New Jersey Early Intervention System Provider Enrollment

New Jersey Early Intervention System Electronic User Enrollment User Guide

PCG Training Team 10/18/2019 and 10/28/2019

www.publicconsultinggroup.comwww.publicconsultinggroup.com

Table of ContentsImportant Message…………...………..…….....…..3

Introduction…………………..…………..……….....4

Helpful Tips……………………..………..…………..5

Before Submitting an Electronic New User

Enrollment Form……………………………….....…6

Submitting an Electronic New User

Enrollment Form…………………..………...…..…..9

After Submitting an Electronic New User

Enrollment Form…………..………….....………....26

Before Submitting an Electronic User

Modification Form………………...……..….....…..28

Modification Enrollment Reasons

Deactivate User from Agency………................30

Change User’s Legal Name………...…….....…43

Change User’s Email…………………...….....…58

Change User’s Phone Number......................…71

Change User’s Specialty…………………..…….84

Change User’s Access Type/Role……….…….100

Add Additional Access Type/Role for User......117

Before Submitting a Procedural Safeguards

Module Completion Certification…………......…134

Submitting a Procedural Safeguards Module

Completion Certification……………..…....……...135

Before Submitting a Professional

License Update………………………………..…….143

Submitting a Professional License Update…….144

Contact Information…………………….….………152

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Important Message

PCG Support is neither responsible for, nor able to, determine if an applicant meets the Personnel Standards for a position prior to a full enrollment packet submission. It is the duty of the agency to complete their own due diligence and determine whether the potential employee meets NJEIS Personnel Standards based on their review of the applicant’s documentation, including transcripts and determination if the degree is a health-related field. PCG Support then verifies the Personnel Standards and conducts specific checks of licenses, etc. to verify correct enrollment.

3


Introduction

Starting November 1, 2019 NJEIS Early Intervention Program Administrators will navigate to the appropriate

JotForm link to submit ALL New User Enrollment Forms, User Modification Forms, Procedural Safeguards Module

Completion Certificates, and Updated Professional Licenses electronically.

Please refer to the user guide prior to submitting a New User Enrollment Form, User Modification Form, Procedural

Safeguards Module Completion Certificate and/or updated professional licenses.

LINKS TO EACH SUBMISSION FORM

• New User Enrollment: https://hipaa.jotform.com/90237265242150

• User Modification: https://hipaa.jotform.com/90305715212143

• Procedural Safeguard Certificate Submission: https://hipaa.jotform.com/90504240532142

• Updated Professional License https://hipaa.jotform.com/92760806114152

4

https://hipaa.jotform.com/90237265242150





Helpful Tips

5

➢ Upload files in a PDF Editor i.e.. Adobe Pro to combine and organize all documents and

pages into one PDF file.

➢ Ensure all pages are rotated upright.

➢ Ensure all pages are legible. Darken and lighten features can be used to make pages

legible.

➢ Organize pages in numerical order.

➢ Highlight all details that support the user meeting all NJ Personnel Standards according to

user specialty/user type.


Before Submitting an Electronic New User Enrollment Form

1. Verify User meets NJEIS Personnel Standards for requested role/specialty.

The NJEIS Personnel Standards provides a list of all enrollment requirements per role/specialty.

2. Obtain Code of Conduct/E-Signature Verification form signed by User.

http://hus.pcgus.com/NJEISBilling/Public/Documents/16/CodeofConduct_ESignature_Form_2-13-19.pdf

3. Collect User demographic information required for this form.

4. Create single PDF packet containing all required documentation for requested role/specialty (incomplete submissions will not be

processed). Please remember that users already enrolled with other agencies still require a completely new enrollment application, packet,

etc.

5. Save the New Jersey Enrollment PDF Packet as (UserLegalName_AgencyName ). It will be uploaded during this online process.

COMPLETING THE STEPS ABOVE WILL ASSIST AGENCY REPRESENTATIVES TO AVOID REQUIRED FIELD ERROR

MESSAGES.

6

https://www.state.nj.us/health/fhs/eis/documents/njeis_pra.pdf

http://hus.pcgus.com/NJEISBilling/Public/Documents/16/CodeofConduct_ESignature_Form_2-13-19.pdf



7

COLLECT REQUIRED USER DEMOGRAPHIC INFORMATION

• Full Legal Name*

• Date of Birth

• Work E-Mail

• Work Phone Number (direct line to user for PCG Help Desk use)

* The name MUST be the same name documented on the user’s professional license

and background check.



8

The New Jersey Enrollment PDF Packet includes…

• ALL documents required according to the NJEIS Personnel Standards.

