Instructions for completing the Accounting/Billing Information Section.
Instructions for updating the Accounting/Billing Information section.
Instructions for reviewing the Accounting/Billing Information Page
Section: Accounting/Billing Information
Select the Application Type from the left navigation menu.
Click +Add Accounting/Billing Information.
Complete the following accounting/billing address and contact Information:
Contact - First Name—Enter the contact's first name.
Contact - Middle Name—Enter the contact's middle name. This field is optional.
Contact – Last Name—Enter the contact's last name.
Street Address 1—Enter the contact's street address.
Street Address 2—Enter the suite or apartment number (if applicable).
City—Enter the city.
State—Enter the state.
ZIP Code—Enter the ZIP Code.
Zip+4 (optional) - Enter the ZIP code +4.
If the address requires corrections or changes and is greyed out, select the “Click to change address” checkbox to make edits.
Verify the information for the location already on file is accurate. If you require any edits, click the ellipses icon (…) and select click Open to review the information on file.
Confirm or update the "Accounting/Billing Address" information below:
Contact - First Name—Update the contact's first name.
Contact - Middle Name—Update the contact's middle name. This field is optional.
Contact – Last Name—Update the contact's last name.
Street Address 1—Update the contact's street address.
Street Address 2—Update the suite or apartment number (if applicable).
City—Update the city.
State—Update the state.
ZIP Code—Update the ZIP Code.
Zip+4 (optional) - Update the ZIP code +4.
Click Verify Address.
Note: If the address is not verified, you may select "Continue with Address entered".
Complete the following for the provider contact information for this enrollment application.
Update the following fields for the provider contact information for this enrollment application:
Contact Phone Number—Enter the contact person's phone number.
Contact Phone Number—Update the contact person's phone number.
Ext.—Enter the contact person's phone number extension. This field is optional.
Ext.—Update the contact person's phone number extension. This field is optional.
Contact Fax Number—Enter the contact person's fax number.
Contact Fax Number—Update the contact person's fax number.
Section: Third Party Biller
Confirm or update the Third-Party Biller information below:
Do you have a Third-Party Biller ? Click Yes or No.
Do you have a Third-Party Biller ? Click Yes or No.
If you select “Yes,” the following information will appear:
Is the Third-Party Biller a company or individual? Select Entity or Individual.
After answering the question above, dependent on the selection, one of the following sections below will be visible:
Tax ID number—Enter the TIN for the Third-Party Biller .
Billing Agent – Address Line 1—Enter the Address information for the location of the Third-Party Biller .
Billing Agent – Address Line 2—Enter the Suite or Building number for the address information (if applicable).
Billing Agent – City—Enter the City for the address information.
Billing Agent – State—Enter the State for the address information.
Billing Agent – Zip Code—Enter the ZIP Code for the address information.
Billing Agent – Zip Code +4—Enter the ZIP Code +4 for the address information.
Click Verify Address.
Contact Phone Number—Enter the phone number for the Third-Party Biller , or point of contact if the identified Third-Party Biller is an Entity
Extension—Enter the extension for the Phone Number (if applicable).
If you select "Yes," the following information will appear:
Is the Third-Party Biller a company or individual? Click Entity or Individual.
Tax ID number—Update the TIN for the Third-Party Biller .
Billing Agent – Address Line 1—Update the address information for the location of the Third-Party Biller .
Billing Agent – Address Line 2—Update the suite or building number for the address information (if applicable).
Billing Agent – City—Update the city for the address information.
Billing Agent – State—Update the state for the address information.
Billing Agent – Zip Code—Update the ZIP Code for the address information.
Billing Agent – Zip Code +4—Update the ZIP Code +4 for the address information.
Click Verify Address.
Contact Phone Number—Update the phone number for the Third-Party Biller, or point of contact if the identified third-party biller is an entity.
Extension—Update the extension for the phone number (if applicable).
Section: Third Party Biller Information - Entity
This section is not required for Third Party Billers that are Individuals.
This section is not required for Third Party Billers that are Individuals.
Billing Agent – Company Name—Confirm or update the billing agent company name.
Contact – First Name—Update the Contact’s First Name.
Contact – Middle Name—Update the Contact’s Middle Name.
Contact – Last Name—Update the Contact’s Last Name.
Billing Agent – Company Name—Enter the Billing Agent Company name.
Contact – First Name—Enter the contact’s First Name.
Contact – Middle Name—Enter the contact’s Middle Name.
Contact – Last Name—Enter the contact’s Last Name.
