Provider Agreement

In order to access the Provider Agreements page (currently located in the IWeb application), organizations/facilities must have these options enabled in IWeb:

To access the Provider Agreements page in IWeb, click the Provider Agreement link in the VOMS menu. If the Linking to IWeb page appears with a grayed-out Continue to IWeb button, enter an organization/facility in the search bar and click the button, which becomes available once an organization/facility is selected.

NOTE: If the IWeb application was previously open and "timed out" or otherwise cancelled the session, it may open to the login page instead of the Provider Agreement (or search) page. Log in to the IWeb application again, click the Inventory Management menu link to return to VOMS, and then re-click the Provider Agreement link in VOMS.

Search for and Approve Provider Agreements

If the Administration > Properties > Vaccine Management provider agreement options are enabled, Registry Client users can search for and approve provider agreements that have been submitted. Click the Provider Agreement link in the VOMS menu to open the Provider Agreements page in the IWeb application.

If the organization/facility had already been selected, the Provider Agreements page opens with a list of available provider agreements. Otherwise, enter search criteria and click Search.

The search criteria fields (if the list of provider agreements is not displayed when the page opens) are as follows:

Field	Description
Organization (IRMS Information Request Management System) Name	Select the Organization (IRMS) from the drop-down list. If none is selected, the Facility Name list is populated with all of the Facilities that have agreements in process.
Facility Name	Select the provider's Facility from the drop-down list. The list is based on the selected Organization (IRMS). If no Organization is selected, the list is populated with all of the Facilities that have agreements in process.
Medical License Number	Enter the provider's medical license number.
Federal Tax ID	Enter the provider's federal tax ID.
Phone Number	Enter the Facility's phone number.
Fax Number	Enter the fax number for the provider's site/Facility.
Email	Enter the email address for the Facility.
Status	Select a provider agreement status to search for.
Submit Date Range	Enter a date range for when the provider agreement was entered. Use the MMDDYYYY date format.
PIN	Select from and through provider PINs from the drop-down lists.

TIP: If no link appears in the PDF-Frozen Vaccine column in the search results, it is because the user did not answer "Yes" to all of the enrollment questions at the time the data was entered.

The following actions can be performed on the search results (if all of the links and buttons are available).

View/Edit/Approve a Provider Agreement

To select a provider agreement to view, edit, or approve, click the arrow button in the Select column. (The provider agreement opens on the Provider Agreement Add/Edit page. See below for more information about this page.)

If the agreement already has an Approved status, the fields are grayed-out and cannot be edited on the Provider Agreements page. Otherwise, authorized users can edit the Approval Status to Approved.

If the provider agreement is up for renewal, authorized users will see the Add button on the Provider Agreements page. Click it to renew the provider agreement.

If any fields have been edited or changed from the previous agreement, local and state approvers will see the modified fields in red text on the Provider Agreements page.

NOTE for Ohio users: When editing a provider agreement, some fields may appear editable but are actually not. For example, the drop-down lists for Contact Details Type1 and Type2 cannot be modified on this page.

The following fields and descriptions are displayed on the Provider Agreement Add/Edit page, which opens when the arrow button in the Select column for a provider agreement is clicked. Note that these fields vary depending on state configuration settings and all fields may not appear, or different wording may be used.

Field

Description

Approver Comments

Enter any comments related to the approval.

Status

Status of the provider agreement (Submitted, Approved, Returned)

VFC PIN

Provider's VFC PIN. This field is required.

Organization (IRMS) Name

Provider's Organization (IRMS).

Facility Name

Name of the facility. This field is required.

Medical Director or Equivalent (New Hampshire)

Name of the medical director or equivalent position. This field is required (New Hampshire).

Medical Director or Equivalent Title (New Hampshire)

Title of the medical director or equivalent position. This field is required (New Hampshire).

Agreement Signatory/Signature

Name of the person responsible for signing the agreement. This field is required.

NOTE: This field label becomes Certifying Provider Name on the Provider Agreement Add/Edit page.

Agreement Signatory Title

Title of the person responsible for signing the agreement. This field is required.

NOTE: This field label becomes Certifying Provider Title on the Provider Agreement Add/Edit page.

Is Information Sharing Agreement current?

Indicates whether or not the information sharing agreement is current (Yes/No).

Is this a Hospital Owned Practice (HOPS)? (New Hampshire)

Indicates whether or not this is a hospital-owned practice.

Employer Tax Identification Number (Ohio)

Tax Identification Number for the employer. This field is required (Ohio).

Agreement Certifying Provider (Alaska)

Name of the person responsible for certifying the agreement. This field is required (Alaska).

Agreement Certifying Provider MLN (Alaska)

Medical license number of the person responsible for certifying the agreement. This field is required (Alaska).

Last Renewed

Indicates the last renewed date, or select the year the provider agreement was last renewed.