• A completed Page 4 of the Code of Conduct/E-Signature Verification form

The PDF Packet file must be named and saved as UserLegalName_AgencyName

For example, Paul Practitioner working with 123ABC Agency, PDF Packet file is to be

named, saved, and uploaded as PaulPractitioner_123ABCAgency

Create New Jersey Enrollment PDF Packet


Personal Information

Navigate to


Confirm that all “Before you begin” steps are completed.

New User Enrollment

9




Steps

1. Select the Agency Name

New User Enrollment

1

10



Steps

2. Enter new User’s Full Legal Name

• First

• Middle

• Last

• Maiden/Other/AKA*

* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.

New User Enrollment

11

2



New User Enrollment

Steps

3. Enter user’s date of birth in the User’s Date of Birth and User’s Date of Birth Verification fields.

3

12



New User Enrollment

Steps

4. Enter User’s Work E-mail

4

13



New User Enrollment

Steps

5. Enter User’s Work Phone Number

5

14



New User Enrollment

Steps

6. Select User’s Access Type

Note: The User Access Type selected will determine User Specialty/User Role dropdown list.

IMPORTANT: TET accessibility will be determined by NJ DOH.

6

15



New User Enrollment

The steps below are dependent on the User Access and User Specialty previously selected.

Steps

7. Enter the user’s License Number

(if applicable)

8. Enter License Effective Date

(if applicable)

9. Enter License Expiration Date

(if applicable)

7

8 9

16



New User Enrollment

Steps

10. Select the checkbox of each document included in the New Jersey User Enrollment PDF Packet.

10

17



New User Enrollment

Steps

11. Select Browse and attach the New Jersey Enrollment Documentation Packet.

Note: The New Jersey Enrollment PDF Packet file must be named as UserLegalName_AgencyName format.

11

18



New User Enrollment

Steps

12. Select the checkbox of each Assurance statement

12

19



New User Enrollment

Steps

13. Enter Agency Representative Name

• First Name

• Last Name

14. Enter Agency Representative Email

13

14

20



New User Enrollment

Steps

15. Select Preview Answers

15

21



New User Enrollment

Preview Answers

Steps

16. Review the information enter for accuracy.

17. Select BACK to edit information.

Select PRINT to print the online enrollment document and file.

Select SUBMIT to submit online enrollment form.

16

22

17



A submission message will appear

New User Enrollment

Submission Message

23



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming new user enrollment form submission.

New User Enrollment

Submission E-mail

24



The user will receive an e-mail from NJEIS Support [email protected] confirming new user enrollment form submission.

New User Enrollment

Submission E-mail

25


After Submitting an Electronic New User Enrollment Form

26

REMINDER: PCG Support is neither responsible for, nor able to, determine if an

applicant meets the Personnel Standards for a position prior to a full enrollment packet

submission. It is the duty of the agency to complete their own due diligence and

determine whether the potential employee meets NJ EIS Personnel Standards based on

their review of the applicant’s documentation, including transcripts and determination if

the degree is a health-related field. PCG Support then verifies the Personnel Standards

and conducts specific checks of licenses, etc. to verify correct enrollment.

The following websites are reviewed to ensure that the user is in good standing.

• Federal exclusions database: http://oig.hhs.gov/fraud/exclusions.asp

• NJ Treasurer’s exclusion database: www.state.nj.us/treasury/debarred

• NJ Department of Health licensure

database: http://www.state.nj.us/health/healthfacilities/search.shtml

• NJ Division of Consumer Affairs licensure database:

https://newjersey.mylicense.com/verification (for OT, COTA, PT, PTA, SLP,

Audiologist, Social Worker, Nurse, Psychologist, Physician, etc.) Providers with

teaching certificates will not typically have a license, nor will interpreters, CDA/CDS,

etc.

http://oig.hhs.gov/fraud/exclusions.asp

http://www.state.nj.us/treasury/debarred

http://www.state.nj.us/health/healthfacilities/search.shtml

https://newjersey.mylicense.com/verification


After PCG Support verifies that the new user enrollment is correct an e-

mail will be sent to the user providing their EIMS username and

temporary password. A follow-up will be sent requesting that the user

replies to the email with a Security Word.

The Security Word must not contain the user’s name and should be

memorable, as it will be requested prior to receiving assistance from

the Help Desk.

After Submitting an Electronic New User Enrollment Form

27

This Photo by Unknown Author is licensed under CC BY-NC-ND

http://lebreton.deviantart.com/art/lock-logon-resource-90850618

https://creativecommons.org/licenses/by-nc-nd/3.0/


Before Submitting an Electronic User Modification Form

28

IMPORTANT: A user modification form submission due to a name

change is to be completed AFTER the user’s background check and

license (if applicable) has been updated with the modified name.

Users are responsible for notifying all agencies of requested

modifications.


