 8
Figure 5-5: Required Field Examples 8
Figure 5-6: Header Fields 8
Figure 6-1: Sign In Hyperlink 9
Figure 6-2: Sign In Screen 9
Figure 6-3: Provider Enrollment Hyperlink 10
Figure 6-4: PEA Screen 10
Figure 7-1: PEA Hyperlinks 11
Figure 8-1: Start Enrollment Screen 11
Figure 9-1: Ordering/Referring Provider Screen 12
Figure 9-2: Ordering Provider Conviction Section 14
Figure 9-3: Provider Type/Specialty Screen 14
Figure 9-4: Additional Fields 16
Figure 9-5: License Type - Title 5 18
Figure 9-6: Ordering Provider - Provider Type/Specialty Dialog Box 18
Figure 9-7: SAVE & CONTINUE Button 19
Figure 9-8: Ordering Provider Taxonomy Screen 20
Figure 9-9: Lookup Search Screen 20
Figure 10-1: Additional Terms Screen 21
Figure 10-2: Supporting Documents Screen 22
Figure 10-3: Document Upload Dialogue Screen 23
Figure 10-4: File Uploaded Successfully Message 23
Figure 11-1: Signature Screen 24
Figure 11-2: Signature Affiliation Dialogue Box 25
Figure 11-3: Signature Affiliation Dialogue Box 25
Figure 11-4: Summary Screen 26
Figure 12-1: Provider Enrollment Hyperlink 27
Figure 12-2: My Enrollment Applications Table 27
List of Tables
Table 1: Communication Types 5
Table 2: Command Buttons and Descriptions 7
Table 3: Enrollment Statuses and Definitions 28
Introduction
This user guide describes the enrollment process for Non-Billing, Ordering, Prescribing, and Referring (NOPR) providers enrolling or re-enrolling in the MaineCare program.
Providers enroll in MaineCare based on the organization types described below:
An individual provider is a provider that owns and operates their own practice or otherwise provides healthcare services under their Social Security number (SSN) and a Type 1 Individual National Provider Identifier (NPI). An individual provider may associate to other entities as a rendering provider. An individual provider employed by an organization is re-enrolled by that organization as a rendering provider when required by MaineCare or the Centers for Medicare & Medicaid Services (CMS).
A NOPR provider orders, prescribes, or refers services for MaineCare members. Billing providers are required to submit the NPI of the ordering, prescribing, or referring provider on certain claims to receive reimbursement for the service. This includes all prescription claims as well as claims from the following providers:
• Clinical laboratories for ordered tests
• Imaging centers for ordered imaging procedures
• Supplies of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
NOPR providers must be enrolled in MaineCare with a Type 1 Individual NPI. NOPR providers may enroll independently or be enrolled as part of a provider that is enrolled in MaineCare. If the user provides services for a group or organization that is enrolled in MaineCare, please discuss the NOPR provider enrollment with them. If the user is enrolled as an individual provider, or is enrolled as a rendering provider employed by a group or organization, the user does not need to have a separate NOPR provider enrollment.
If the provider who is enrolling is not a NOPR provider, refer to the Enrollment Guide.
In the following sections, identify the information that must be readily available before starting the enrollment process, as well as, a detailed description of how to complete each of the enrollment steps.
Information Needed
Before initiating the enrollment process, gather all necessary information to enter during each step.
For a complete list of the information, forms and other documents needed to enroll a provider, refer to the Enrollment Checklist.
System Requirements
To successfully use all Provider Enrollment Application (PEA) features of the MIHMS Health PAS Online Portal (online portal), ensure that the computer system meets the following minimum requirements:
• Reliable online connection
• Web browser—the latest version of Microsoft Internet Explorer is recommended. As new versions of Internet Explorer become available it is recommended that these versions are used.
• The latest version of Adobe Acrobat Reader
Public Navigation
The following screens of the online portal are accessible to all visitors: Home, News, Contact Us, and Provider Directory.