Field	Description
Street Address	First line of the facility's street address.
Street Address 2	Second line of the facility's address.
City	Facility's city name. This field is required for the First Responder application.
State	Facility's state. This field is required for the First Responder application.
County/Parish/Borough/Census Area	Facility's county/parish/borough/census area. Enter the city and state first.
Zip Code	Facility's zip code. This field is required for the First Responder application.

Field	Description
Check if vaccine delivery address is the same as facility address	Select this option if the vaccine delivery address is exactly the same as the facility's address.
Street Address	First line of the vaccine delivery address.
Street Address 2	Second line of the vaccine delivery address.
City	City for the vaccine delivery address.
State	State for the vaccine delivery address.
County/Parish/Borough/Census Area	County/Parish/Borough/Census Area for the vaccine delivery address. Enter the city and state first.
Zip Code	Zip code for the vaccine delivery address.

Field	Description
Check if mailing address is the same as facility address	Select this option if the mailing address is exactly the same as the facility's address.
Street Address	First line of the mailing address.
Street Address 2	Second line of the mailing address.
City	City for the mailing address.
State	State for the mailing address.
County/Parish/Borough/Census Area	County/Parish/Borough/Census Area for the mailing address. Enter the city and state first.
Zip Code	Zip code for the mailing address.

Field	Description
Type 1-5	Select the type of contact from the drop-down list. Examples: Vaccine Delivery Mailing Facility
Contact Name 1-5 / Contact First Name, Middle Initial, and Last Name 1-5	Contact name: First, middle, last.
Phone Number 1-5	Contact's phone number.
Phone Number Extension 1-5	Contact's phone number extension.
Fax Number 1-5	Contact's fax number.
Email Address 1-5	Contact's email address.
Completed Annual Training 1-5	Indicates whether or not annual training was completed (Yes/No).
Type of Training Received 1-5	The type of training received. Examples: In Person, Offsite, Online.
Completed Annual Training Requirements	Enter the date that the annual training requirements were completed.
Method of Training Completion	The method of training. Examples: Online Training, Site Visit.

Field	Description
Privately purchased childhood vaccines (Indiana)	Indicates whether or not childhood vaccines were privately purchased. Selected (enabled) is Yes; deselected is No.
All ACIP Recommended Vaccines	Select this option if the provider offers all of the ACIP-recommended vaccines.
Offers Selected Vaccines	Select this option if the provider is a specialty provider that only offers specific vaccines, then select the appropriate options in this section. Also select specific vaccines that are offered.

Field	Description
Monday-Friday	Select the days and times the facility is open to receive vaccines. Select one or more days and select the start and end times (24-hour time). If there are two sets of start and end times, you can use them to indicate being closed during lunch time. For example, Monday 09:00-12:00 13:00-17:00.
Are you a State Public Health Nursing Facility or Indian Health Service? (Wyoming)	Indicates whether or not this is a state public health nursing facility or Indian health service (Yes/No).
Which vaccine program(s) would you like to enroll in? (Wyoming)	Indicates which vaccine programs the provider wants to enroll in, if any. Examples: VFC, WVIP, AHV, VUA.
Facility Type	Select the type of facility from the drop-down list. Examples: Private, Hospital, Public Health Department.
Facility Type Other	If Other is selected for facility type, enter the type of facility in this textbox.
Facility Comments	Enter any pertinent comments related to the facility/provider agreement.

After entering the information for at least the required fields, click Save and Add Provider to go to the Authorized Providers [Add/Edit] page.

If the provider agreement is for an organization, a View Provider button appears at the bottom of the page, click it to open the Authorized Providers [Add/Edit] page and see the list of authorized providers for this organization. See Add a New Provider, below.

Add a New Provider

Note for Alaska users: This page may be pre-populated with information from the system.

On the Authorized Providers [Add/Edit] page, enter at least the physician or vaccinator's last name, first name, title, specialty and (if applicable) subspecialty. Select Yes/No as to whether or not the provider is active with this practice, and enter his or her medical license number, Medicaid license number (Mississippi), and NPI number (and, in some cases, the tax ID number), and then click Add New Provider. Continue adding new providers as needed. At least one physician/vaccinator is required.

Click Verify Current ImpactSIIS Users to verify whether or not current ImpactSIIS users for the practice are still active. After selecting Yes or No, click Continue.

Click Save and Add Provider/Practice Profile when finished adding new providers. The Provider/Practice Profile page opens.

For authorized users, the View Provider/Practice Profile button may display instead. See the Approve the Provider Agreement section for more information on this.

Mississippi users: Click Verify MIIX Users to verify the users under the facility for this agreement. Select Yes or No as to whether or not the providers are active with this practice. If a provider is marked as no longer active, their account with the facility becomes inactivated.

On the Provider/Practice Profile page, enter the information, answer the question about the data source, and click Save and Certify Frozen Vaccine. (Note that this button displays only if the Administration > Settings > Properties > Vaccine Management > Enable Frozen Vaccine Certification for Provider Enrollment option is enabled (selected).

