VIRGINIA PREMIER (54176) EDI ENROLLMENT INSTRUCTIONS
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1 VIRGINIA PREMIER (54176) EDI ENROLLMENT INSTRUCTIONS WHICH FORM(S) SHOULD I DO? Capari EDI Enrllment Frm Emden Claims Prvider Setup Frm Emden Claims Prvider Infrmatin Frm Virginia Premier Health Plan, Inc. EDI 837 Claims Enrllment Frm A W-9 frm is REQUIRED WHERE SHOULD I SEND THE FORMS? Capari EDI Enrllment Frm: Once cmpleted, save and t supprt@fficeally.cm r Fax the frms listed belw t batchenrllment@emden.cm r (615) Emden Claims Prvider Setup Frm Emden Claims Prvider Infrmatin Frm Virginia Premier Health Plan, Inc. EDI 837 Claims Enrllment Frm HOW AM I NOTIFIED OF REJECTIONS? Once Office Ally receives yur Capari Prvider Enrllment infrmatin, we will uplad it t the Capari web site within hurs. If there are any errrs in the enrllment frm, yu will receive an identifying the errrs frm an Office Ally representative. Yu will be required t crrect and re-submit in rder fr yur enrllment t be prcessed. Please nte that the prcessing time starts ver each time the enrllment frm is re-submitted. Office Ally P.O. Bx Vancuver, WA Phne: Fax:
2 CAPARIO EDI ENROLLMENT FORM In rder t send claims electrnically t this payer, please fill ut this frm and return it via t Supprt@fficeally.cm, the Subject shuld read: Capari EDI Enrllment - Virginia Premier PAYER INFORMATION OF THE PAYER YOU ARE ENROLLING FOR EDI SUBMISSION TO: VIRGINIA PREMIER - PAYER ID INFORMATION: Prvider Name: Prvider Address: IDENTIFIERS INFORMATION: Prvider Federal Tax Identificatin Number (TIN) OR Emplyer Identificatin Number (EIN): Natinal Prvider Identifier (NPI): CONTACT INFORMATION: Prvider Cntact Name: Telephne Number: Address: SUBMISSION INFORMATION: Reasn fr Submissin: Authrized Signature: Nte: Electrnic Signature (typed name) f Persn Submitting EDI Enrllment. Office Ally P.O. Bx Vancuver, WA Phne: Fax:
3 Emden Claims Prvider Setup Frm 1 Prvider Organizatin Practice/Facility Name batchenrllment@emden.cm Fax: (615) Billing NPI Prvider Name Prvider Specialty Cde Practice/Facility Prvider Address Cntact Name Street Tax ID Site ID City State Zip Cde Cntact Phne EDI Team Number (800) Opt 1 2 Vendr (Emden Certified Vendr used t submit files t Emden) Vendr Name Vendr Submitter ID Cntact Name 3 Reprt Methd TSO ID F042 Capari EDI Team Cntact Phne Number (800) Opt 1 Cmmunicatin Prtcl/Output PMCA K=PK Zipped/CmmServer, FTP, ITS, VPN Reprt Type 4 Payer M = Medical B Reprt Frmat H = Hspital Please list additinal payers belw Check the Emden Payer List t see if additinal enrllment is required at: M Payer ID Grup ID Individual ID NPI ID Payer ID Grup ID Individual ID NPI ID 5 Cnfirmatins (Enter address) Cnfirmatins (Enter address) **Sectin 1** Prvider Organizatin sectin must be fully cmpleted with Facility/Prvider infrmatin, failure t cmplete all fields may result in frm rejectins. D nt list Vendr r Billing Service infrmatin. Billing NPI is required t cmplete enrllment. Revised 01/19/2010
4 PAYER ID: SUBMITTER ID: 1 Prvider Organizatin Emden Claims Prvider Infrmatin Frm *This frm is t ensure accuracy in updating the apprpriate accunt Practice/ Facility Name Prvider Name Tax ID Client ID Site ID Address City/State Zip Cde Cntact Name EDI Team Address Prvider.Enrllment@Capari.cm Telephne (800) Opt 1 Fax (404) Vendr (Emden certified vendr used t submit files t Emden) PMCA Vendr Name Cntact Name Address 3 Payer Payer ID Vendr Submitter ID Capari EDI Team Prvider.Enrllment@Capari.cm VIRGINIA PREMIER Grup ID Individual Prvider ID NPI ID Divisin ID 4 Cnfirmatins Send Emden Claim Cnfirmatins T: Special Instructins: All Payer Registratin frms must cntain signatures when applicable, stamped signatures r phtcpies are accepted. SUBMIT COMPLETED FORM TO: Fax: (615) batchenrllment@emden.cm IF YOU ARE CURRENTLY SUBMITTING ELECTRONIC CLAIMS SUCCESSFULLY NO ADDITIONAL ENROLLMENT IS REQUIRED. EMDEON REVISION FORM DATE: 05/09/2009
5 EDI 837 Claims Enrllment Frm (T Send Electrnic Claims t VPHP) Date 1 Submitter Infrmatin (t be filled ut by the clearinghuse) CLEARINGHOUSE Clearinghuse Cntact Name Clearinghuse Address EMDEON ENROLLMENT HELP DESK 3055 LEBANON PIKE STE 1000 City NASHVILLE State TN Zip Phne payerregistratin@emden.cm [Nte: VPHP will send enrllment cnfirmatin t the address abve.] 2 Billing Agent/Service Infrmatin [refers t the clearinghuse] Billing Agent Tax ID Prvider Grup Infrmatin ( W-9 Required) Internal Use ID# W-9 n file Database FAX Date Grup Name Grup Tax ID Grup NPI # (if applicable) 4 Prvider Remittance/Billing Address Address City State Zip NAME (Including TITLE) (e.g. MD, DO, DPM) SPECIALTY (e.g. Family Practice) NPI # (10 Digits) TAXONOMY CODE PAR (Participating) Or Nn-Par Page 1 f 2 05/06/09
6 NAME (Including TITLE) (e.g. MD, DO, DPM) SPECIALTY (e.g. Family Practice) NPI # (10 Digits) TAXONOMY CODE PAR (Participating) Or Nn-Par Page 2 f 2 05/06/09
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