NEW PAYER 835 INFO SHEET

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1 NEW PAYER 835 INF SHEET PAYER NAME: KAISER PERMANENTE F GERGIA REGIN 835 ERA SUBMITTER ID: PAYER ID: CNTACT INFRMATIN EDI CNTACT: NAME CUST. SVC PHNE:_ , PT 2, PT 4, PT 2 IS PRE-ENRLLMENT REQUIRED: (CIRCLE) N YES NTE: IF YU WERE RECEIVING YUR ERA S THRUGH ANTHER CLEARINGHUSE AND YU WULD LIKE T NW RECEIVE THRUGH FFICE ALLY, YU MUST CMPLETE THE CHANGE F VENDR LETTER. THERWISE, YU NLY NEED T CMPLETE THE ENRLLMENT FRM. SPECIAL INSTRUCTINS, CUSTM SET UPS, ETC: SECTIN 1 PRVIDER RGANIZATIN THIS IS THE PRVIDER S INFRMATIN. SECTIN 2 VENDR THIS IS FFICE ALLY INFRMATIN AND IS PREFILLED SECTIN 3 ERA RECEIVER - THIS IS FFICE ALLY NFRMATIN AND IS PREFILLED SECTIN 4 PAYER THIS IS WHERE THE ID(S) FR THE PAYER(S) ARE ENTERED. MAY ENTER UP T 10 PAYERS N THE SAME FRM. PREFILLED FR CRESURCE LITTLE RCK. PAYER ID EMDEN PAYER ID GRUP ID WULD BE A NUMBER ASSIGNED BY FFICE ALLY. THIS IS NT REQUIRED. INDIVIDUAL PRVIDER ID THIS WULD BE AN ID ASSIGNED BY THE PAYER. THIS IS NT REQUIRED. SECTIN 5 CNFIRMATINS PREFILLED WITH VENDR INDICATING CNFIRMATINS ARE T CME T FFICE ALLY. QUESTINS FR PRE-ENRLLMENT INSTRUCTIN FRM FR USERS: HW LNG DES PRE-ENRLLMENT TAKE? UP T 21 BUSINESS DAYS WHERE SHULD I SEND THE FRMS? SHULD THEY SENT BY FAX R ARE RIGINALS REQUIRED? SEND FRMS T EMDEN FAX T WH CAN SIGN THE FRMS? S. Coast Highway * Laguna Beach CA * Phone: Fax:

2 N SIGNATURE REQUIRED HW D I CHECK STATUS (IE, WHAT # D I CALL, AND WHAT D I SAY WHEN I CALL?) YU MAY CALL , PT 2, PT 4, PT S. Coast Highway * Laguna Beach CA * Phone: Fax:

3 Change of Vendor Procedures for ERA A change of vendor (CV) letter is required when an existing Emdeon provider changes software vendors. The letter is required when the provider changes from their existing Emdeon certified software vendor (submitter id) to a different Emdeon certified software vendor (submitter id). Any new ERA Provider Set-Up Form (PSF) sent to Emdeon that requires a Change of Vendor (CV) letter will be considered incomplete without the accompanying letter. Emdeon will notify the provider if the change of vendor letter is required but not received. Following are steps required for a provider to change Emdeon certified software vendors: Step #1 Complete a Change of Vendor letter using the template provided. Split files If the ERA files require splitting then the attached PSF(s) will need to list each payer If the ERA files Do Not require splitting then the attached PSF can indicate All Payers * All Payers is only for existing payers associated with the provider Tax Id at Emdeon * THE LETTER MUST BE N THE PRVIDER/SITE S LETTERHEAD AND CNTAIN ALL INFRMATIN LISTED IN THE BELW TEMPLATE. Step #2 Step #3 Step #4 The letter must be signed by an authorized representative from the provider. to batchenrollment@emdeon.com or fax or mail the Change of Vendor letter to Emdeon: ATTN: BATCH SETUP & ENRLLMENT DEPT FAX: (615) Emdeon Enrollment Department P Box Nashville, TN This CV must be attached to a Provider Set-Up Form (PSF) - Emdeon Set-Up Forms Emdeon will make the change in the appropriate Emdeon systems. Confirmation will be sent to the individual indicated within the PSF when the set up is complete within 5 business days.

4 This letter MUST be sent on the letterhead for the practice/provider requesting this change! Please do NT alter the Change of Vendor Letter. If this form is altered, it will be rejected. [Date] Emdeon Enrollment Department Attn: Enrollment Department Set Up P Box Nashville TN batchenrollment@emdeon.com Dear Emdeon Currently, I am receiving my Electronic Remittance Advice through [Name of Current Vendor]. I would like to start receiving my Electronic Remittance Advice through Emdeon Corporation using [Name of New Vendor]. This Change of Vendor Letter [will/will not] require my files to be split. If this requires my files to be split, only the payers listed on the Provider Setup Form will be carried over to the new vendor. If this does not require my files to be spilt, all of the payers associated with this tax ID will be carried over to the new vendor. This change request will also include ALL PRVIDERS associated with this tax ID. Please accept this letter as my request to change vendors. Following is specific information regarding my practice: Name: Practice: Address: Phone #: : Tax Id: [Name of Doctor] [Name of Practice] [Address of Practice] [City, State & Zip Code] [Phone number of Practice] [ at Practice] [ of contact at Practice] [Tax ID of Practice] Please send acknowledgement of receipt and confirmation of set up to my attention via at [ Address]. I understand testing may be involved for the new set up. If you have any questions or need additional information, please contact me at [(XXX) XXX-XXXX]. Sincerely, [Your Signature] [Your Name] [Your Title]

5 Emdeon ERA Provider Setup Form Fax: (615) Provider rganization Practice/ Facility Name Tax ID Address City/State Zip Code First Name Address Last Name Telephone NPI Title Fax Select from List 2 Vendor (Emdeon contracted & certified customer used to retrieve ERA files) Vendor Name ffice Ally Submitter ID First Name Address Virginia 3 ERA Receiver Last Name Mungia Title None support@officeally.com Telephone Fax Receiver ID Who will be receiving the ERA? Vendor Distribution Method (Check only one) Emdeon ffice Mail to: NDM S Node Name: FTP Internet Log In ID: offalley FTP Dial-up TS ID: GTEDS or ITS TS ID: Do you want your ERA file split? Yes No How? Select from List Format requested A ( ) Specify 4 Payer (If additional rows are required for payer ID selection, complete additional ERA Provider Setup Forms.) Payer ID Group ID Individual Provider ID Payer ID Group ID Individual Provider ID Confirmations Send Emdeon ERA Setup Confirmations To: Both - Sections 1 and 2 Send Additional ERA Setup Confirmations To:

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