Get Dmap 3110 Provider Enrollment For Billing Providers

Completing the DMAP 3110 Provider Enrollment For Billing Providers form is crucial for billing providers seeking enrollment with Oregon Medicaid. This guide will provide step-by-step instructions to help users accurately fill out the form online.

Follow the steps to successfully complete and submit your form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by providing the identifying information. This includes listing any current or previous OHA provider numbers and any names or business names used with the Oregon Health Authority.
3. Address whether the Billing Provider is owned by a government unit. Mark the applicable government types such as County, School District, or City.
4. List all Performing Providers associated with the Billing Provider. For each provider, ensure to include their OHA provider number, NPI number, and their individual Tax Identification Number, ensuring it does not match the Billing Provider's Tax ID.
5. Provide specific answers to indicate the nature of the Billing Agreement with Performing Providers. This includes marking 'Yes' or 'No' for various conditions that describe the billing relationship.
6. Detail electronic billing information by indicating whether the Billing Entity submits claims electronically and if they are authorized as the EDI Submitter.
7. Certify the Billing Provider's agreement by confirming understanding and compliance with the statements regarding submission data accuracy, record maintenance, and inspection rights.
8. Complete the Provider signature section. Input the Billing Provider name, the date, and the name and title of the authorized representative, ensuring the signature is included.
9. Once all sections are filled out, review the form for accuracy. Save changes, download a copy for your records, and prepare to submit the form according to the outlined guidelines.

Complete your DMAP 3110 Provider Enrollment For Billing Providers form online to ensure compliance and timely processing.