Train Web Provider Enrollment User Guide

Confidential and Proprietary © 2011, Magellan Medicaid Administration, Inc. All Rights Reserved.

Web Provider Enrollment User Guide Version 1.3 May 27, 2011

Web Provider Enrollment User Guide

Confidential and Proprietary Page 2

Privacy Rules

The Health Insurance Portability and Accountability Act of 1996 (HIPAA – Public Law 104-191) and the HIPAA Privacy Final Rule1

and the American Recovery and Reinvestment Act (ARRA) of 2009 provides protection for personal health information. Magellan Medicaid Administration developed and maintains HIPAA Privacy Policies and Procedures to ensure

operations are in compliance with the legislative mandates.

Protected health information (PHI) includes any health information and confidential information, whether verbal, written, or electronic, created, received, or maintained by Magellan Medicaid Administration. It is health care data plus identifying information that would allow the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or recipient; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. Claims data, prior authorization information, and attachments such as medical

records and consent forms are all PHI.

1 45 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule


Page 3 Magellan Medicaid Administration

Revision History

Document Version

Date Name Comments

1.0 06/29/2010 Training and Development Initial creation

1.1 02/21/2011 Training and Development Revised due to application changes

1.2 02/25/2011 Training and Development;

Documentation Mgmt. Team Revised

1.3 05/27/2011 Training and Development; Documentation Mgmt. Team

Revised due to application changes



Table of Contents Privacy Rules .............................................................................................................................. 2

Revision History .......................................................................................................................... 3

Table of Contents ........................................................................................................................ 4

1.0 Introduction ..................................................................................................................... 6

2.0 System Access ................................................................................................................ 8 2.1 Log In ............................................................................................................................ 8

2.2 Log Out.......................................................................................................................... 8

3.0 Provider Enrollment ...................................................................................................... 10

3.1 Non-Registered Users ................................................................................................. 10

4.0 Demographics Tab ........................................................................................................ 14

4.1 Identification Tab ......................................................................................................... 14

4.2 Licenses Tab ............................................................................................................... 17

4.3 Classification Tab ........................................................................................................ 19

5.0 Address Tab .................................................................................................................. 22

5.1 Service Tab ................................................................................................................. 22

5.2 Billing Tab.................................................................................................................... 24

5.3 Correspondence Tab ................................................................................................... 25

5.4 Audit Correspondence Tab ......................................................................................... 27

6.0 Ownership Tab .............................................................................................................. 30

6.1 Direct Ownership Tab .................................................................................................. 30

6.2 Indirect Ownership Tab ............................................................................................... 40

6.3 Subcontractor Tab ....................................................................................................... 45

6.4 Managing Employee Tab ............................................................................................ 48

7.0 Conviction Tab .............................................................................................................. 50

8.0 Declaration Tab ............................................................................................................. 52

9.0 Review Tab .................................................................................................................... 56

9.1 Review/E-mail ............................................................................................................. 57

10.0 Tracking ......................................................................................................................... 61





1.0 Introduction

Web Provider Enrollment is a web-based application developed to provide authorized users with an online tool to apply for enrollment in the Michigan Department of Community Health fee-for-services programs. Once successfully registered, the provider will be able to go online and

submit their application to enroll.





2.0 System Access

2.1 Log In

To access Web Provider Enrollment

1. Access the Internet by opening the web browser.

2. Type https://providerenroll.magellanmedicaid.com into the Address field and press the Enter key. The Provider Enrollment window displays. See Figure 2.1.1.

Figure 2.1.1 – Provider Enrollment

2.2 Log Out

To log out of the Web Provider Enrollment application

Click the Logout link. See Figure 2.2.1. You are taken back to the Provider Enrollment window. Refer to Figure 2.1.1.

Figure 2.2.1 – Logout





3.0 Provider Enrollment

3.1 Non-Registered Users

First-time users need to register to use the application.

1. Enter the following information in the required fields. See Figure 3.1.1.

NPI (National Provider Identifier)

State Tax ID

E-mail

If you enter an invalid number or you fail to enter data into one of the required fields, you get an error message advising you the field is required. The e-mail entered is the party that will receive e-mail notifications.

To view or edit an existing enrollment, enter the Application Tracking ID in the Application Tracking # field and click the Continue button. See Section 9.0 – Review Tab.