1 Home
The Home screen includes the Health PAS Online navigation bar, and the following three sub-tabs: General, Member, and Provider. Refer to Figure 4-1 below.
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Figure 4-1: Sign In Hyperlink
1 Health PAS Online Banner
Located on the top of each screen, the banner provides a list of all the functions available to the provider from the current screen. This list may be different for each provider because it is based on user permissions. Some of the functions may include the following:
• Enable Accessibility – When the Enable Accessibility hyperlink is clicked, it enables the website to present information in a way that is more understandable for accessibility software such as Job Access With Speech (JAWS).
• Help – This is basic website functionality help.
• Sign In or Register – These hyperlinks allow the provider to sign in or register. Use the Register hyperlink if you are a first-time user and use the Sign In hyperlink if you are an existing user.
• Search field – This allows the provider to enter search criteria and complete a basic website functionality search. In Health PAS Online, all search fields perform partial search without wildcards. Refer to Figure 4-2 below.
• A language drop-down list contains available languages. English is the default language.
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Figure 4-2: Health PAS Online Banner
2 General Sub-Tab
The General sub-tab provides information about the MaineCare program for members, providers, trading partners, and the public. Refer to Figure 4-3 below.
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Figure 4-3: General Sub-Tab
3 Member Sub-Tab
This sub-tab is specific to MaineCare members. Refer to Figure 4-4 below.
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Figure 4-4: Member Sub-Tab
4 Provider Sub-Tab
This sub-tab is specific to providers. The Provider sub-tab includes an event calendar, a news section, and important hyperlinks. Refer to Figure 4-5 below.
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Figure 4-5: Provider Sub-Tab
2 Contact Us
The Contact Us screen provides valuable contact information for MaineCare as well as office hours. Refer to Figure 4-6 below.
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Figure 4-6: Contact Us Screen
Table 1 below provides a list of the communication types found on the Contact Us screen and the communication type description.
Table 1: Communication Types
|Communication Type |Description |
|[pic] |Phone Support − Provides local and toll-free phone numbers available to reach a customer support |
| |representative during regular business hours. Voice mail is available after hours. |
|[pic] |TDD/TTY Support – Provides number available for TDD/TTY support |
|[pic] |Messaging Support − Sends a secure message or send an email inquiry to DXC Technology. If sending|
| |an email inquiry, it should not contain protected health information (PHI). |
Provider Enrollment Application (PEA) Navigation
This section describes the various navigation features of the online portal (PEA.)
1 PEA Banner
Located on the top of each screen, the banner provides a list of all the functions that are available for the current screen. This list may be different for each provider because it is based on user permissions. Some of the functions may include the following:
• Enable Accessibility – When the Enable Accessibility hyperlink is clicked, it enables the website to present information in a way that is more understandable for accessibility software such as Job Access With Speech (JAWS).
• Help – This is basic website functionality help.
• A language drop-down list contains available languages. English is the default language.
Refer to Figure 5-1 below.
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Figure 5-1: PEA Banner
2 Help Links and Guidance
On the PEA screen, there is a Help Links & Guidance section, and includes hyperlinks to:
• NPI Registry
• Provider Enrollment FAQ
• Provider Enrollment Glossary of Terms
• Provider Disclosure Requirements and FAQ
These hyperlinks are used to assist the provider during the enrollment application process. Refer to Figure 5-2 below.
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Figure 5-2: Help Links & Guidance Section
3 Navigation Features
Every screen of the PEA has a set of standard navigation features, including:
• The navigation menu – Shown at the top of each page, the navigation menu provides a list of all the enrollment steps, to guide the provider to where they are in the enrollment process. Refer to Figure 5-3 below. NOTE: Although all of the menu items are always accessible throughout the application process, it is recommended to complete each step in order during the initial completion of the enrollment application.
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Figure 5-3: Navigation Menu
• The command buttons – Located below the fields on each PEA screen, are a set of buttons that perform certain actions. The available actions depend on the purpose of the screen. Table 2 and Figure 5-4 below display the command buttons.