Before Submitting an Electronic User Modification Form

29

• The User Modification PDF Packet must be created for the following modification

types…• Change User’s Legal Name

• Change User’s Specialty

• Change User’s Access Type/Role

• Add Additional Access Type/Role for User

• ALL documents required according to the NJEIS Personnel Standards supporting the

modification request.

The PDF Packet file must be named and saved as UserLegalName_MOD_Month Date Year

For example, Paula Practitioner completed all requirements and has a name change to Paula Peterson,

the PDF Packet file is to be named, saved, and uploaded as PaulaPeterson_MOD_100219

Create User Modification PDF Packet



Steps

1. Select Deactivate User from Agency

User Modification

Modification ReasonDeactivate User from Agency

1

30



Steps


User Modification


31

2



Steps

3. Enter User’s Legal Name

• First

• Middle

• Last



User Modification


3

32



Steps

4. Enter user’s Date of Birth

User Modification


4

33



Steps

5. Enter user’s CURRENT Work E-mail

User Modification


5

34



Steps

6. Enter user’s CURRENT Work Phone Number

User Modification


6

35



Steps

7. Select the checkbox of each Assurance statement.

User Modification


7

36



Steps


• First Name

• Last Name


User Modification


8

9

37



Steps


User Modification


10

38



Steps




Select SUBMIT to submit online user modification form.

User Modification


39

11

12




User Modification


40



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the deactivate user from agency form submission.

User Modification


41



The user will receive an e-mail from NJEIS Support [email protected] confirming the deactivate user from agency form submission.

User Modification


42



Steps

1. Select Change User’s Legal Name (First, Middle/Maiden, Last)

User Modification

Modification ReasonChange User’s Legal Name

43

1



Steps

2. Select Agency

User Modification


44

2



Steps

3. Enter user’s Legal Name • First

• Middle

• Last


4. Enter user’s PREVIOUS Legal Name

• First

• Middle

• Last



User Modification


3

4

45



Steps


User Modification


5

46



Steps


User Modification


6

47



Steps


User Modification


7

48



Steps

8. Select each checkbox of the New Jersey User Modification Documents Included.

User Modification


8

49



Steps

9. Select the Browse and attach the New Jersey User Modification Supporting Documentation PDF Packet.

Note: The New Jersey User Modification Supporting PDF Packet file must be named as UserLegalName_MOD_Month Date Year PDF Packet was uploaded.

For example, PaulaPeterson_MOD_100819

User Modification


9

50



Steps


User Modification


10

51



Steps


• First Name

• Last Name


User Modification


11

12

52



Steps


User Modification


13

53



Steps





User Modification


15

54

14




User Modification


55



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the change user’s legal name form submission.

User Modification


56



The user will receive an e-mail from NJEIS Support [email protected] confirming the change user’s legal name form submission.

User Modification


57



Steps

1. Select Change User’s E-Mail Address

User Modification

Modification ReasonChange User’s E-Mail

58

1



Steps


User Modification


59

2



Steps

3. Enter user’s Legal Name

• First

• Middle

• Last



User Modification


3

60



Steps


User Modification


4

61



Steps

5. Enter user’s CURRENT work E-mail and user’s UPDATED Work E-mail.

User Modification


5

62



Steps


User Modification


6

63



Steps


User Modification


7

64



Steps


• First Name

• Last Name


User Modification


8

9

65



Steps


User Modification


10

66



Steps





User Modification


12

67

11




User Modification


68



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the change user’s e-mail form submission.

User Modification


69

69



The user will receive an e-mail from NJEIS Support [email protected] confirming the change user’s e-mail form submission.

User Modification


70

70



Steps

1. Select Change User’s Work Phone Number

User Modification

Modification ReasonChange User’s Work Phone Number 1

71



Steps


User Modification

Modification ReasonChange User’s Work Phone Number

2

72



Steps


• First

• Middle

• Last



User Modification


3

73



Steps


User Modification


4

74



Steps


User Modification


5

75



Steps

6. Enter user’s CURRENT Phone Number and user’s UPDATED Phone Number.

User Modification


6

76



Steps


User Modification


7

77



Steps


a) First Name

b) Last Name


User Modification


8

9

78



Steps


User Modification


10

79



Steps





User Modification


11

12

80




User Modification


81



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s phone number change form submission.

User Modification


82



The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s phone number change form submission.