If the NPI number, State Tax ID number, or E-mail address was entered incorrectly, click the Change Profile hyperlink and make the changes on the Edit screen. Click Update to save the changes. Log in using the new information and tracking number.

The Registered Users section is not utilized at this time.

The Internal User box is utilized by Magellan Medicaid Administration reviewers.



Figure 3.1.1 – Provider Enrollment, Non-Registered Users

2. Click the Continue button. The Provider Agreement/Conditions and Provisions tab displays. See Figure 3.1.2.

At any time, you can print the window you are viewing by clicking the Printer icon at the bottom of the window.

If you have questions concerning enrollment, contact the phone number at the bottom of the Provider Enrollment window.



Figure 3.1.2 – Provider Agreement, Conditions and Provisions

Click the Book icon on the User Toolbar to view or print the Web Provider Enrollment User Guide.

3. Scroll down to read the Conditions and Provisions in its entirety.

4. Click the I Agree button if you agree to the Conditions and Provisions set forth for Provider Enrollment. The Demographics/Identification tab displays. See Figure 3.1.3.



Figure 3.1.3 – Demographics, Identification

If you click the Do Not Agree button, the Notice window displays alerting you to call Magellan Medicaid Administration with your questions. See Figure 3.1.4. If you click the OK button, you are logged out of the application and the Provider Enrollment screen displays. Refer to Figure 2.1.1.

Figure 3.1.4 – Notice



4.0 Demographics Tab

The Demographics tab consists of three sub-tabs: Identification tab, Licenses tab, and Classification tab. All tabs must be completed to submit the Provider Enrollment.

4.1 Identification Tab

1. Enter the legal name of the pharmacy or the name of the parent company in the Legal Name of Pharmacy field.

2. Enter the name under which the pharmacy is doing business in the Doing Business As field.

3. Enter the name of the individual’s title that is completing the enrollment in the Applicant Title field.

4. Enter the first name of the provider in the First Name field.

5. Enter the last name of the provider in the Last Name field.

6. Enter the Telephone Number. If there is an extension, you can enter up to five digits in the Ext field.

7. Enter the Fax number. See Figure 4.1.1.



Figure 4.1.1 – Demographics, Identification tab

8. Click the Save button and all tabs become accessible. The following message displays: “Provider Identification successfully saved.” See Figure 4.1.2.

Once you save the information on the Identification tab, the application tracking number is assigned to the request and displays in the Application Tracking # field. See Figure 4.1.2. It is recommended that you make note of the application tracking number so that you can access the application at a later time. Refer to Section 9.0 – Review Tab for more info on when to use the application tracking number.

If you need to access the Web Provider Enrollment User Guide, click the Guide icon at the bottom of the page.



Figure 4.1.2 – Provider Identification successfully saved.



4.2 Licenses Tab

The Licenses tab requires you to enter the license numbers for yourself or your pharmacy.

The NPI number and the State Tax ID number auto-populate with the information you entered on the Non-Registered Users window.

1. Enter the DEA Number. The Drug Enforcement Agency (DEA) number is a combination of two alphas and seven numerics.

2. The State Tax ID field will auto-populate with information you entered on the Non-Registered Users window.

3. Enter the State License number. This field can be a combination of alphas and numerics. The NPI number entered on the Non-Registered Users window auto-populates in the NPI field.

4. Enter the NCPDP Number. This field is a seven-digit numeric field.

5. Enter the Tax ID Number/EIN Number. This field is a nine-digit numeric field; do not enter the hyphens.

6. Click the Save button. The “License Information saved” message displays. See Figure 4.2.1.



Figure 4.2.1– License Information saved.

If after saving the license information you realize that you entered the incorrect data, click the box in the Delete column and then click the Save button. The incorrect information is deleted from the field. You can then enter the correct data and click the Save button.



4.3 Classification Tab

The Classification tab allows you to choose the classification and type of pharmacy that is being enrolled.

1. Select the appropriate radio button for the Classification of Pharmacy that best describes your primary business.

Radio buttons only allow you to choose one selection; whereas a box allows you to check more than one option.

2. Select the appropriate Pharmacy Type(s) that best describes your primary business. You can choose more than one if applicable.

You are required to check at least one box.

If you choose Specialty Pharmacy, a box displays and you need to explain the type of specialty pharmacy your business is.

If you choose Others, a box displays and you need to explain the pharmacy type if none of the other types apply.

