220 Burnham Street South Windsor, CT Vox Fax OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION

Size: px
Start display at page:

Download "220 Burnham Street South Windsor, CT Vox Fax OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION"

Transcription

1 OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER CKOR1 SPECIAL NOTES Change Healthcare Dental signature is required. EDI packets must be mailed to Change Healthcare Dental in their entirety to obtain this required signature. All forms must contain original signatures in BLUE ink. All fields marked with an * are required. OMAP enrolled group practices need only submit one EDI Registration Packet listing the group as the Trading Partner. ELECTRONIC REGISTRATIONS Agreements Required Change Healthcare Provider Enrollment Form Please complete all requested information. Trading Partner Agreement Oregon Department of Human Services. Please complete all requested information SEND REGISTRATION FORMS TO Change Healthcare 220 Burnham Street South Windsor, CT Attn: Provider Enrollment Page 1 of 3

2 ENROLLMENT CONFIRMATION Change Healthcare will notify the provider or their PMS vendor, as defined by the PMS vendor, when registration is complete. CHANGING ELECTRONIC BILLING AGENTS If the Provider currently submits claims through another Billing Agent other than Change Healthcare Dental each Provider must re-enroll following the procedures listed above. CONTACT PHONE NUMBERS Oregon Medicaid EDI Helpdesk Change Healthcare Dental Page 2 of 3

3 PROVIDER ENROLLMENT FORM Insurance Carrier: Oregon Medicaid - payer ID CKOR1 Print/Type the following: Provider/Organization Name: Tax Identification or Social Security Number: (Number that will be used to submit electronic claims) Software Vendor: Group Legacy Number as assigned by the payer: (if applicable) Group Type 2 NPI: (if applicable) Rendering Provider Information Name Legacy Number NPI Type 1 Address: City, State, Zip Code: Office Contact Name: Telephone Number: Fax Number: Date: Page 3 of 3

4 Trading Partner s National Provider Identifier (NPI): List all taxonomy code(s) registered to this NPI: HEALTH SYSTEMS DIVISION EDI Support Services List all Oregon Medicaid ID(s) associated with this NPI Trading Partner Agreement for Electronic Health Care Transactions Trading partners: Use this TPA to sign up to exchange electronic data interchange (EDI) transactions with Oregon Medicaid, and to authorize who will exchange these transactions for you. You will need to submit a new TPA anytime you have changes to your trading partner or submitter information. If you need to exchange transactions for more than one NPI, complete a TPA for each NPI. If you need to exchange transactions for multiple Oregon Medicaid provider numbers with the same NPI, you can use one TPA but only if all locations need the same transactions. If you need to authorize more than one clearinghouse/submitter, complete a TPA for each one. Please type or print clearly. Fill in all required fields designated with an asterisk (*). Include full names and direct contact information in parts 2 through 5. Incomplete forms will NOT be processed. Please maintain a copy for your records. Mail the completed form to: EDI Support Services, 500 Summer St NE, E44, Salem, OR Questions? DHS.EDISupport@state.or.us. This TPA is: New Revised. This form replaces all previous TPAs for this Provider/Submitter combination. Trading partner (provider, prepaid health plan, coordinated care organization, clinic or allied agency) information *Business name: *Physical address: Secondary address: *City, state and ZIP: ONE TWO THREE FOUR Trading partner authorized signer information The primary signer signs Part 7 of this form. *Primary signer s name: Secondary signer s name: Phone number: address: Claims contact information *Primary contact s name: Secondary contact s name: Phone number: address: Oregon Medicaid Electronic Data Interchange Trading Partner Agreement OHA 2080 (Rev 8/16) - Page 1 of 2 EDI submitter information If your company intends to submit its own transactions, mark submitter type as Self and enter your company s EDI contact information. *Company name: Submitter ID (MB#): *Address line 1: Address line 2: *City, state and ZIP:

5 *Submitter type (check all that apply): Self Prepaid Health Plan Clearinghouse Billing service Other (please specify): FIVE EDI submitter s contact information The Business Contact signs Part 8 of this form. OHA will the Technical Contact when transaction testing is needed. Do not enter a billing service contact as the Technical Contact. Please list individual s (not group s). *Business contact s name: *Technical contact s name: Third contact on reverse (if needed) SIX SEVEN Authorized transactions Check all transactions that OHA should authorize for your EDI submitter. HIPAA 5010A1 transactions for: FFS provider or PHP/CCO X222A1 837P X224A2 837D X223A2 837I X221A1 835 Professional Claim Submission Dental Claim Submission Institutional Claim Submission Electronic Remittance Advice X279A1 270 and 271: Batch Real-time Eligibility Benefits Inquiry and Response X and 277: Batch Real-time Claims Status Request and Response X Group Premium Payments X220A1 834 NCPDP 1.2/D.0 Pharmacy Status file Benefit Enrollment and Maintenance (PHP/CCO only) Request and Response (B1, B2, B3) (PHP/CCO only) Rx Carve-Out File (PHP/CCO only) CCO Status File (PHP/CCO only) Trading Partner signature By signing below, the Trading Partner certifies the following: I have read the Electronic Data Transmission Oregon Administrative Rules (Chapter 943, Division 120) at and understand my responsibilities as stated in these rules. I authorize OHA to transmit to the EDI Submitter listed in Part 4 of this form the return computer file electronic vouchers of all transactions I have marked in Part 6 of this form. *Provider, PHP/CCO, clinic or allied agency name: *Authorized trading partner signature (original signature only): *Date: EIGHT EDI Submitter signature By signing below, the EDI Submitter certifies the following: I have read the Electronic Data Transmission Oregon Administrative Rules (Chapter 943, Division 120) at and understand my responsibilities as stated in these rules. I agree to protect the confidentiality of the data as required by law. *Business contact name, title: *Authorized EDI submitter signature (original signature only): *Date: Oregon Medicaid Electronic Data Interchange Trading Partner Agreement OHA 2080 (Rev 8/16) - Page 2 of 2

PAYER ID NUMBER SPECIAL NOTES. ELECTRONIC REGISTRATIONS Agreements Required SEND ENROLLMENT FORMS TO: ENROLLMENT CONFIRMATION

PAYER ID NUMBER SPECIAL NOTES. ELECTRONIC REGISTRATIONS Agreements Required SEND ENROLLMENT FORMS TO: ENROLLMENT CONFIRMATION Page 1 of 1 4/17/2014 400 Vermillion Street Hastings, MN 55033 Ph 800-482-3518 Fax 651-389-9152 www.edsedi.com COLORADO MEDICAID EDI UPDATE DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER

More information

BCBS NJ DENTAL PRE ENROLLMENT INSTRUCTIONS 22099

BCBS NJ DENTAL PRE ENROLLMENT INSTRUCTIONS 22099 BCBS NJ DENTAL PRE ENROLLMENT INSTRUCTIONS 22099 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing is 30 45 business days. WHERE SHOULD I SEND THE FORMS? The forms need to be sent to Office Ally.

More information

MISSISSIPPI MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION

MISSISSIPPI MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION 220 Burnham Street South Windsor CT 06074 Vox 888-255-7293 Fax 860-289-0055 MISSISSIPPI MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER CKMS1 ELECTRONIC REGISTRATIONS Agreements

More information

MEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS

MEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS MEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Maryland Medical Care Programs Submitter Identification Form Trading Partner Agreement o Both Forms must have original

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax NEVADA MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CKNV1 Participation in Dental Electronic Remittance Advice

More information

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax 220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 KANSAS MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER CKKS1 SPECIAL NOTES 1. Upon

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax WASHINGTON BLUE CROSS BLUE SHIELD (PREMERA) DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 47570 ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ REASSOCIATION SEND

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax NEBRASKA MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES CKNE1 Paper Remittance Advice Statements and Refund Request Reports statements will cease