Table 2: Command Buttons and Descriptions
|Command Button |Description |
|[pic] |Save & Continue – Saves the information on the current screen and continues to the next screen. |
|[pic] |Edit – Allows for the editing of existing information. Select the item requiring modification. Click Edit. |
| |Edit material. Click Save. |
|[pic] |Add – Allows for the adding of information to a table. |
|[pic] |Close – Saves the information on the current screen and closes the PEA to continue at a later time. A warning|
| |box appears with the following message, “The incomplete application has been saved and will be available for |
| |completion for a period of 30 days.” |
|[pic] |Save – Saves sub-section content within a section of a screen; for example, license information. |
|[pic] |Cancel – Cancels sub-section content within a section of a screen; for example, license information. |
|[pic] |Reset – Resets all of the fields on the current screen. |
|[pic] |Back – Returns to the previous screen. |
|[pic] |Delete – Allows for the deletion of existing information or the deletion of the application. |
|[pic] |Submit – Submits the application. |
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Figure 5-4: Command Buttons Example
• Required fields – Each screen of the PEA has required fields. These fields are marked with a red asterisk (*). Examples of required fields are shown below in Figure 5-5.
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Figure 5-5: Required Field Examples
NOTE: Tool Tips appear when hovering the cursor over an icon or menu function within the PEA. Tool Tips appear for a few seconds and give a brief description of the target icon.
Notice that there are header fields, which will appear on every PEA screen, as shown in Figure 5-6 below.
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Figure 5-6: Header Fields
• Billing Provider ID – Displays the Pay-To NPI of the enrollment application
• Enrollment Case Number – Displays the case number of the enrollment application
• Status – Displays the status of the enrollment application
Additional information, such as service location name, can appear in the header fields, depending on the screen being viewed. The header field content is appropriate to the context of the screen.
Trading Partner Login
To access the PEA, providers must be a registered trading partner.
NOTE: If a trading partner account has not been created, refer to the Trading Partner User Guide for Providers Not Yet Enrolled.
To sign into the trading partner account, follow these steps:
1. Navigate to the online portal home screen; click Sign In. Refer to Figure 6-1 below. NOTE: When signing into the trading partner account, if the incorrect password is entered five times, the trading partner account locks indefinitely. To unlock the account, contact the EDI Help Desk at 1-866-690-5585, Option 2.
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Figure 6-1: Sign In Hyperlink
The Sign In screen displays.
2. In the User Name field, enter the trading partner user name.
3. In the Password field, enter the password.
4. Read and accept the Attention HIPAA PHI: Special Handling Required statement by selecting the “I have read and accept HIPAA PHI privacy policy” check box.
5. Click SIGN IN. Refer to Figure 6-2 below.
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Figure 6-2: Sign In Screen
The Non-Enrolled Provider screen displays.
6. Click the Account Maintenance drop-down list. Click the Provider Enrollment hyperlink. Refer to Figure 6-3 below.
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Figure 6-3: Provider Enrollment Hyperlink
The PEA screen displays. Refer to Figure 6-4 below. Located within the screen are the enrollment links for the different types of applications and a table containing the enrollment information entered under the trading partner account.
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Figure 6-4: PEA Screen
• Case Number - Displays the case number of the enrollment application.
• Provider ID - Displays the provider’s NPI.
• Provider Name - Displays the provider’s name.
• Email Address - Displays the email address used in the enrollment application.
• Enumeration Type - Displays the enumeration type selected when starting the enrollment application.
• Enrollment Status - Displays the status of the enrollment application.
• Actions – The actions button displays different options. These options are dependent on the enrollment status of the enrollment application.
Start the PEA
From the PEA screen, there are a series of available Provider Enrollment hyperlinks. Refer to Figure 7-1 below.
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Figure 7-1: PEA Hyperlinks
To begin an enrollment, choose the Provider Enrollment hyperlink. Continue to the next section.
Provider Enumeration Information
All providers enroll based upon their enumeration in the National Plan & Provider Enumeration System (NPPES). NOPR providers must be enrolled in MaineCare with a Type 1 Individual NPI.