User Modification


83



Steps

1. Select Change User’s Specialty

User Modification

Modification ReasonChange User’s Specialty

84

1



Steps


User Modification

Modification ReasonChange User’s Specialty 2

85



Steps


• First

• Middle

• Last



User Modification


3

86



Steps


User Modification


4

87



Steps


User Modification


5

88



Steps


User Modification


6

89



Steps

7. Select the user’s CURRENT Specialty and Update User’s Specialty to

User Modification


7

90



Steps

8. Select each checkbox of the New Jersey User Modification Documents Included

User Modification


8

91



Steps

9. Select Browse and attach the New Jersey User Modification Supporting Documents Packet.


For example, PaulaPractitioner_MOD_100819

User Modification


9

92



Steps


User Modification


10

93



Steps


• First Name

• Last Name


User Modification


Change User’s Specialty

11

12

94



Steps


User Modification


13

95



Steps





User Modification


14

96

15




User Modification


97



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s specialty change form submission.

User Modification


98



The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s specialty change form submission.

User Modification


99



Steps

1. Select Change User’s Access Type/Role

User Modification

Modification ReasonChange User’s Access Type/Role

10

0

1



Steps


User Modification

Modification ReasonChange User’s Access Type/Role 2

10

1



Steps


• First

• Middle

• Last



User Modification


3

10

2



Steps


User Modification


4

10

3



Steps


User Modification


5

10

4



Steps


User Modification


6

10

5



Steps

7. Select the user’s CURRENT Access Type/Role and update user’s Access Type/Role.

User Modification


7

10

6



Steps

8. Select User’s Specialty

User Modification


8

10

7



Steps


User Modification


10

10

8



Steps




User Modification


11

10

9



Steps


User Modification


12

11

0



Steps


• First Name

• Last Name


User Modification


13

14

11

1



Steps


User Modification


14

11

2



Steps





User Modification


11

3

16

17




User Modification


114



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.

User Modification


115



The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.

User Modification


116



Steps

1. Add Additional Access Type/Role for User

User Modification

Modification ReasonAdd Additional Access Type/Role for User

11

7

1



Steps


User Modification

Modification ReasonAdd Additional Access Type/Role for User 2

11

8



Steps


• First

• Middle

• Last



User Modification


3

11

9



Steps


User Modification


4

12

0



Steps


User Modification


5

12

1



Steps


User Modification


6

12

2



Steps

7. Select user’s CURRENT Access Type/Role and select the Additional Access Type/Role for user

User Modification


7

12

3



Steps

8. Select User’s Specialty (if applicable)

NOTE: The Select User’s Specialty field can be left blank or “Not Applicable” can be selected.

User Modification


8

12

4



Steps


User Modification


9

12

5



Steps




User Modification


10

12

6



Steps


User Modification


11

12

7



Steps


• First Name

• Last Name


User Modification


12

13

12

8



Steps


User Modification


14

12

9



Steps





User Modification


15

16

13

0




User Modification


131



The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.

User Modification


132



The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.

User Modification


133


Before Submitting a Procedural Safeguards Module Completion Certificate

134

IMPORTANT: Save the Procedural Safeguards Module Completion

Certificate as a PDF and name the file using the naming convention

below.

The document must be named and saved as UserLegalName_PSMCC

For example, Paul Practitioner’s Procedural Safeguards Module Completion

Certificate document is named, saved, and uploaded as PaulPractitioner_PSMCC



Steps


• First

• Middle

• Last



Procedural Safeguards Module

Completion Certificate

1

13

5



Steps




2

136



Steps

3. Enter user’s Work E-mail.



3

137



Steps

4. Select Browse and attach the Procedural Safeguards Modules Completion Certificate

Note: The user’s Procedural Safeguards Module Completion Certificate must be named as (UserLegalName_PSMCC) format.

For example, PaulaPractitioner_PSMCC



4

138



Steps




139

5



Steps




Select SUBMIT to submit theProcedural Safeguards Module Completion Certificate.



140

7

6






141



The user will receive an e-mail from NJEIS Support [email protected] confirming their Procedural Safeguards Module Completion Certificate submission.



142


Before Submitting a Professional License Update

143

Save the updated professional license as a PDF and name the file

using the naming convention below.

The document must be named and saved as UserLegalName_PLU_Month Date and Year

For example, Paul Practitioner’s updated professional license PDF document is named,

saved, and uploaded as PaulPractitioner_PLU_101819

Only existing users can submit an updated professional license.



Steps


• First

• Middle

• Last



Professional License Update

1

14

4



Steps



2

145



Steps

3. Enter user’s Work E-mail.


3

146



Steps

4. Select Browse and attach the Updated Professional License

Note: The user’s professional license must be named as (UserLegalName_PLU_Month Date Year) format.

For example, PaulaPractitioner_PLU_101819


4

147



Steps



148

5



Steps




Select SUBMIT to submit theupdated professional license.


149

6

7





150



The user will receive an e-mail from NJEIS Support [email protected] confirming their updated professional license submission.


151

TM

Customer Service CenterMonday-Friday, 8am-5pm

1-844-378-2936