• Enter your name in the Name field

• For Individual- Credentialing Agent

• Select if you are submitting as a Credentialing Agent (Provider must log-in to Partner Portal and submit application) or as an Authorized Delegate ( You will Esign and Submit on behalf of the Provider which will require an uploaded Authorized Delegate form signed by the Provider)

• If Credentialing Agent- Select Credentialing Agent and click Esign & Submit

• If Authorized Delegate

• Select Authorized Delegate

• Click the link that appears to download the Authorized Delegate Form

• Upload the completed and signed form, and click Esign & Submit

• For Group/ Entity Only- Credentialing Agent

• Select your appropriate title from Title dropdown (Group and Entity only), Date will pre-populate with current date

• If Legally Authorized Agent is selected, the checkbox Upload Document that authorizes agent to legally bind the Group or Entity will appear

• Check the box

• Click ESign & Submit to submit application for approval, Back to return to the previous screen, View MAP-811 PDF to view the MAP-811 on file, or Exit to return to the Dashboard

• After clicking ESign & Submit, if Legally Authorized Agent was previously selected in the dropdown, return to 8.0 Document Upload screen and upload the required Legally Authorized Agent statement signed by the Provider. This statement will come from the group/ entity, or its legal department.

• If Group or Entity has an individual owner, the owner's signature is required

• If Group or Entity has no individual owner, an officer or board member's signature is required

• After uploading the document, return to the 10.0 Submit screen, enter your name, select Legally Authorized Agent from the dropdown, and click ESign & Submit  

Required Fields:

• Please note that all fields marked with an asterisk (*) are required fields that must be populated in order to move forward. If they are left blank you will receive an error message

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