The first Provider Enrollment screen is the Start Enrollment screen. On this screen, specify how the provider has enumerated with NPPES. All fields marked with a red asterisk (*) are required fields. Refer to Figure 8-1 below.
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Figure 8-1: Start Enrollment Screen
1. In the Billing Provider NPI Number field, enter the NPI. This is a required field.
2. In the Business Enumeration Type drop-down list, select NOPR. This is a required field.
3. Once NOPR is selected for the Business Enumeration type the system defaults the Business Enrollment Type to NOPR. This is a required field.
4. The Tax ID Type field will default to SSN for a NOPR. This is a required field.
5. In the Enter Tax ID field, specify the provider’s SSN. This is a required field.
6. In the Re-Enter Tax ID field, re-enter the provider’s SSN. This is a required field. NOTE: For security purposes, the Tax ID and Re-Enter Tax ID fields only display the last four digits of the number entered.
7. Click the “I attest that I have read and I will agree to the terms and conditions of Maine Provider Enrollment Application version 2.0” checkbox. This is a required field.
8. Verify that the information on this screen is correct, and make any necessary modifications.
Do one of the following:
• To submit the information entered and continue to the next enrollment step, click the SAVE & CONTINUE button. Continue with the next section.
• To cancel all changes, click the CANCEL button.
• To reset the fields, click the RESET button.
Ordering/Referring Providers
Upon completing the Start Enrollment screen, the Ordering/Referring Providers screen will appear, populated with the information downloaded from the NPPES directory. Please complete any required field that has not been populated.
NOTE: The bulk upload feature is not available for an independent NOPR provider.
1 Ordering/Referring Provider
An example of the Ordering/Referring Provider screen is shown below in Figure 9-1.
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Figure 9-1: Ordering/Referring Provider Screen
The ordering/referring provider’s information is pulled from the CMS NPI Registry and pre-populates in the Ordering/Referring Provider section. If the ordering/referring provider’s information did not pre-populate, follow the steps below to complete the Ordering/Referring Provider screen. All fields marked with a red asterisk (*) are required fields.
1. In the First Name, Middle Name, Last Name, and Suffix fields, enter the ordering/referring provider’s first name, middle name, last name, and suffix, if applicable. This First Name and Last Name are required fields.
2. In the Email field, enter the ordering/referring provider’s email address. This is a required field.
3. In the Primary Phone, Emergency Phone, and Fax fields, enter the ordering/referring provider’s primary phone number, emergency phone number, and fax number, if applicable. Of these fields, the Primary Phone field is required, but it is recommended that providers enter as many of the phone numbers as possible.
4. In the Date of Birth field, enter ordering/referring provider’s date of birth in MM/DD/YYYY format or use the Calendar icon. This is a required field.
5. In the Gender drop-down list, select the ordering/referring provider’s gender. This is a required field.
6. In the SSN or ITIN field, enter the rendering provider’s SSN. This is a required field.
7. If the mailing address is the same as the W9 address, select the Same as Billing Provider Mailing checkbox. The billing provider mailing address populates in the mailing address fields.
8. If the mailing address is different from the W9 address, in the Address Line 1 field, type the first line of the mailing address. This is a required field.
9. In the Address Line 2 field, type the second line of the address, if applicable. Do not enter city and/or state on this line. This is an optional field.
10. In the Zipcode field, type the zip or postal code for the ordering/referring provider’s address. This is a required field.
11. After entering the zip code, the City, County, State/Province, and Country fields are automatically populated. Verify that these fields contain the correct information. These are required fields.
12. In the Zipcode Extn drop-down list, select the zip code extension for the ordering/referring provider’s address. This is a required field, but will default to “0000” if not entered.
13. If the ordering/referring provider’s physical address is different from the mailing address, select the Same as Mailing Address checkbox. The mailing address populates in the physical address fields.
14. If the physical address is different from the mailing address, in the Address Line 1field, type the first line of the physical address. This is a required field.
