Tip: A provider may have multiple provider accounts if the provider bills for services using multiple Tax ID numbers. Some of the information displayed on the Provider Account Detail page is read-only and cannot be changed.Use this page to view and/or update specific and detailed information about a provider account.
Tip: A provider may have multiple provider accounts if the provider bills for services using multiple Tax ID numbers. Some of the information displayed on the Provider Account Detail page is read-only and cannot be changed.
The following information on the Provider Account Detail page is read-only and cannot be changed:
Provider First Name displays the provider's first name.
MI displays the provider's middle initial.
Last Name displays the provider's last name.
Agency/Billing Name displays the payee's name on the provider account (for billing purposes).
Provider Account ID displays the provider's identification number.
Medicaid ID displays the provider's individual Medicaid identification number (if the provider is enrolled with Medicaid).
Account Active Date displays the date on which the provider's account became active.
To displays the date through which the provider's account remains active.
Provider Enrollment Date displays the date on which the provider enrolled with the CFO.
Degree displays the provider's degree.
E-Signature indicates whether the provider's electronic signature is currently on file with the CFO.
Prov. Acct. Address displays the current address information for the provider.
City displays the name of the city in which the provider is currently located.
State/Zip displays the name of the state and the ZIP code in which the provider is currently located.
Phone displays the primary telephone number for the provider.
Mobile displays the mobile telephone number for the provider.
Phone2 displays the secondary telephone number for the provider.
Phone3 displays an alternate telephone number for the provider.
Fax displays the fax telephone number for the provider.
The following information on the Provider Account Detail page can be entered and/or updated as necessary:
In Email, enter or update the email address for the provider. You can enter up to 50 characters in this text box. This is required information unless this provider is a transportation provider.
Note: When you are viewing detailed information about a provider from the provider's billing entity, the above information is read-only and cannot be changed.
Click the following button(s) as necessary:
Click Specialty to view and/or update the provider's specialties as necessary.
Click Reset to clear any unsaved changes and restore the previously displayed information.
Click Back to return to the previous page.
Click Save to save information that has been changed.
Note: You can click the tabs along the top of the page to view and/or update additional information about the provider account.
Click the following link(s) to see how to complete a task step-by-step:
How Do I Enter or Update Provider Account Detail Information
How Do I View a List of Billing Entity Providers
How Do I View a List of Billing Entity Providers by Site
How Do I View a Provider's Specialty List
How Do I View Detailed Information for a Billing Entity Provider
How Do I View Detailed Information for a Billing Entity Provider by Site