Contracting Provider Termination

Terminate a contracting provider's association with a funding source.

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• Submitting this form will clear the Submitter Identification from the contracting provider registration in order to allow that ID to be used for another registration.

Prerequisites:

• The provider must have been associated with a funding source in the Contracting Provider Registration form.

1. In the Select Provider screen, enter the provider name. Choose the provider name from the list of Results, and click Select.

• If the provider has been registered for multiple funding sources, a pre-display dialog displays.

• Select Edit to edit a contracting provider and funding source association

• Select Add to register a contracting provider with a funding source.

2. The Eligible Funding Source field displays the funding source selected in the pre-display.

3. The Registration Date field displays the date that the contracting provider was registered to the funding source.

4. In the Termination Date field, enter the funding source termination date. Dates must be entered DDMMYY.

• Services claimed on or after this date will be denied authorization.

5. In the Reason for Termination field, select the termination reason.

6. In the Comments field, enter information associated with the termination.

7. Click Submit.