Performing Provider's Information Section

Associate a performing provider to the contracting provider.

• Information entered for the provider in the Performing Provider Registration form populates these fields, and can be edited.

1. In the Performing Provider's Information Table, click Add New Item.
2. In the Inactive Performing Provider Registration? field, select whether or not this registration record is inactive.
3. In the Performing Provider field, search for the provider by name or ID.
4. The Performing Provider's Name field displays the provider's name.
5. In the Performing Provider Registration field, select the registration for the provider.
6. ​In this first set of Effective Start and End Date fields, enter the provider's start date, and if applicable, the end date.
7. In the Registration Start and End Date fields, displays the registration start date and end dates.
8. In the Performing Provider's Birth Date field, enter the provider's birth date.
9. In the Performing Provider's Social Security Number field, enter the social security number.
   Note: Access to the Social Security Number field is defined in the User Definition and User Role Definition forms (Social Security Number Access field). This is defined by a system administrator. The user may be able to:
   • Enter new data for a client, edit and view data
   • Enter new data for a client, and view data
   • Enter new data for a client
10. In the Primary License Type Effective Dates field, choose either Create New or select an existing Provider License Type Claim to edit.
11. In the Primary License Type for Claims field, select the the license type to include with the 837 Professional or Institutional file.
    Note: There must be at least one entry created for Primary License Type for Claims with an Effective Start Date matching the Registration Start Date in order for this form to file successfully.
12. In this second set of Effective Start and End Date fields, enter the date range for the specific entry selected in the Primary License Type for Claims field.
13. Click File Primary License Type Effective Date to process the dates for that entry.
14. Click Delete Primary License Type Effective Date to remove the dates for that entry from the system.
15. Click Display Primary License Type Effective Dates to see a report of the entries that exist for the performing provider.
16. In the Performing Provider's E-mail Address field, enter the e-mail address.
17. In the Performing Provider's Gender field, select the performing provider's gender.
18. In the Performing Provider's License Type field, select the license types.
19. In the Performing Provider's Race/Ethnicity field, select the race or ethnicity.
20. In the Performing Provider's Age Group field, select the age groups.
21. In the Treatment Age Group Specialties field, select the age groups the provider specializes.
22. In the Hospital Privileges field, select the hospitals where the provider has privileges.
23. In the Special Accommodations field, select the special accommodations the provider has available.
24. In the Other Languages field, select the other languages the provider can knows.
25. In the Specialties field, select the provider's specialties.
26. In the Does Performing Provider have Accessibility for Handicapped Persons field, select Yes if the provider has handicapped accessibility.
27. In the Performing Provider's Address ZIP Code field, enter the performing provider's ZIP code.
28. In the Default Demographics from Program Address field, select Yes to populate program address information to associated fields.
29. In the Default Program Address field, select the treatment program to populate address information.
30. In the 'Performing Provider Address' fields, enter the information as appropriate.
31. In the Medicaid Provider # field, enter the provider's Medicaid number.
32. In the Performing Provider's State Reporting #1 field, enter the state reporting number.
33. In the Provider ID Qualifier field, select whether the ID is a Health Care Financing Administration National Provider Identifier, or a Unique Physician Identification Number.
    • This field is used to populate the Rendering Provider Identification Qualifier (2100-NM1-08) on an 835. The Provider ID Qualifier currently supports the values 'XX-Health Care Financing Administration National Provider Identifier' and 'UP-Unique Physician Identification Number (UPIN)'. Any additional values can be supported by adding the code/value to the Provider ID Qualifier dictionary and specifying the appropriate ID in the Provider ID field.
34. In the Provider ID field, enter the number.
    • This field is used to populate the Rendering Provider ID (2100-NM109) on an 835. 
35. In the DEA License # field, enter the provider's DEA License number.
36. In the Degree/Year Graduated field, enter the degree and year the provider graduated.
37. In the Residency Institution Name field, enter the institution name.
38. In the Residency Institution Address field, enter the institution address.
39. In the From and To Month/Year of Residency MM/YY - MM/YY field, enter the residency date range.
40. In the Have Copies of Curriculum Vitae been Received field, select Yes if the provider has copies of the curriculum vitae.
41. In the Board Certified field, select Yes if the provider is board certified.
42. In the Credential Board Approval Date field, enter the date the provider received their credentials.
43. In the Board Eligible field, select Yes if the provider is board eligible.
44. In the Received Copies of Board Certification Etc field, select Yes if the provider submitted copies of their board certification.
45. In the Are You Available for Evaluations on an Immediate Basis field, select Yes if the provider is available for evaluation.
46. In the Are You Available for Evaluations in 48 Hours field, select Yes if the provider is available for evaluations within 48 hours.
47. In the Have You Ever Had a Problem with Hospital Membership or Privileges field, select Yes if the provider has had these problems.
    • In the Explanation of Membership or Privileges Problem field, enter information to describe problems encountered by the provider.
48. In the Have You Ever Been Convicted of a Felony field, select Yes if the provider has been convicted of a felony.
    • In the Explanation of Felony Conviction field, enter information to describe the provider felony.
49. Save when finished.

► SQL Tables

• SYSTEM.performing_license_dates
• SYSTEM.provider_license_dates 
• SYSTEM.provider_performing_data