More information

MEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD

MEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD MEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax NEW HAMPSHIRE MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES CKNH1 ERAs can only be sent to one Trading Partner, if a provider has previously requested

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

MEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD

MEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD MEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification

More information

Mississippi Medicaid. Mississippi Medicaid Program Provider Enrollment P.O. Box Jackson, Mississippi Complete form and mail original to:

Mississippi Medicaid. Mississippi Medicaid Program Provider Enrollment P.O. Box Jackson, Mississippi Complete form and mail original to: Mississippi Medicaid Complete form and mail original to: Blank forms may by copied. Call LTC at 888-941-8967 if you have questions. Please complete the following Mississippi Medicaid Provider EDI Enrollment

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax MISSISSIPPI MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Dual Delivery of v5010 X12 835 and Proprietary

More information

MISSISSIPPI MEDICAID ERA CONTRACT INSTRUCTIONS (SKMS0)

MISSISSIPPI MEDICAID ERA CONTRACT INSTRUCTIONS (SKMS0) MISSISSIPPI MEDICAID ERA CONTRACT INSTRUCTIONS (SKMS0) An original signature is required. Please MAIL all pages of your completed and signed forms to: ABILITY ATTN: Enrollment One MetroCenter 4010 W. Boy

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax 220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 DELTA DENTAL OF WISCONSIN DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 39069 SPECIAL NOTES

More information

EDI-ERA Provider Agreement and Enrollment Form (Page 1 of 5)

EDI-ERA Provider Agreement and Enrollment Form (Page 1 of 5) (Page 1 of 5) Please complete the following Mississippi Medicaid EDI ERA Provider Agreement and Enrollment Form. Please print or type. Complete all areas of the form, unless otherwise indicated. Once the

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax 220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 DELTA DENTAL OF ILLINOIS GROUP PLANS DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 05030

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax DELTA DENTAL OF ILLINOIS GROUP PLANS DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 05030 SPECIAL NOTES Participation with Direct Deposit (EFT) is required for receipt

More information

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax LOUISIANA BLUE CROSS BLUE SHIELD DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 23739 SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ REASSOCIATION SEND

More information

Provider Billing Agent/Clearinghouse EDI, Inc Authorization Form

Provider Billing Agent/Clearinghouse EDI, Inc Authorization Form Provider Billing Agent/Clearinghouse EDI, Inc Authorization Form Section A. Provider Information. Business Name Provider Name (Last, First, MI and Suffix) Provider Number Federal Tax ID Number Business

More information

BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801

BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801 BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801 HOW LONG DOES PRE ENROLLMENT TAKE? 3 to 5 business days WHERE SHOULD I SEND THE FORMS? Fax the form to 785 290 0720 WHAT

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

1304 Vermillion Street Hastings, MN Ph Fax

1304 Vermillion Street Hastings, MN Ph Fax Page 1 of 1 2/24/2014 NEW MEXICO MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBERS CKNM1 ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ Reassociation SEND REGISTRATION

More information

Data Type and Format (Not all data elements require a format specification)

Data Type and Format (Not all data elements require a format specification) Individual Data Element Name (Term) Sub-element Name (Term) Data Element Description Data Type and Format (Not all data elements require a format specification) Data Element Requirement for Health Plan

More information

CORE-required Maximum EFT Enrollment Data Set

CORE-required Maximum EFT Enrollment Data Set CORE-required Maximum EFT Data Set The following table is taken directly from CORE Operating Rule 380 and identifies all details related to the fields contained within this document. Individual Data Element

More information

HIPAA 837 Claims EDI Agreement. Agreement. HIPAA 837 Claims EDI Agreement

HIPAA 837 Claims EDI Agreement. Agreement. HIPAA 837 Claims EDI Agreement HIPAA 837 Claims EDI Agreement Agreement All New Jersey Medicaid and Charity Care Providers desiring to submit HIPAA formatted electronic claims must complete a HIPAA 837 Claims EDI Agreement as required

