Edit Existing Provider

To edit an existing Non-Medicaid Provider, find the provider and click on the corresponding Edit icon. This will open a page with the provider's information displayed in a form to allow for editing of all displayed information. NOTE: Medicaid Provider information may not be edited, and therefore will not have an Edit icon.

Radio Buttons: Select the entity type for the Provider, either Person or Non-Person.

Last Name: The last name of the Provider, if the entity is a Person, or the Organization Name for all Non-Person Entities.

First Name: This field should remain blank for all Non-Person Entities.

Middle Initial: This field should remain blank for all Non-Person Entities.

EIN or SSN: Either the EIN or the SSN is required for all Providers. The setting of the radio button will determine which is to be entered. Valid entries must be 9 digits and may be entered with or without the appropriate dashes.

NPI#: Enter 10 digit assigned National Provider ID . Enter either National Provider ID or State License Number or both.

State License Number: Enter the 3-digit Profession Code, 2-character State Code (out of state providers) or Privilege Code (in state providers) and 6-digit license for a total of 11 characters. If the license number does not equal 6-digits, zero-fill the appropriate positions preceding the license number. Enter either National Provider ID or State License Number or both.

Provider Type: Select the value to be used and displayed along with the Provider Name to differentiate Providers who may have the same name.

Address: If entered, the address information will be displayed as Contact Information when selecting a Provider during the Claim Entry, SA/DVS/Eligibility or Prior Approval Request process.

Telephone: As with the Address, if entered, the telephone number will be displayed as part of the Provider's Contact Information.

Clicking Close will save the changes and return you to the main Provider Support page. Depending on the quality of the information in the provider record, it may be more beneficial to simply delete the provider. Clicking on the Remove from Support File link at the top of the page will allow you to delete the provider.