PES Manual — Lists, Other Provider List

The Other Provider list allows you to enter information about additional providers such as referring, attending, or operating physicians. As with other lists, once the code is entered into the list, it may be accessed from drop-down boxes within the claim form screens. Other providers can be either individual providers or organizations. To enter other providers, follow these steps:

Tip

In general, no special characters (such as apostrophes) may be entered in name boxes. Spaces and dashes are allowed.

Names must be submitted the same way they appear in Medicaid files.

Select the Lists option on the menu bar.
Select the Other Provider list.
Enter data into all of the required boxes on the Other Provider screen using the table below as a guide.

Tip

In the Provider ZIP field on the Other Provider List screen, a ZIP code is required. If a ZIP+4 code is known for the provider, please enter this code; it will help identify the provider’s practice location.

Other Provider List
Field	Description
Provider ID	Enter the National Provider Identifier (NPI), Medicaid billing provider number, state license number, or Unique Provider Identification Number (UPIN).
Provider ID Code Qualifier	Select the appropriate code to identify the type of provider identification number used, if applicable.
Taxonomy Code	Enter the taxonomy code that corresponds to the provider ID entered.
Entity Type Qualifier	Select "1 — Person" for an individual provider, or "2 — Non-Person" for a group or institution.
Last/Org Name	Enter the last name of the provider if the entity qualifier is "1," or the organization name if the entity qualifier is "2."
First Name	Enter the first name if the provider is an individual. This field is not required if the entity qualifier is "2."
SSN/Tax ID	Enter the Social Security number (SSN) for an individual provider, or the employer's identification number (EIN) for an organization. This field is required for institutional providers; however, if you are a professional provider, you may use all zeros in place of an SSN or EIN.
ID Code Qualifier	Select "24" for EIN, or "34" for SSN.
Provider Address Line 1	Enter the provider's street or mailing address. This field is optional.
Provider Address Line 2	This field is optional.
Provider Address City	Enter the name of the provider's city. This field is optional.
Provider Address State	Select the two-digit state code designation. This field is optional.
Provider ZIP	Enter the provider's ZIP code. This field is optional.

Click Save to save the data or New to add a provider.

Tip

Providers who have one NPI with multiple taxonomy codes or multiple ZIP+4 codes may make duplicate Provider and Other Provider lists.

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