15. In the Address Line 2 field, type the second line of the address, if applicable. Do not enter city and/or state on this line. This is an optional field.
16. In the Zipcode field, type the zip or postal code for the ordering/referring provider’s physical address. This is a required field.
17. After entering the zip code, the City, County, State/Province, and Country fields are automatically populated. Verify that these fields contain the correct information. These are required fields.
18. In the Zipcode Extn drop-down list, select the zip code extension for the ordering/referring provider’s physical address. This is a required field, but will default to “0000” if not entered.
19. In the Ordering Provider Conviction section, indicate whether the ordering/referring provider has ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare or MaineCare, as specified in Federal Medicaid regulation 42 CFR §455.104. Click the Yes radio button and select Sanctioned, Excluded, or Convicted. An Explanation field displays to provide details of an offense. Click the No radio button if there are no offenses related to Medicare. Refer to Figure 9-2 below.
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Figure 9-2: Ordering Provider Conviction Section
After completing the fields on this screen, do one of the following:
• To save the enrollment and continue to the next screen, click the SAVE & CONTINUE button.
• To save and continue with the enrollment process later, click the CLOSE button.
• To go to the previous screen, click the BACK button.
• To reset all fields on the screen, click the RESET button
2 Provider Type/Specialty
Specify the provider types and specialties that describe the ordering/referring provider’s practice at the Pay-To provider’s service location(s). On the Provider Type/Specialty screen, the provider can add one or more provider type-specialty pair(s). An example of the Provider Type/Specialty screen is shown in Figure 9-3 below.
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Figure 9-3: Provider Type/Specialty Screen
The example in Figure 9-3 above shows this screen in its initial state. Depending on the selections made from the Provider Type and Specialty drop-down lists, this screen updates to include the appropriate fields needed to describe the provider’s licensure, certification, education, bonding, and/or other supporting documentation for the provider type-specialty pair.
Additionally, depending on the provider type-specialty pair selected, this screen might display one or more questions related to licensing, laboratory services, and prescribing privileges.
Use the red asterisks (*) that appear in the screen to determine which fields are required. Asterisks can also appear, depending on previous selections and field entries as shown below in Figure 9-4. In addition, depending on the screen resolution and size of the browser window, providers may need to scroll to the right to see all fields.
[pic]
Figure 9-4: Additional Fields
1. In the Provider Type drop-down list, select the appropriate provider type. This is a required field. After selecting a provider type, the online portal updates the remaining fields on this screen.
2. In the Specialty drop-down list, select the appropriate specialty. This is a required field. Some provider types have multiple possible specialties, others have only one possible specialty, and others do not require a specialty. Depending on the situation for the provider type selected, do one of the following:
a. If the provider type has multiple possible specialties, select the specialty that best reflects the provider’s practice. (If the provider practices multiple specialties, choose the primary specialty first. Another provider type-specialty pair may be added after completing the information for the current one.) Continue with the next step.
b. If the provider type has only one possible specialty, the online portal automatically selects it. Continue with the next step.
c. If the provider type does not require a specialty, the online portal automatically displays No Specialty Required in this field. Continue with the next step.
3. In the Begin Date field, indicate the begin date when the provider began practicing this specialty using the MM/DD/YYYY format or use the Calendar icon. This is a required field.
4. In the Add PTSP section, if applicable, answer the required questions displayed. NOTE: Answering Yes to specific questions will populate additional questions. Use the red asterisks (*) that appear on the screen to determine what fields are required.
