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MassHealth Provider Online Service Center

Provider Enrollment Application

Add Base Information

The Base Information panel is used to capture basic provider information. The data entered here will be used to register the provider and to determine the panels that will be presented during enrollment on the web portal

  • Fields marked with a red asterisk (*) are required.

  • Dates must be in mm/dd/ccyy format. Clicking on the calendar box creates a popup calendar to aid in date selection and entry.

  • Error Resolution:

    • If an error is detected a statement is displayed in the upper portion of the panel. The statement indicates the problem and the method of correction and is preceded by a small red circle with a white "x" (Error Message) in it. The small red circle with a white "x" (Error Message) also appears next to required fields that are in error.

  • Click Leave Helpto close this Help panel.

Step

Action

Response

1

Directions for entering any of the values on the Base Information panel follow:

 

Type Values

Type values in the

(Last Name, First Name, MI and SSN fields)

OR

(Organization Name and FEIN fields).

 

Type Values

Type values in the NPI field if applicable

Legal Entity = Select the appropriate value from the dropdown. This selection will determine which ownership screens are displayed

 

(Drop Down List Box

Select a value from the drop down list box for the Provider Type field

OR

Assign Available Codes

1) Select values from panels for the Selected Primary Specialty field:

2) A text box of all available values appears on the left side of the panel with a text box of assigned values on the right. A column of arrows is in between the two text boxes.

3) Clicking on the right single arrow (>) sends one value at a time from the available list to the assigned. Clicking on the left single arrow (<) sends one value at a time back from the assigned list to the available list.

4) Clicking on the right double arrow (>>) sends all the values from the available list to the assigned list. Clicking on the left double arrow (<<) sends all the values back from the assigned list to the available list.)

By selecting the available specialties the system will return the list of available Provider types.

 

2

To back out any changes on any panels that have not been saved yet, click on Cancel Service on the Base Information panel.

OR

Any unsaved modifications or deletes to any panels during this process are backed and the system returns to the initial Start An Enrollment Application - Security Warning panel.

3

Click on Continue on the Base Information panel.

The system continues the provider enrollment process and displays the Regulations and Requirements panel, the Physician Participation Requirements panel, and the PCC Participation Requirements panel.