3. Select the appropriate Business Type(s) that best describes the pharmacy. You can choose more than one if applicable. Click the Save button. The “Classification has been successfully saved” message displays. See Figure 4.3.1.



Figure 4.3.1 – Classification has been successfully saved.





5.0 Address Tab

The Address tab displays four more tabs that need to be completed for the enrollment process. These tabs are Service, Billing, Correspondence, and Audit Correspondence. This section

outlines what is required in the individual tabs.

All sub-tabs under the Address tab are required to be completed.

5.1 Service Tab

The Service tab allows you to enter the address of the physical location for the business.

Figure 5.1.1 – Service tab, Address List

1. Enter the PO Box or Street Address 1. If you enter the street address, it must be the street address of the physical location of the business.

2. If there is an additional address, enter that in the Street Address 2 field.

3. Enter the City.

4. Select the State from the drop-down menu of the physical location of the business.

5. Enter the zip code in the Zip code field. You can enter the additional four digits as well.

6. Enter the Telephone Number. If there is an extension, you can enter up to five digits. Hyphens are not required.

7. Enter the County name.

8. Click the Save button. The “Service Address successfully saved” message displays. See Figure 5.1.2.

If some of the addresses on the address tabs are duplicate addresses, select the appropriate option from the Address List drop-down menu and the address for that specific list auto-populates in the appropriate fields. Refer to Figure 5.1.1.



Figure 5.1.2 – Service Address successfully saved.



5.2 Billing Tab

This is a required tab and once completed, this tab allows you to receive checks, remittance advices (RAs), and Internal Revenue Service (IRS) 1099 forms sent to an address other than the

service address required on the Billing tab.

If some of the addresses are duplicate addresses, select the appropriate option from the Address List drop-down menu and the address for that specific list auto-populates in the appropriate fields. Refer to Figure 5.1.1.

1. If the address is the same as the service address entered on the Service Address tab, then select Service Address from the Address List drop-down menu. The Service Address auto-populates into the billing address fields. See Figure 5.2.1.

-OR-

Enter the post office (PO) box or street address to mail checks, remittance advices, or IRS 1099 forms in the PO Box or Street Address 1 field.

2. If there is an additional street address, enter that in the Street Address 2 field.

3. Enter the City name.

4. Select the State from the drop-down menu.

5. Enter the zip code and the additional four digits in the Zip field.

6. Enter the Telephone Number. You can also enter an extension up to five digits. Hyphens are not required.

7. Click the Save button. The “Business Address successfully saved” message displays. See Figure 5.2.1.



Figure 5.2.1 – Business Address successfully saved.

5.3 Correspondence Tab

This tab is required to be completed and allows you to have letters, bulletins, etc., from Michigan Department of Community Health (MDCH) sent to an address other than the service

address.


1. If the address is the same as the billing or service address entered on the Billing or Service tabs, then select the appropriate option from Address List drop-down menu. The selected address auto-populates in the Correspondence address fields. You are required to enter the contact person’s name. See Figure 5.3.1.

-OR-



Enter the contact person’s name in the Contact Person Name field.

2. Enter the e-mail of the contact person in the Email field.

3. Enter the PO Box or Street Address 1.


5. Enter the City.



8. Enter the Telephone Number. You can also enter an extension up to five digits.

9. Click the Save button. The “Correspondence Address successfully saved” message displays. See Figure 5.3.1.

Figure 5.3.1 – Correspondence Address successfully saved.



5.4 Audit Correspondence Tab

This tab is required to be completed and allows a corporate entity to receive notification on MDCH audit findings and gross adjustments for individual pharmacies.


1. If the address is the same as the billing, service, or the correspondence address entered on the Billing, Service, or Correspondence tabs, then select the appropriate option from the Address List drop-down menu. The selected address auto-populates in the Audit Correspondence address fields. You are required to enter the audit contact person’s name. See Figure 5.4.1.

-OR-

Enter the contact name for the audit information in the Audit Contact Name field.



4. Enter the City.



7. Enter the Telephone Number. You can also enter an extension up to five digits.

8. Click the Save button. The “Audit Correspondence Address successfully saved” message displays. See Figure 5.4.1.



Figure 5.4.1 – Audit Correspondence successfully saved.





6.0 Ownership Tab

The Ownership tab displays four additional tabs: Direct Ownership, Indirect Ownership, Subcontractor, and Managing Employee. The Ownership tab must be completed for each individual having 5 percent or more ownership of the business identified in the Doing Business

As field on the Identification tab. Refer to Figure 4.1.1.