5. In the License section, if applicable, follow the steps below to add a license:
a. In the License Type drop-down list, select the appropriate license type. This is a required field. NOTE: More than one license may be required. Provide information for all licenses specified by a red asterisk (*) prior to continuing to the Additional Information section.
b. In the Licensing Board drop-down list, select the appropriate licensing board.
c. In the License # field, enter the license number.
d. In the Begin Date field, enter the begin date in MM/DD/YYYY format or use the Calendar icon.
e. In the Term Date field, enter the termination date in MM/DD/YYYY format or use the Calendar icon.
f. In the State drop-down list, select the appropriate state the license was issued for.
g. Click SAVE to save the license. The license displays in the License Table.
h. To add an additional license, click ADD.
i. When a provider has been designated Title 5 review status for licensure, enter the date of Title 5 designation (Begin Date) and assign a termination date 6 months from date of Title 5 review assignment (Term Date). Example, if you are enrolling and today’s date is 11/1/20xx, use that date as your Begin Date, add 6 months and enter Term Date 4/30/20xx. Providers are required to update Title 5 status in consecutive 6 month increments utilizing the provider enrollment maintenance function until their Title 5 review status is resolved and standard licensing status is returned. At such time, Providers are required to return to their enrollment case utilizing maintenance functionality and update their licensure status with appropriate State Licensing and Regulatory Services or State Licensure – Non- Maine, terming Title 5 and adding the appropriate licensing with Begin and Term dates as received from Licensing Bureau once the Title 5 has been resolved.
[pic]
Figure 9-5: License Type - Title 5
NOTE: Based on the provider type and provider specialty specified, additional sections may populate in this screen. If applicable, use the steps below to complete the Additional Information section. Based on the provider type and specialty not all information listed below may be required for the provider.
1. In the Education field, provide the name of the college, university, or other educational institution where the provider received the education for the specialty listed above.
2. In the fields beside the Education field, provide the last date of attendance at that educational institution and indicate the degree obtained at the educational institution (Doctorate, Master’s, Bachelor’s, or no degree).
3. If enrolling a provider with clinical laboratory certification, indicate the Clinical Laboratory Improvement Amendment (CLIA) certificate number, the dates during which the certificate is valid, and the certification level.
4. If enrolling a provider with prescribing privileges, indicate the DEA certificate number and the dates during which the certificate is valid.
After completing the fields on this screen, do one of the following:
• To save the enrollment and continue to the next screen, click the SAVE & CONTINUE button.
• To save and continue with the enrollment process later, click the CLOSE button.
• To go to the previous screen, click the BACK button.
• To reset all fields on the screen, click the RESET button
NOTE: Completely describe one provider type and specialty selection before identifying and describing subsequent provider types and specialties.
NOTE: When an existing provider type and specialty is deleted, a warning dialog box appears. Refer to Figure 9-6 below. Click Yes to continue action or No to discontinue action.
[pic]
Figure 9-6: Ordering Provider - Provider Type/Specialty Dialog Box
Select a provider type and specialty from the table and click SAVE & CONTINUE to advance to the next screen. Refer to Figure 9-7 below.
[pic]
Figure 9-7: SAVE & CONTINUE Button
3 Ordering Provider Taxonomy
Ordering/referring provider taxonomies can be added, deleted, or updated in the Ordering Provider Taxonomy screen. An example of the Ordering Provider Taxonomy screen appears in Figure 9-8 below. All fields marked with a red asterisk (*) are required fields.
NOTE: The ordering provider taxonomy information is pulled from the NPPES registry and pre-populates in the Ordering Provider Taxonomy table.
[pic]
Figure 9-8: Ordering Provider Taxonomy Screen
To complete the Ordering Provider Taxonomy screen, follow these steps:
1. To add a taxonomy code, click ADD.
2. In the Provider Taxonomy field, enter the appropriate taxonomy code. NOTE: Click on the hyperlink to identify the correct provider taxonomy code:. Select Health Care Provider Taxonomy Code Set from the list of hyperlinks.
a. A Lookup Search screen displays.
b. Click the radio button next to the correct taxonomy code selection. Refer to Figure 9-9 below.
c. Click the OK button.
d. The Lookup Search screen closes and returns to the Ordering Provider Taxonomy screen.
[pic]
Figure 9-9: Lookup Search Screen
3. In the Begin Date field, enter the begin date in MM/DD/YYYY format or use the Calendar icon.
Do one of the following:
• To save the enrollment and continue to the next screen, click the SAVE & CONTINUE button.
• To save and continue with the enrollment process later, click the CLOSE button.
