Welcome to the Online Provider Enrollment System
To start a NEW application please click the “Start” button in the bottom right corner to begin the enrollment process. The application will automatically save each time you click “Continue”.
To RESUME an application click Here
To start a REVALIDATION click Here
To check the STATUS of an application click Here
MCO Contracting Request
To ADD an MCO to an already enrolled provider click Here
Please note that only one service location and one provider type can be enrolled per application. All attachments must be complete, legible and current. You will be notified if your application cannot be processed because it is incomplete or the information is incorrect.
Existing Group members (Individuals in a Group) only need to be enrolled once for each state in which they practice. Individual in a Group providers may affiliate to multiple organizations.
All providers may need the following minimum information to complete your enrollment request:
- Address information
- Tax Identification Number/Social Security Number
- Application Fee
Additional information may also be required depending on provider type such as:
- National Provider Identifier
- Taxonomy code(s)
- License Number(s) and Effective Dates
- CLIA Number and Effective Dates – if billing laboratory codes
For general enrollment Frequently Asked Questions, click Here
For any questions related to your application, call 800–933–6593.