In addition to completing all four tabs, you are required to mail or fax a copy of ownership and control interest documents as required by 42 CFR 455.104. Write the tracking number displayed to you by this application on the documentation. The tracking number is also displayed on the confirmation e-mail that will be sent to you when you complete and submit your application. Mail this documentation to Magellan Medicaid Administration Provider Operations 4300 Cox Road Glen Allen, VA 23060

-OR-

Fax to (804) 965-7647

6.1 Direct Ownership Tab

This tab allows you to list the names of the individual owners.

1. Click the Add More hyperlink on the Direct Ownership tab. See Figure 6.1.1. The Add or Edit Ownership Information window displays. See Figure 6.1.2.



Figure 6.1.1 – Direct Ownership tab



Figure 6.1.2 – Add or Edit Direct Ownership Information

To close the Add or Edit Direct Ownership Information window, click the Close link at the top of the window.

2. If there are not any individuals or entities that meet the requirement of having a 5 percent or more ownership in the business, select the No individual or entity meets the requirement. (Ownership less than 5%) check box.

3. Click the Save button and the Direct Ownership window displays and in the column titled Entity Name/Owner Last Name, First Name, the following message displays: “No Individual or Entity meets the Requirement.” See Figure 6.1.3.



Figure 6.1.3 – Direct Ownership, No Individual or Entity meets the Requirement

If there is a person who has more than 5 percent ownership, follow the steps below:

1. Click the Add More hyperlink. The Add or Edit Direct Ownership window displays. Refer to Figure 6.1.2.

2. Choose the Ownership Type by clicking on the Person radio button. The Save and Cancel options display. See Figure 6.1.4.

To cancel this step, click the Cancel button at the bottom of the Add or Edit Data Ownership window.



Figure 6.1.4 – Add or Edit Direct Ownership, Person option

3. Enter the Title.

4. Enter the Last Name, First Name.

5. Enter the Social Security Number (SSN) for the individual in the SSN field.

6. Enter the P.O. Box or Street Address.

7. Enter the City.



10. Enter the Date of Ownership or click on the Calendar icon and choose the date. See Figure 6.1.5.



Figure 6.1.5 – Calendar icon

To go back a month, click the single arrow pointing left on the calendar; to go back a year, click the double arrow pointing left. To go forward a month, click the single arrow pointing right; to go forward a year, click the double arrow pointing right. To choose the current date, click Today.

11. Enter the percentage of the business owned in the Percentage Owned field.

Do not enter the percent sign when entering the percentage owned.

12. Enter the Relationship to other Owners with a 5 percent or more controlling interest. (i.e., spouse, parent, child, siblings, etc.).

13. Click the Save button. The Direct Ownership Identification window displays showing the individual owner’s name and information. See Figure .6.1.6.



Figure 6.1.6 – Direct Ownership Identification

If you want to change any information on the ownership information, the owner name is a hyperlink. Click the hyperlink to display the Add or Edit Direct Ownership Information window. You have the option to save your changes, delete the information entered, or cancel the window. Make the necessary changes and click the Save button. The Direct Ownership Identification window displays. See Figure 6.1.7.

To add additional owners, click the Add More hyperlink and complete the required fields until all owners are listed.



Figure 6.1.7 – Add or Edit Direct Ownership

To add an Entity

The Entity radio button should be chosen if there is a corporation that has direct ownership in the pharmacy.

1. Choose the Ownership Type by clicking on the Entity radio button. The Save and Cancel options display. See Figure 6.1.8.



Figure 6.1.8 – Add or Edit Direct Ownership, Entity option

2. Enter the Entity Name.

3. Enter the employee identification number (EIN) in the EIN field.

4. Enter the P.O. Box or Street Address.

5. Enter the City.



8. Click the Calendar icon and choose the Date of Ownership. See Figure 6.1.9.





9. Enter the Relationship to other Owners with a 5 percent or more controlling interest. (i.e., spouse, parent, child, siblings, etc.).

10. Click the Save button. The Direct Ownership Identification window displays showing the individual owner’s name and information. See Figure 6.1.10.



Figure 6.1.10 – Direct Ownership tab

6.2 Indirect Ownership Tab

The purpose of this tab is to submit information if any owners have interests in other entities reimbursable by Medicaid and/or Medicare.