• To go to the previous screen, click the BACK button.
• To reset all fields on the screen, click the RESET button.
Documents
1 Additional Terms
The Additional Terms screen displays policy sections to which the provider must attest. The online portal displays the appropriate documents based on all the provider types and specialties that were specified for the provider’s service locations. An example of the Additional Terms screen appears below in Figure 10-1.
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Figure 10-1: Additional Terms Screen
Once the provider has read the document, complete this screen by selecting the Click to Read hyperlink and check the check box next to the document name to attest that the provider has read it and agrees to its terms and conditions. NOTE: The Click to Read hyperlink brings the provider to appropriate sections of MaineCare Policy.
Every provider must attest to Chapter One, MaineCare General Administrative Policies and Procedures. Depending on the provider type and specialties chosen in the application, there may be additional attestations to Policy requiring the provider’s sign-off.
After reviewing and attesting to all the documents, do one of the following:
• To save the enrollment and continue to the next screen, click the SAVE & CONTINUE button.
• To save and continue with the enrollment process later, click the CLOSE button.
• To go to the previous screen, click the BACK button.
• To reset all fields on the screen, click the RESET button.
2 Supporting Documents
On the Supporting Documents screen, the online portal provides a list of documents that are required for the NOPR provider to submit with the enrollment application. An example of the Supporting Documents screen appears in Figure 10-2 below.
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Figure 10-2: Supporting Documents Screen
The documents displayed on this screen are based on the NOPR provider’s information entered in the enrollment application. Depending on the supporting documents needed, the providers have the ability to submit supporting documentation by the following methods:
• Sign Electronically
• Upload
• Mail-In
• E-mail- MaineCareenroll@
NOTE: If the email link does not open into an Outlook message containing the email address, copy and paste the link into an email.
• Fax
For documents that have to be signed electronically, do the following:
1. Click the Review before Signing hyperlink in the Submitted/Signed Documents column to view a PDF of the form.
a. If the form is acceptable, return to this screen and click the Sign Electronically hyperlink in the row for the viewed form.
b. If the form is unacceptable, return to the appropriate screen to modify the data for the form.
For documents to be downloaded, do the following:
1. Click the Download hyperlink in the Actions column. Follow normal procedures for downloading forms and for viewing and printing PDF files.
2. Print the form.
3. Complete the form, according to its instructions.
4. Indicate the enrollment case number at the top of the form.
5. Downloaded forms can be mailed, faxed, or e-mailed.
For documents that are being uploaded, do the following:
1. In the Method Of Submission column for the form to be uploaded, select Upload from the drop-down list.
2. Click the Upload hyperlink in the Actions column.
3. The Document Upload dialogue screen displays. Click the Browse button. Refer to Figure 10-3 below.
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Figure 10-3: Document Upload Dialogue Screen
4. Browse the provider’s computer to find the document that needs to be uploaded. Once the document is loaded, click SUBMIT.
5. The File Uploaded Successfully message displays in the Document Upload dialogue box as shown in Figure 10-4 below.
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Figure 10-4: File Uploaded Successfully Message
After completing the tasks for the documents listed on this screen, do one of the following:
• To save the enrollment and continue to the next screen, click the SAVE & CONTINUE button.
• To save and continue with the enrollment process later, click the CLOSE button.
• To go to the previous screen, click the BACK button.
• To reset all fields on the screen, click the RESET button.
Signature
The Signature and Summary screens are the final steps in completing the PEA.
1 Signature
After the provider has addressed all the documentation in the previous screens, the final step is to sign the application electronically in the Signature screen. An example of the Signature screen is shown below in Figure 11-1.
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Figure 11-1: Signature Screen
To complete the Signature screen, follow the steps below. All fields marked with a red asterisk (*) are required fields.
1. Read the information in the Signature section and select the “I Agree” check box. All electronic signature fields must be completed. This combination of the provider’s name, the signatory name, the signatory’s SSN or Federal Employer Identification Number (FEIN) and today’s date ensures that the electronic signature is unique to the provider. The computer’s IP address is also captured in the IP Address field.
