Enrollment Check List
Before starting the Enrollment process, have this information available.
- Tax ID Number (TIN)/Employer Identification Number (EIN)
- Billing NPI(s)
- Medicare PTAN
- Medicaid Provider ID number
- Billing and Physical Address
- Enrollment (person to contact for Enrollment issues).
- Contact Name
- Contact Email
- Contact Phone number
- Contact FAX number
- Authorized Signer (Agent):
- This is usually the Provider or the owner but is sometimes a biller or practice manager from the past that may no longer be with the Practice.
- This person must match the person the Payer has on file.
- Follow Up Contacts (up to 5)
- Have your W9 form available
- You will need a voided check for Electronic Fund Transfers (EFTs) to confirm the following information.
- Financial Institution
- Routing Number
- Type of Account: Checking, Savings, etc)
- Account Number
- Logins for Provider portals to the Payer websites.
- Some Payers, such as Tricare, required two recent paper check examples to enroll for ERAs. This may not be required any longer.