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account THE 2018 HNFS ENROLLMENT IS ALSO REQUIRED WHEN FILLING THIS OUT PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to

More information

MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM

MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM https://provider.bluecrossma.com/providerhome/portal/home/forms/forms/era Instructions for Completing BCBSMA Electronic Remittance

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider

More information

Authorization Agreement

Authorization Agreement Authorization Agreement For Electronic Health Care Claim Payment / Advice 835 Thank you for your interest in the Electronic Health Care Claim Payment/Advice (835), also known as Electronic Remittance Advice

More information

MEDICARE IDAHO PRE ENROLLMENT INSTRUCTIONS MR003

MEDICARE IDAHO PRE ENROLLMENT INSTRUCTIONS MR003 MEDICARE IDAHO PRE ENROLLMENT INSTRUCTIONS MR003 HOW LONG DOES PRE ENROLLMENT TAKE? Standard Processing time is 3 4 weeks WHERE SHOULD I SEND THE FORMS? Fax the form to Office Ally at 360 896 2151, or;

More information

MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS

MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Xerox EDI Provider Enrollment Form WHERE SHOULD I SEND THE FORM(S)? ; or Mail form to: WHAT IS THE TURNAROUND

More information

WELCOME TO OFFICE ALLY!

WELCOME TO OFFICE ALLY! WELCOME TO OFFICE ALLY! BCBS KANSAS / BCBS KANSAS CITY / MEDICARE OF KANSAS CITY PRE-ENROLLMENT INSTRUCTIONS HOW LONG DOES PRE-ENROLLMENT TAKE? O 3-5 business days WHAT PROVIDER NUMBER DO I USE? O Provider

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

Value Options. Submit the completed Payer Request Form to: INSTRUCTIONS

Value Options. Submit the completed Payer Request Form to:   INSTRUCTIONS Value Options Submit the completed Payer Request Form to: ABILITY Network, ATTN: Enrollment EMAIL: setup@abilitynetwork.com INSTRUCTIONS Complete all sections of the form if - You are a billing service

More information

TRICARE PGBA, LLC Electronic Data Interchange PO Box Augusta, GA Fax: Phone , Option #2

TRICARE PGBA, LLC Electronic Data Interchange PO Box Augusta, GA Fax: Phone , Option #2 TRICARE PGBA, LLC Fax: 803-264-9864 Phone 1-800-325-5920, Option #2 Dear Provider: Thank you for your interest in Electronic Remittance Advice (ERA) with PGBA, LLC. We also offer Electronic Funds Transfer

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027

MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027 MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027 HOW LONG DOES PRE-ENROLLMENT TAKE? Please allow 3 weeks for processing. HOW DO I ENROLL / WHAT FORM(S) SHOULD I DO? Option 1:

More information

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider

More information

BCBS LOUISIANA PRE-ENROLLMENT INSTRUCTIONS 53120

BCBS LOUISIANA PRE-ENROLLMENT INSTRUCTIONS 53120 BCBS LOUISIANA PRE-ENROLLMENT INSTRUCTIONS 53120 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard Processing time is 3 business days WHAT FORM(S) DO I COMPLETE? BCBS LA EDI Transaction Addendum Business Associate

More information

If you have any questions, please contact the Enrollment Department at , Option 1.

If you have any questions, please contact the Enrollment Department at , Option 1. 1755 Telstar Drive, Ste 400 Colorado Springs, CO 80920 www.optum.com Value Options Multiple user ids Thank you for choosing Electronic Network Systems Clearinghouse, a division of Optum, to submit your

More information

TRICARE West Region Electronic Data Interchange PO Box Augusta, GA Fax:

TRICARE West Region Electronic Data Interchange PO Box Augusta, GA Fax: Dear Provider: Thank you for your interest in Electronic Remittance Advice (ERA) with PGBA, LLC. Please take a moment to review the enrollment guidelines (Appendix A). Once you have reviewed the guidelines,