5. The Date field automatically populates with the current date. Verify the date is correct.
6. To submit the enrollment application, click SUBMIT. The Signature Affiliation dialog box appears; click OK to confirm the enrollment has been successfully submitted. Refer to Figure 11-2 below.
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Figure 11-2: Signature Affiliation Dialogue Box
7. A confirmation email is sent to the office contact submitted during the application process confirming successful submission of the enrollment.
8. If any required information or supporting documentation is missing, the online portal displays the missing information or documentation in a Signature Affiliation dialog box. Navigate to the appropriate screen and enter the required information. Refer to Figure 11-3 below.
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Figure 11-3: Signature Affiliation Dialogue Box
9. Click the appropriate command button. NOTE: The SUBMIT button submits the enrollment application.
2 Summary
The Summary screen indicates the enrollment application has been submitted, and a list of the required documents that must be submitted to MaineCare Provider Enrollment. Additionally, there are hyperlinks to documents requiring a signature and documents that have not been already submitted. Ensure to download, print, sign, and mail all of these documents, along with the coversheet. An example of the Summary screen is displayed in Figure 11-4 below.
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Figure 11-4: Summary Screen
Resuming an Enrollment
If at any point in time during the enrollment application process the application is closed, the provider can resume the enrollment and complete the application by following these steps:
1. Sign in to the trading partner account.
2. The Provider screen of the trading partner account displays. Click the Account Maintenance drop-down list.
3. Click the Provider Enrollment hyperlink. Refer to Figure 12-1 below.
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Figure 12-1: Provider Enrollment Hyperlink
4. The PEA screen displays. In the My Enrollment Application table, locate the enrollment application to resume.
5. In the Actions column, click the double arrow icon.
6. Select Resume Enrollment from the menu. Refer to Figure 12-2 below.
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Figure 12-2: My Enrollment Applications Table
7. The provider will be returned to the last tab and screen where the application was saved prior to closing.
Provider Enrollment Application Statuses
The enrollment application will go through several different statuses as it is processed. A provider can view the status of his or her enrollment application by logging into their trading partner account and viewing applications listed in the My Enrollment Applications table. Table 3 below lists the possible statuses and definitions for the enrollment application.
Table 3: Enrollment Statuses and Definitions
|Enrollment Status |Enrollment Status Definition |
|New |A new enrollment application has been initiated. |
|Inactive |The enrollment application is no longer active. |
|Submitted |The enrollment application has been submitted. |
|Credential Request |The enrollment application’s information has been sent for credentialing review. |
|Credential Submitted |The credentialing information for the enrollment application has been submitted. |
|Credential Submit Error |There was an error when the enrollment application was submitted for |
| |credentialing review. |
|Need More Info |The enrollment application needs more information before the review can be |
| |completed. |
|On Hold – Pending Payment |The enrollment application is on hold while the application fee payment is being |
| |processed. |
|Enrolled – Not Moved to Production |The enrollment application has been processed and approved but has not been moved|
| |into the production database. |
|Enrolled |The enrollment application has been approved and moved to the production |
| |database. |
|Enrolled – Maintenance in Process |A maintenance request has been started on an approved application. |
|DisenrollmentRequested |A request has been submitted for the provider’s application to be disenrolled. |
|Disenrolled Canceled |The disenrollment request has been canceled and the provider remains enrolled. |
|Disenrolled – Not Moved to Production |The disenrollment request has been processed and approved but has not been moved |
| |into the production database. |
|Disenrolled |The disenrollment request has been approved and moved to the production database.|
|Reactivation Requested |A request to reactivate a previously terminated application. |
|Ordering Provider Rejected |An ordering provider was rejected in the enrollment application. |
|Service Location Rejected |A service location was rejected in the enrollment application. |
|Rendering Provider Rejected |A rendering provider was rejected in the enrollment application. |
|Denied |The enrollment application was denied. |
|Withdrawn Application |A submitted enrollment application was withdrawn from the PEA. |
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