1. Click the Add More hyperlink on the Indirect Ownership tab. See Figure 6.2.1. The Add or Edit Ownership Information displays. See Figure. 6.2.2.



Figure 6.2.1 – Indirect Ownership tab



Figure 6.2.2 – Add or Edit Indirect Ownership Interest

To close the Add or Edit the Indirect Ownership Information window, click the Close hyperlink at the top of the window.

2. If there are no individuals or entities that meet the requirements of ownership interest in another business, then select the No entity meets the requirement. check box.

3. Click the Save button. The Direct Ownership window displays and in the column titled Entity Name/Owner Last Name, First Name, the following message displays: “No Entity meets the Requirement.” See Figure 6.2.3.



Figure 6.2.3 – Indirect Ownership tab, No Entity meets the Requirement

If there are individuals that have ownership in other entities that are reimbursable by Medicaid and/or Medicare, follow the steps below. Refer to Figure 6.2.2.

1. Enter the Entity Name.

2. If the entity is a subcontractor, select the Is this a subcontractor? check box.

If you select the Is this a subcontractor? check box, you are required to complete the Subcontractor tab.

3. Enter the Entity Percent Ownership Interest.

Do not enter the percent sign when entering the percentage owned.

4. Enter the Entity P.O. Box or Street Address.

5. Enter the Entity City.


7. Enter the zip code and the additional four digits in the Entity Zip field.



8. Enter the Entity Federal Tax ID (format is nine digits).

9. Enter the Entity Telephone Number.

10. Click the Save button. The Indirect Ownership Identification window displays showing the entity’s name and information. See Figure 6.2.4.

Figure 6.2.4 – Indirect Ownership tab

To add additional indirect owners, click the Add More hyperlink and complete the required fields until all owners are listed.

If you want to change any information on the indirect ownership information, the indirect owner name or entity name is a hyperlink. Click the hyperlink to display the Add or Edit Indirect Ownership Information window. You have the option to save your changes, delete the information entered, or cancel the window. Make the necessary changes and click the Save button. The Indirect Ownership Identification window displays. Refer to Figure 6.2.1.



6.3 Subcontractor Tab

The Subcontractor tab is required for any person who has a contract to render services (business transactions) totaling more than $25,000. See Figure 6.3.1.

If you select the Is this a Subcontractor? check box on the Indirect Ownership tab, you are required to complete this tab. Refer to Figure 6.2.2.

Figure 6.3.1 – Subcontractor tab

1. Enter the Title.

2. Enter the Last Name and First Name.

3. Enter the Contracted Date or choose the date using the Calendar icon. See Figure 6.3.2.





4. Enter the P.O. Box# or Street Address 1.


6. Enter the City.



9. Click the Save button. The Subcontractors window displays showing the information entered at the bottom of the window. See Figure 6.3.3.



Figure 6.3.3 – Subcontractor tab

If there are more subcontractors to add, follow steps 1–9 in Section 6.3 – Subcontractor Tab.

If you want to change any information on the contractor tab, the Subcontractor name is a hyperlink. Click the hyperlink to display the Edit Subcontractor window. You have the option to save your changes, delete the information entered, or cancel the window. Make the necessary changes and click the Save button. The Subcontractor window displays. Refer to Figure 6.3.1.



6.4 Managing Employee Tab

The purpose of this tab is to enter the information of the managing employee who is the senior level employee or owner who is responsible for the day-to-day operations of the pharmacy and

is designated to be a decision maker. (As defined by 42 CFR 455.101 (c))

1. Enter the Title.

2. Enter the First Name and Last Name.

3. Enter the Social Security Number.



6. Enter the City.



9. Click the Save button. The “Managing Employee is successfully saved” message displays. Figure 6.4.1.



Figure 6.4.1 – Managing Employee is successfully saved.



7.0 Conviction Tab

Federal Laws 42 CFR, 455.106 and 42 USC, §1320a-7 requires the State to collect criminal convictions information related to Medicare (Title XVIII), Medicaid (Title XIX), or other State Health Care Programs (Title V, Title XX, or Title XXI) for any person who has ownership, control interest, or a managing employee of the provider. This tab allows you to declare this

information. All individuals must be listed on this tab.