More information

ERA Enrollment Form Enrolling Through emomed

ERA Enrollment Form Enrolling Through emomed ERA Enrollment Rule 382 requires an electronic option for providers and trading partners to complete and submit the ERA enrollment effective January 1, 2014. An online ERA enrollment link from the emomed

More information

Electronic Transaction Registration Packet

Electronic Transaction Registration Packet Electronic Transaction Registration Packet Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota are Independent Licensees of the Blue Cross and Blue Shield

More information

Thank you for your interest in Blue Cross Blue Shield of Michigan s internet claim tool (ICT).

Thank you for your interest in Blue Cross Blue Shield of Michigan s internet claim tool (ICT). Dear Provider, Thank you for your interest in Blue Cross Blue Shield of Michigan s internet claim tool (ICT). The ICT is software designed for Michigan providers who only have the ability to submit paper

More information

Guide to Completing the Electronic Remittance Advice (ERA) Enrollment Form

Guide to Completing the Electronic Remittance Advice (ERA) Enrollment Form Guide to Completing the Electronic Remittance Advice (ERA) Enrollment Form The ERA service enables Blue Cross and Blue Shield of Louisiana to provide you with an electronic remittance advice, which is

More information

MISSISSIPPI MEDICAID EDI CONTRACT INSTRUCTIONS (SKMS0)

MISSISSIPPI MEDICAID EDI CONTRACT INSTRUCTIONS (SKMS0) MISSISSIPPI MEDICAID EDI CONTRACT INSTRUCTIONS (SKMS0) An original signature is required. Please MAIL all pages of your completed and signed forms to: ABILITY ATTN: Enrollment One MetroCenter 4010 W. Boy

More information

AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS

AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Emdeon ERA Provider Information Form Emdeon ERA Provider Setup Form Optum ERA Setup Form WHERE SHOULD I SEND THE FORM(S)?

More information

Please print or type. Complete all areas of Agreement and Enrollment form, unless otherwise indicated.

Please print or type. Complete all areas of Agreement and Enrollment form, unless otherwise indicated. Please complete the following Mississippi Medicaid Provider EDI Enrollment Packet. The package consists of the Conduent EDI Form, Mississippi EDI Provider Agreement and the Conduent EDI Gateway Inc., Trading

More information

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider

More information

BLUE CROSS BLUE SHIELD LOUISIANA (53120) ERA ENROLLMENT INSTRUCTIONS

BLUE CROSS BLUE SHIELD LOUISIANA (53120) ERA ENROLLMENT INSTRUCTIONS BLUE CROSS BLUE SHIELD LOUISIANA (53120) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Electronic Remittance Advice (ERA) Enrollment Form WHERE SHOULD I SEND THE FORM(S)? Email to: edich@bcbsla.com;

More information

MEDICAID PENNSYLVANIA ERA ENROLLMENT INSTRUCTIONS - MCDPA

MEDICAID PENNSYLVANIA ERA ENROLLMENT INSTRUCTIONS - MCDPA MEDICAID PENNSYLVANIA ERA ENROLLMENT INSTRUCTIONS - MCDPA HOW LONG DOES PRE-ENROLLMENT TAKE? Please allow four (4) weeks for the enrollment application process. If after five (5) weeks you do not start

More information

JURISDICTION K NEW YORK MEDICARE CONTRACT INSTRUCTIONS (SMNY0 SMNY1 SMNY2)

JURISDICTION K NEW YORK MEDICARE CONTRACT INSTRUCTIONS (SMNY0 SMNY1 SMNY2) CONTRACT Please read the following NGS Medicare instructions carefully in order to properly complete the enrollment forms. Incorrect or incomplete provider or submitter information will cause delays in

More information

Feel free to scan and return the attached paperwork to or fax to HealthComp at (559) IMPORTANT:

Feel free to scan and return the attached paperwork to or fax to HealthComp at (559) IMPORTANT: Thank you for your interest in EFT/ERA. Attached you will find the forms to register for EFT and ERA with HealthComp. Please Note: You must fully complete all three of the included forms or your enrollment

More information

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider

More information

Electronic Remittance Advice (ERA) EDI Agreement

Electronic Remittance Advice (ERA) EDI Agreement Electronic Remittance Advice (ERA) EDI Agreement (Form EDI-801) All New Jersey Medicaid and Charity Care Providers desiring to receive a HIPAA formatted electronic remittance advice (ERA) must complete

More information

VALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP

VALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP VALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 week. WHAT FORMS DO I NEED TO COMPLETE? You must complete the 2 forms listed below: o Online

More information

Page 1 of 10 Questions? Call (844) or for assistance

Page 1 of 10 Questions? Call (844) or  for assistance Manual Form The Provider EFT/ERA service makes it easier for Providers to receive payments and remittance from Payers by eliminating paper checks and EOB s, and depositing funds into your financial institution

More information

Instructions for Completing the Paper Electronic Remittance Advice (ERA) Enrollment Application

Instructions for Completing the Paper Electronic Remittance Advice (ERA) Enrollment Application Instructions for Completing the Paper Electronic Remittance Advice (ERA) Enrollment Application General Instructions for completing the Paper ERA Enrollment Application: Please type or print legibly Complete

More information

BCBS LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS

BCBS LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS BCBS LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? BCBS LA Business Associate Profile Electronic Remittance Advice (ERA) Enrollment form If you would like to receive ERAs through

More information

MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0)

MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0) MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0) Submit the completed Contract Setup Form to: ABILITY Network, ATTN: Enrollment FAX: 888.837.2232 EMAIL: setup@abilitynetwork.com INSTRUCTIONS Print

More information

4350 E. Cotton Center Boulevard Building D Phoenix, AZ / Fax

4350 E. Cotton Center Boulevard Building D Phoenix, AZ / Fax Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

837 Health Care Claim Professional, Institutional & Dental Companion Guide

837 Health Care Claim Professional, Institutional & Dental Companion Guide 837 Health Care Claim Professional, Institutional & Dental Companion Guide 005010X222A1 & 005010X223A1 V. 1.2 Created 07/18/14 Disclaimer Blue Cross of Idaho created this companion guide for 837 healthcare

More information

HEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS

HEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS HEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Electronic Remittance Advice (ERA) Authorization Agreement Electronic Funds Transfer (EFT) Authorization Agreement WHERE SHOULD

More information

TEXAS MEDICARE (TRAILBLAZERS) CHANGE FORM MR085

TEXAS MEDICARE (TRAILBLAZERS) CHANGE FORM MR085 TEXAS MEDICARE (TRAILBLAZERS) CHANGE FORM MR085 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 20 days WHAT PROVIDER NUMBERS DO I USE? Six digit Medicare legacy provider ID NPI Number WHAT

More information

AETNA BETTER HEALTH OF ILLINOIS 333 W. Wacker Drive Suite 2100, MC F646 Chicago, IL Fax

AETNA BETTER HEALTH OF ILLINOIS 333 W. Wacker Drive Suite 2100, MC F646 Chicago, IL Fax Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

AETNA BETTER HEALTH OF OHIO 7400 W. Campus Rd. New Albany, OH Fax

AETNA BETTER HEALTH OF OHIO 7400 W. Campus Rd. New Albany, OH Fax Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

MEDICARE FLORIDA PRE ENROLLMENT INSTRUCTIONS MR025

MEDICARE FLORIDA PRE ENROLLMENT INSTRUCTIONS MR025 MEDICARE FLORIDA PRE ENROLLMENT INSTRUCTIONS MR025 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 3 4 weeks. WHAT FORM(S) SHOULD I COMPLETE? If you do not currently submit electronically

More information

Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation

Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

AETNA BETTER HEALTH OF LOUISIANA 2400 Veterans Memorial Blvd., Suite 200 Kenner, LA Fax