Section: Third Party Biller Information - Person
This section is not required for Third Party Billers that are entities.
1. Billing Agent – First Name: Enter the Billing Agent First Name.
2. Billing Agent – Middle Name: Enter the Billing Agent Middle Name.
3. Billing Agent - Last Name: Enter the Billing Agent Last Name.
Section: Attachments
If you have attachments to upload, click Click here to select files to upload your documentation.
Click Save.
Once complete, go to the left-hand section of the page and select the Form W-9 page.
Instructions for completing the Form W-9 page.
Go to www.irs.gov/formw9 for instructions and the latest information.
Section: Form w9
1. Enter the Name (as shown on your income tax return).
2. Enter the Business/Disregarded Entity Name (if different from above).
If you require updates to your tax information on the W9 form, make the edits to the following information accordingly:
Note: This is also known as “Doing Business As” name.
If a "Doing Business As" name was entered, attach a copy of the Assumed Name certificate
Sole Proprietors—Obtain from the County Clerk's office.
Other entity types—Obtain from the Secretary of State’s office .
3. Select the appropriate tax classification for “Check the appropriate box for federal tax classification of the person whose name is entered on line 1. Check only One of the following seven boxes.”
Individual/sole proprietor or single-member LLC.
C Corporation
If selected, attach the following required documentation:
A copy of the Certificate of Incorporation (Texas corporations).
A copy of the Certificate of Authority to do business in Texas (for foreign corporations).
An organizational structure chart showing all individuals and/or organizations holding ownership interests in the corporation.
S Corporation
If selected, attach the following required documentation:
a copy of the Certificate of Incorporation (Texas corporations).
a copy of the Certificate of Authority to do business in Texas (for foreign corporations).
An organizational structure chart showing all individuals and/or organizations holding ownership interests in the corporation.
Trust/estate
Limited Liability Company. Enter the tax classification (C=Corporation, S=S corporation, P=Partnership).
A copy of the Articles of Organization or Certificate of Filing.
If your federal tax classification is not one of the available options, select Other, and specify your classification in the space provided.
This includes classifications that pertain to:
Governmental Agency/Entity
General/Limited Partnership
Professional Association
If selected, the following documentation is required:
A copy of the Certificate of Incorporation is required.
a copy of the Certificate of Authority to do business in Texas (for foreign corporations)
An organizational structure chart showing all individuals or organizations holding ownership interests in the partnership is required.
Confirm the "Address" field.
Confirm the "City, state, and Zip code" field.
Note: This will automatically populate the address that appears in the "Accounting/Billing Address" page; if changes are required, you must make updates on the "Accounting/Billing Address" page.
Enter the List account number(s) here (optional) field if applicable.
Enter the Exempt payee and Exemption from the Foreign Account Tax Compliance Act (FATCA) reporting code, if applicable.
Section: Part I Taxpayer Identification Number (TIN)
1. Enter the Social Security Number or Employer Tax Identification Number.
Confirm or update the Social Security Number or Employer Tax Identification Number field.
Section: Part II Certification
Review each statement for certification.
Check the box to cross out item 2 if you have been notified by the Internal Revenue Service (IRS) that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.
When you have completed and confirmed all sections as accurate, check the box to acknowledge “I attest this is what appears on my W-9.”
Section: Public / Private
1. Are you a private or public entity?: Select Private or Public.
2. Definition: Public entities are those that are owned or operated by a city, state, county or other government agency or instrumentality, according to the Code of Federal Regulations, including any agency that can do intergovernmental transfers to the State. Public agencies include those that can certify and provide state matching funds.
Section: Additional Entity Information
Enter the following information:
Confirm or update the following information:
State of Entity's Formation—Select from the drop-down menu.
Do you have a 501(c)(3) Internal Revenue Exception? - Answer Yes or No
If you answered "Yes," attach the Internal Revenue Service (IRS) Exemption Letter.
The letter must be from the IRS and must list a Tax ID that matches the Tax ID listed on the Form W-9.
Letters submitted from any organization other than the IRS are not acceptable (includes Texas Sales Tax Exempt Letters).
Charter Number: If you uploaded a Certificate of Filing document, enter the Charter Number as stated on your Certificate of Filing document.
For any required documents, click Click here to select files.
Click Save
Once complete, go to the left-hand section of the page and select the EFT page.
Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application.
Section: Electronic Funds Transfer (EFT)
Complete all sections below and upload a copy of a voided check or a signed letter from your bank on the bank's letterhead.
