Identifier Type

• The applicant should enter all identifiers required per Provider Type

• Click the” Identifier Type” dropdown and enter the information for each identifier that applies

• Once all information has been entered, select “Add to Grid” to add to the grid

• If applicable, add all CLIA (Clinical Laboratory Improvement Amendments) numbers that are assigned to this provider for the requested enrollment period

• If CLIA Number is selected, additional field of CLIA Address will appear

• One single field available to enter the address linked to corresponding CLIA

• Maximum 600 Characters

• Select all the NPIs listed that correspond to the CLIA Number

• Click “Add” if you wish to add Additional Identifiers, “Edit” to change existing record, “Discard” to delete existing record

Identifier Number

Identifiers include the following types and if selected the following must be entered:

• CLIA Number (Clinical Laboratory Improvement Amendments)

• • Identifier Number (10 alphanumeric characters)

  • CLIA data currently collected in MMIS will be populated from the CLIA file based on the CLIA number entered by the Provider

• If “Other Identifiers” is selected, the following fields are optional but not required

• Identifier Number

• Effective Date

• Expiration Date

• Medicare Number

• Identifier Number

• Effective Date

• Expiration Date

• Other State (non-KY)- Medicaid Number

• Identifier Number

• Issue State

• Effective Date

• Expiration Date

• XDEA Number (should only the allowed Provider Types)

• Identifier Number

• Effective Date

• Expiration Date

• CAQH (Council for Affordable Quality Healthcare)

• • Number

  • Issue Date

  • Expiration Date-Which cannot be prior to issue date

• DEA Number (Drug Enforcement Administration)

• Identifier Number

• Effective Date

• Expiration Date

• ASAM (American Society of Addiction Medicine)

• Identifier Number

• Effective Date

• Expiration Date

• Driver’s License

• Existing Provider Number (Provider Type 45 Individual-EPSDT Special Services Only)

•  

Issue State

• Choose the applicable state from the dropdown box

• If the provider selects “Other” under Identifier Type, this field is required, otherwise it is optional

Effective Date

• Enter the Effective Date for the appropriate Identifier Type. If the provider selected “Other,” then this field is optional

Expiration Date

• Enter the Expiration Date for the appropriate Identifier Type

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page