AETNA BETTER HEALTH OF LOUISIANA 2400 Veterans Memorial Blvd., Suite 200 Kenner, LA Fax Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

EDI ENROLLMENT AGREEMENT INSTRUCTIONS

EDI ENROLLMENT AGREEMENT INSTRUCTIONS EDI ENROLLMENT AGREEMENT INSTRUCTIONS The Railroad EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed

More information

Railroad Medicare Electronic Data Interchange Application

Railroad Medicare Electronic Data Interchange Application Electronic Data Interchange Application Action Requested: Add New EDI Provider(s) Change/Update Submitter Information Apply for New Submitter ID Apply for New Receiver ID Delete Date: Submitter ID: ERN

More information

PAYER ENROLLMENT INSTRUCTIONS FOR

PAYER ENROLLMENT INSTRUCTIONS FOR PAYER ENROLLMENT INSTRUCTIONS FOR Before enrolling please be sure your Revenue Performance Advisor contract includes the transactions you will be using. If you are unsure of the transactions you are contracted

More information

Part A/Part B/HHH EDI Enrollment (Agreement) Form and Instructions

Part A/Part B/HHH EDI Enrollment (Agreement) Form and Instructions Part A/Part B/HHH EDI Enrollment (Agreement) Form and Instructions The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should

More information

2777 Stemmons Frwy, Suite 1450 Dallas, TX Fax

2777 Stemmons Frwy, Suite 1450 Dallas, TX Fax Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.

More information

MEDICARE PART B HAWAII PRE ENROLLMENT INSTRUCTIONS MR057

MEDICARE PART B HAWAII PRE ENROLLMENT INSTRUCTIONS MR057 MEDICARE PART B HAWAII PRE ENROLLMENT INSTRUCTIONS MR057 TO COMPLETE THIS FORM YOU WILL NEED: Medicare Hawaii Provider Number (PTAN) Billing NPI on file with Palmetto for the Hawaii PTAN Name and Address

More information

JURISDICTION 11 EDI CONTRACT INSTRUCTIONS

JURISDICTION 11 EDI CONTRACT INSTRUCTIONS JURISDICTION 11 EDI CONTRACT INSTRUCTIONS Submit the completed form to: ABILITY Network, ATTN: Enrollment FAX: 888.837.2232 EMAIL: setup@abilitynetwork.com INSTRUCTIONS Refer to these instructions as you

More information

MEDICARE Texas (TRAILBLAZERS) PRE-ENROLLMENT INSTRUCTIONS 00900

MEDICARE Texas (TRAILBLAZERS) PRE-ENROLLMENT INSTRUCTIONS 00900 MEDICARE Texas (TRAILBLAZERS) PRE-ENROLLMENT INSTRUCTIONS 00900 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 5 business days after receipt. WHAT FORM(S) SHOULD I COMPLETE? EDI Provider

More information

Trading Partner Account (TPA) Registration and Maintenance User Guide. for. State of Idaho MMIS

Trading Partner Account (TPA) Registration and Maintenance User Guide. for. State of Idaho MMIS Trading Partner Account (TPA) Registration and Maintenance User Guide for State of Idaho MMIS Date of Publication: 3/8/2018 Document Number: RF019 Version: 5.0 This document and information contains proprietary

More information

Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERALEMPLOYEEPROGRAM (FEP) DentalClaims

Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERALEMPLOYEEPROGRAM (FEP) DentalClaims Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERALEMPLOYEEPROGRAM (FEP) DentalClaims HIPAA Transaction Companion Document Guide Refers to the X12N Implementation Guide: 005010X224A2:

More information

NATIONWIDE HEALTH PLANS ERA

NATIONWIDE HEALTH PLANS ERA 3/21/2007 Cover Page 1 PAYER ID: 31417 NATIONWIDE HEALTH PLANS ERA For Initial Enrollment with this payer: You MUST be enrolled for EDI with this payer, and have a minimum of one successful claim processed

