Applicant Enters Parent NPI Business Process Flow Does not include loginsecurityflow logic Validations Validate parent organization per SPEC003 Applicant Enters Physician NPI Validations Validate enrolling provider can submit via new elephant per ID: 1002097
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1. BP001Physician new enrollment with existing parent billing organization
2. Applicant Enters Parent NPIBusiness Process Flow (Does not include login/security/flow logic)ValidationsValidate parent organization per SPEC003Applicant Enters Physician NPIValidationsValidate enrolling provider can submit via new elephant per SPEC003Edit / Enter Required DataValidationsValidate entered data elements per SPEC004Upload Required Documents and SubmitEnd – Cancel ApplicationValidationsValidate uploaded documents per SPEC005Enrollment Submission Process CompleteOwnership Control Disclosure1345Data IntegrationLoad data per SPEC004Collect Survey Data7Final ActionsTake action per SPEC0062UID001UID002UID003UID004UID005UID011Sign Enrollment Application6UID006
3. Welcome to The Medicaid Provider Portal!Currently, this portal supports our physician providers. We are working to add functionality to include additional provider types in the future.Already have a username and login?Need to register?LoginRegisterUID010
4. Welcome to The Medicaid Provider Portal!Please start by telling us about what you are seeking to accomplish.Add or change the organization who handles billingProcess a new enrollment applicationEnrollAdd Billing RelationshipUpdate contact information, service addresses, etcProcess ChangesUID009
5. Let’s begin the enrollment process!Please indicate the organizational structure of the physician you would like to enroll:The physician provides services under a parent organization that handles billingThe physician provides services and handles billingContinueUID008
6. Ok, got it. Please note, you must have the following information and documentation ready to submit in order to complete your application:Parent organization NPIPhysician NPI - NPPES (hhs.gov)Physician’s licenseIRS Form W9CLIA (if performing laboratory functions)Iowa photo IDBegin the Application ProcessUID007
7. Group AffiliationPlease enter the NPI of the parent organization / group to which this application applies Physician InfoUpload DocsOCDCompleteNPI:SearchUID001
8. Please confirm this is the group to which the physician application should be addedNPI:ConfirmGroup AffiliationPhysician InfoUpload DocsOCDCompleteName:548451566Best Physician Group Inc.Go BackUID001
9. Please enter the NPI of the Physician:NPI:SearchGroup548451566Physician InfoUpload DocsOCDCompleteUID002
10. We found the below information for NPI XX03940322Physician InfoUpload DocsOCDCompleteGroup548451566ConfirmPlease edit the information for accuracy and confirm when completeFirst Name: PeanutLast Name: GalleryDOB: 12/02/1967SSN: XXX-XX-3402Demographic informationPhone: 515-555-3933E-mail: peanut@provider.comedit234 First StCarnagie, IA 52245Mailing AddresseditBilling Addressedit2234 Second AveCarnagie, IA 52245234 First StCarnagie, IA 52245Service Locationsedit234 First StCarnagie, IA 52245License InformationeditLicense #: XXYY333Eff Date: 12/14/2018TaxonomyTaxonomy: XX38323Grouping: Allopathic…Classification: DermatologyOpen questions:Should we design this to use NPPES as the system of record?May need to define by data type.Also questions around how we leverage CAQHUID003
11. Please identify the type of physicianContinueDoctor of Medicine (MD)Doctor of Osteopathic Medicine (DO)BackPhysician InfoUpload DocsOCDCompleteGroup548451566TBD
12. Please upload the following documents:ContinuePhysician XX03940322Upload DocsOCDCompletePhysician LicenseCLIA (only if performing labs)IRS Form W-9State ID of designated contactGroup548451566UploadUID004
13. Does any organization or person (other than the physician applying) have more than 5% ownership of the physician’s organization?Physician XX03940322Upload DocsOCDCompleteGroup548451566NoYesContinueUID005
14. <Legal words> - click here to sign the provider agreement 470-2965Physician XX03940322Upload DocsOCDCompleteGroup548451566SignUID006Rules for submitting on behalf of someone: <Need to get this information from legal> - Lisa ReelSchmidtAuthorization to submit:
15. Almost done! Please provide us with some feedback on the application process: Physician XX03940322Upload DocsOCDCompleteGroup548451566SubmitHoursHow much time did you spend completing the provider enrollment application? Please include time spent gathering information and getting answers to questions:Please provide suggestions/feedback for how the enrollment process could be improvedHoursRate your experience on a scale from 1-5UID011
16. Thank you for your application submission! Your application has been processed and approved with an effective date of <date><Include MCO instructions><Add messaging around any provider identification numbers we determine we’d like to use>Physician XX03940322Upload DocsOCDCompleteGroup548451566Success!! UID012