1. Enter the name of the individual with the criminal conviction in the Name field.

2. In the Notes field, enter the following:

Type of conviction

The individual(s) SSN or Tax ID

Court and Docket number

Location/Region of the conviction

3. Click the Save button. The information entered displays on the Conviction tab. See Figure 7.0.1.



Figure 7.0.1 – Conviction tab

If you want to change any information on the Conviction tab, the name of the convicted individual is a hyperlink. Click the hyperlink to display the Edit Conviction window. You have the option to save your changes, delete the information entered, or cancel the window. Make the necessary changes and click the Save button. The Conviction window displays. Refer to Figure 7.0.1.

To enter additional individuals with criminal convictions, follow steps 1–3 in Section 7.0 – Conviction Tab.



8.0 Declaration Tab

To submit the provider enrollment, this tab must be completed. The applicant who can be held responsible for this business must sign and date this agreement. The name entered on this tab

must match the first and last name on the Identification tab.

1. Enter first and last name of the person named on the Identification tab in the Signature of Applicant field. The Date Signed field displays the current date and cannot be changed.

If you do not enter the same name from the Identification tab in the Signature of Application field, you receive an error message that states, “Applicant Signature does not match. Make sure you have entered the First Name and the Last Name as on the identification tab.”

To view the name on the Identification tab, click the Demographics tab and the Identification tab displays.

2. If there are notes you want to add to the application, enter them in the Notes field.

3. Click the Submit button. The “Enrollment has been successfully saved” message displays. Your tracking number for the application displays as well. See Figure 8.0.1.

It is recommended that you make note of the application tracking number so that you can access the application at a later time.



Figure 8.0.1 – Declaration, Enrollment successfully saved

If you have failed to complete any fields or tabs, you receive an error message advising you of what information you have failed to complete.

Click the Print Enrollment hyperlink at the bottom of the window to print your enrollment application. The application displays. See Figure 8.0.2 .Click the Click to Print this Page hyperlink.



Figure 8.0.2 – Provider Application Information



After you submit the Provider Application information, you receive an e-mail notification advising you that your application is being processed and it includes the application number. The e-mail contains the contact phone number for the “Magellan Medicaid Administration, Inc. Provider Enrollment Department.” See Figure 8.0.3. It is strongly recommended that you check your junk e-mail folder to determine if the e-mail from the Provider Enrollment department was

received as junk e-mail. If it was, please move the e-mail to your e-mail inbox.

Figure 8.0.3 – E-mail notification



9.0 Review Tab

The Review tab displays the enrollment information for the application. See Figure 9.0.1.

Figure 9.0.1 – Review tab



9.1 Review/E-mail

As the application is reviewed, you receive an e-mail message at the e-mail address supplied. Magellan Medicaid Administration reviewers send an e-mail if more information is needed or missing. It is strongly recommended that you check your junk e-mail folder to determine if the e-mail from the Provider Enrollment department was received as junk e-mail. If it was, please move the e-mail to your e-mail inbox. You are also able to view this information on the Review

tab in the Web Provider Enrollment Application. See Figure 9.1.1.

Figure 9.1.1 – Request for Additional Information E-mail

Make the requested updates to the application by logging in using the NPI, State Tax ID Number, E-mail Address, and the Application Tracking # and click the Continue button. See Section 10.0 – Tracking.

If your application has been approved, you will receive an e-mail with a letter attached advising

you of the approval. See Figures 9.1.2 and 9.1.3.



If you receive the approval e-mail in your junk e-mail folder, you must move the e-mail to your inbox to view the approval letter.

Figure 9.1.2 – Confirmation E-mail





Figure 9.1.3 – Provider Enrollment Confirmation Letter



10.0 Tracking

If there are any changes needed after the enrollment has been completed, you are able to access the completed enrollment form to make the changes.

1. Log in to the application by following the steps in Section 2.1 – Log In.

2. Enter the NPI, State Tax ID, and E-mail address that was entered on the original enrollment in the appropriate fields.

3. Enter the tracking number that was attached to the original enrollment in the Application Tracking Number # field. See Figure 10.0.1.

Figure 10.0.1 – Provider Enrollment

4. Click the Continue button. The Provider Details window displays and the tabs are activated allowing changes to be made. See Figure 10.0.2.



Figure 10.0.2 – Provider Details

5. Make the required updates and click the Save button to save the changes on that particular tab.

Once the changes are made, it is critical that you click the Declaration tab and click the Submit button to resubmit the application. The revised application is sent to the Magellan Medicaid Administration Provider Enrollment department where someone reviews the application.

Documents

Train Web Provider Enrollment User Guide