More information

Availity TM Electronic Remittance Advice

Availity TM Electronic Remittance Advice Availity TM Electronic Remittance Advice Electronic Remittance Advice (ERA) or ANSI 835 is a HIPAA-compliant method of receiving claim payment and remittance details from Blue Cross and Blue Shield of

More information

ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments

ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments Alameda Alliance for Health is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers who enroll in EFT will have Fee-For-Service

More information

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name

More information

Part A/Part B/HHH Provider Authorization Form Instructions

Part A/Part B/HHH Provider Authorization Form Instructions Part A/Part B/HHH Provider Authorization Form Instructions The purpose of the notice is to authorize a clearinghouse and/or billing service as an electronic submitter and recipient of electronic claims

More information

New York Medicaid Provider Resource Guide

New York Medicaid Provider Resource Guide New York Medicaid Provider Resource Guide Thank you for being a star member of our provider team. WellCare Health Plans, Inc., (WellCare) understands that having access to the right tools can help you

More information

WV MMIS EDI File Exchange User Guide Version 1.0 West Virginia Trading Partner Account Electronic Data Interchange (EDI) File Exchange User Guide

WV MMIS EDI File Exchange User Guide Version 1.0 West Virginia Trading Partner Account Electronic Data Interchange (EDI) File Exchange User Guide West Virginia Trading Partner Account Electronic Data Interchange (EDI) File Exchange User Guide Date of Publication: 01/19/2016 Document Version: 1.0 Privacy and Security Rules WV MMIS The Health Insurance

More information

Kentucky Health Insurance Exchange Provider Resource Guide

Kentucky Health Insurance Exchange Provider Resource Guide Kentucky Health Insurance Exchange Provider Resource Guide WellCare Health Plans, Inc. (WellCare) understands that having access to the right tools can help you and your staff streamline day-to-day administrative

More information

New Jersey. NCPDP D.0/1.2 Payer Sheet. Page 1 of 41 January 2018 Version

New Jersey. NCPDP D.0/1.2 Payer Sheet. Page 1 of 41 January 2018 Version New Jersey NCPDP D.0/1.2 Payer Sheet Page 1 of 41 Table of Contents Section 1 Version History... 3 Section 2 Introduction... 6 2.1 New Jersey DMAHS Introduction... 6 2.2 HIPAA Background... 7 Section 3

More information

AETNA BETTER HEALTH AETNA BETTER HEALTH KIDS 2000 Market Street, Suite 850 Philadelphia, PA Fax

AETNA BETTER HEALTH AETNA BETTER HEALTH KIDS 2000 Market Street, Suite 850 Philadelphia, PA Fax Instructions for Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Funds Transfer (EFT) Authorization Agreement Form. Missing,

More information

UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629

UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629 UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629 HOW DO I ENROLL TO RECEIVE 835s/ERAs? STEP 1: Complete the Availity Multi Payer ERA Enrollment Form. (Standard processing time is 1 week) Fax the form to

More information

Louisiana Medicaid Management Information System (LMMIS)

Louisiana Medicaid Management Information System (LMMIS) Louisiana Medicaid Management Information System (LMMIS) Electronic 835 Remittance Advice (ERA) Authorization Agreement Application User Manual Date Created: 08/06/2018 Date Modified: 12/03/2018 Prepared

More information

Infinedi, LLC. Frequently Asked Questions

Infinedi, LLC. Frequently Asked Questions Infinedi, LLC Frequently Asked Questions Who are we? Infinedi has been helping medical providers better manage their practices since 1986 by providing the finest EDI services available. Infinedi is a privately

More information

Group Provider Enrollment Tutorial. Revised 4/5/18

Group Provider Enrollment Tutorial. Revised 4/5/18 Group Provider Enrollment Tutorial Revised 4/5/18 1 Group Provider Enrollment Documents you will need: Copy of Confirmation Letter or email from the National Plan and Provider Enumeration System (NPPES)

More information