Field	Description
VFC Vaccine Eligibility Categories	Enter the number of children for each age category (<1 year, 1-6 years, 7-18 years) who received each VFC vaccine listed. The total fields for each VFC vaccine type and age category automatically populate.
Non-VFC Vaccine Eligibility Categories	Enter the number of children for each age category (<1 year, 1-6 years, 7-18 years) who received each non-VFC vaccine listed. The total fields for each non-VFC vaccine type and age category automatically populate.
What data source (or type of data) was used?	Select the appropriate answer. Examples: Benchmarking, Medicaid Claims, Doses Administered, Billing System.

When the Save and Certify Frozen Vaccine button is clicked, the Cold Storage Unit page opens. If a qualified cold storage unit has not yet been set up in the application, a warning message appears. See the Cold Storage Units topic for more information. Note that at least one cold storage unit (i.e., refrigerator) and its associated thermometer must be entered before moving forward.

If a cold storage unit has already been set up, many of the fields are pre-populated. Enter or update the fields as necessary and answer the questions, such as:

Ohio users: Between the freezer section and refrigerator section is an option: By checking this box, I certify that appropriate storage is in place for frozen vaccine. If this is true, select it.

The wording of these two options may vary depending on configuration settings, but at least the second one must be read and selected. After selecting the option, an authorized signer can type their name in the textbox and click Add Comments and Submit, which opens the Provider Agreement Approval page.

Submit the Provider Agreement

On the Provider Agreement Approval page, select the Organization (IRMS) Confirmed option if it has been confirmed, enter any approver comments (in either or both the internal-use-only box and the external-view textboxes), and click Submit.

The Provider Agreement status changes to Submitted. Once the agreement has been reviewed and approved by the state, the status changes to Approved. If additional changes need to be made to the provider agreement, the state changes the status to Returned and adds a comment. The provider and facility then need to address the requested changes and resubmit the agreement for approval.

Approve the Provider Agreement

Authorized users may see the View Certify Frozen Vaccine button on the Provider/Practice Profile page. Click it to open the Frozen Vaccine Certification page and answer the questions. To approve the provider agreement, click Approve Provider Agreement. The Provider Agreement Approval page opens.

On the Provider Agreement Approval page, enter the approved date and expiration date, change the status if necessary, and enter any approver comments. Click Save when finished. The provider agreement now has the status of Approved.

View the Full PDF Agreement or Signature Page

To view the full provider agreement, click the PDF link in the PDF-Full column. To view just the signature page, click the PDF Signature link in the PDF Signature Page column (not available for Ohio users). Each PDF will open in a new browser window. Click the X in the browser window to close the PDF when finished.

View/Edit/Approve a Frozen Vaccine Certification

To view, edit, or approve a frozen vaccine certification, click the arrow button in the Select Frozen Vaccine column.

Only approvers can approve the frozen vaccine certification. After verifying the data, click Approve Provider Agreement to display the Provider Agreement Approval screen and approve the agreement.

View the PDF of the Frozen Vaccine Certificate

NOTE: This option is not available for Ohio users.

To view the PDF version of the frozen vaccine certificate, click the PDF-Frozen Vaccine link in the PDF-Frozen Vaccine column.

Create an Organization

If the provider is enrolling for the first time and they do not have an organization already created in the system, a Create Organization (IRMS) link appears for authorized users. Click it to create a new provider organization. This link does not appear if the organization is already in the system.

Delete a Provider Agreement Submitted in Error

Only approvers have the ability to delete provider agreements. Click the Delete button and follow any prompts to delete the provider agreement. This action cannot be undone.

Archive/Unarchive a Provider Agreement

Approvers can archive an older provider agreement to keep only the most current version on the list. Click the Archive button to archive a particular provider agreement. To unarchive an agreement, click Un-Archive.

Add a New Provider Agreement

Click Add to add a new provider agreement. However, the Add button does not appear if the search returns multiple agreements. A search with more specific criteria provides fewer search results.

Export a Provider Agreement

To export all of the fields from the Provider Agreement Add/Edit page, all of the fields from the Frozen Vaccine Certificate page, and all of the fields from the Approval page, click Export Agreement.

Export a Provider

To export all of the fields from the Authorized Providers Add/Edit page, click Export Provider. The export also includes these fields: VFC PIN, facility name, shipping address, mailing address, fax number, provider last name, first name, middle initial, title specialty, status (Active/Inactive), medical license number, NPI number, yellow fever stamp indicator, certified physician name, and yellow fever stamp number.

Export a Provider or Practice Profile

To export all of the fields from the Provider/Practice Profile page, click Export Provider/Practice Profile. The export also includes the following fields: VFC PIN, facility name, shipping address, mailing address, fax number, provider profile table fields and date, and the additional profile questions and data. For Alaska users, the Provider Practice Profile is populated using information from the system.

Return to VOMS

To return to the VOMS application, click the Inventory Management menu link in IWeb.