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