If you do not wish to be reimbursed electronically, you may select “I do not wish to participate in the EFT program.” This will opt you out and provide you with paper checks to your accounting/billing address.
Note: Providers enrolling into Kidney Health Care, Children with Special Healthcare Needs - Family Support Services, Long Term Services Supports, and Long Term Care program are not required to enroll into the Electronic Funds Transfer program.
Provider name—This field is prepopulated from the provider name on the "Provider Information" page.
Doing Business As—This field is populated from the Doing Business As name on the "Provider Information" page.
Street—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
City—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
State—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
Zip Code/Postal Code—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
Country Code—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)—This field is prepopulated from the Accounting/Billing address on the "Accounting/Billing Information" page.
Provider License Number—This field is prepopulated from the License number on the "Licenses/Certification/Accreditation" page.
License Issuer—This field is prepopulated from the License Issuer on the "Licenses/Certification/Accreditation" page.
National Provider Identifier—This field is prepopulated from the NPI on the "NPI Taxonomy Information" page.
Provider Type— This field is prepopulated from the "Services Provided" page.
Provider Taxonomy Code—This field is prepopulated from the Eligible Taxonomy code on the "NPI Taxonomy Information" page.
Assigning Authority—This field is prepopulated as "Medicaid."
Trading Partner ID—This field is not required.
Other Identifier—This field is not required.
Section: Contact Information
Provider Contact Name—Enter the provider’s Contact First and Last name.
Title—Enter the title for the Provider Contact.
Contact Phone Number—Enter the 10-digit telephone number for the Provider Contact.
Extension—Enter the extension for the Provider Contact, if applicable.
Email Address: Enter the email address for the Provider Contact.
Contact Fax Information—Enter the Fax Number for the Provider Contact, if applicable.
Section: Agent Information
Agent Name—This field is not required.
Agent Contact Name—This field is not required.
Title—This field is not required.
Street—This field is not required.
City—This field is not required.
State—This field is not required.
Zip Code—This field is not required.
Zip Code +4—This field is not required.
County Code—This field is not required.
Email Address—This field is prepopulated from the "Provider Information" page.
Agent Phone Number—This field is not required
Agent Phone Number Extension—This field is not required.
Agent Fax Number—This field is not required.
Provider Agent Contact Name—This field is not required.
Title—This field is not required.
Contact Phone Number—This field is not required.
Section: Federal Agency Information
Federal Program Agency Name—This field is not required.
Federal Program Agency Identifier—This field is not required.
Federal Program Agency Code—This field is not required.
Section: Retail Pharmacy Information
Pharmacy Name—For Pharmacies, enter the pharmacy name. For all other providers, enter "N/A".
Chain Number—This field is not required.
Parent Organization Name—This field is not required.
Payment Center ID—This field is not required.
NCPDP Provider ID Number—This field is not required.
Medicaid Provider Number—This field is not required.
Section: Financial Institution Information
Financial Institution Name—Enter the name of your bank.
Account Number—Enter the account number for your bank account.
Routing Number—Enter the routing number for your bank account.
Type of Account—Select Checking or Savings from the drop-down menu.
Account Number Linkage to Provider Identifier— Select either Provider Tax Identification Number or National Provider Identifier (NPI).
Select either Provider Tax Identification Number or National Provider Identifier (NPI):
If you select Provider Tax Identification Number. This will be pre-populated from the W9 form page.
If you select National Provider ID (NPI), this will be pre-populated from the NPI/Taxonomy page.
A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Street—Enter the street for your bank.
City—Enter the city for your bank.
State—Enter the state for your bank.
Zip Code—Enter the ZIP Code for your bank.
Zip Code +4—Enter the ZIP Code +4 for your bank, if you have this information.
Contact Phone Number—Enter the contact phone number for the bank.
Extension—Enter the extension for the phone number for the bank, if applicable.
Section: Submission Information
Reason for submission:
New Enrollment
Change Enrollment
Cancel Enrollment
Voided Check—This will be a blank check with your address, routing, and account number information clearly shown.
Bank Letter—This is a letter from your bank that shows your account information.
Requested EFT Start Date—Enter the start date for your Electronic Funds Transfer (EFT) enrollment.
For any required documents, select Click here to select files.
Click Save.
Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application.
This page is not applicable for Performing Provider enrollments. Please continue to the next page.
The Accounting/Billing Information section and subpages are Not required to be filled when enrolling as an Ordering- or Referring-Only provider.