BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801
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1 BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS HOW LONG DOES PRE ENROLLMENT TAKE? 3 to 5 business days WHERE SHOULD I SEND THE FORMS? Fax the form to WHAT FORM SHOULD I DO? EDI Change of Information Form If you want to receive your electronic remittance advice through Office Ally you need to complete the Application for Electronic Remits (835) Enrollment WHO CAN SIGN THE FORMS? No signature is required on the EDI Change of Information Form. The Electronic Remits (835) Enrollment form requires the provider or designated responsible party s signature. HOW DO I CHECK STATUS? Call and ask if your legacy provider ID is linked to Office Ally s Trading Partner # If you are linked you MUST call Office Ally at opt. 1 and tell them you are approved BEFORE submitting claims for electronic transmission. Office Ally P.O. Box Vancouver, WA Phone: Fax:
2 EDI Change Form Instructions The change form is to be used to: a) change trading partner or vendor information, OR b) add additional NPI or transaction Section 1 Trading Partner Information: Trading Partner Number - enter your existing trading partner number Organization Name - print name of the organization submitting files Mailing Address - print the address of the organization City, State, Zip - print the city, state and zip code of the organization Contact Name(s) - print the contact name(s) for the organization (information will only be released to names on file) Telephone # - print telephone number of organization Fax # - print fax number of organization Address - print address of contact at the organization Section 2 Vendor Information: Software Company Name - print name of software company that supports your practice management software Mailing Address - print address of software company City, State, Zip - print city, state and zip code of software company Contact Name(s) - print contact name(s) for the software company Telephone # - print telephone number of software company Fax # - print fax number of software company Address - print address for software company Section 3 NPI and Transactions: Blue Cross and Blue Shield of Kansas (BCBSKS) 10 digit NPI billing number Blue Cross and Blue Shield of Kansas City (BCBSKC) 10 digit NPI billing number **HealthNow New York (HNNY)/ Blue Cross and Blue Shield of Western New York (BCBSWNY)/ Blue Shield of Northeastern New York (BSNENY) 10 digit NPI billing number Preferred Health Professional (PHP) - Tax ID number and 10 digit NPI billing number EDI Midwest Tax ID number and 10 digit NPI billing number (Contract Required) ** New York customers must also submit Individual (Rendering) NPI numbers ***You must indicate the transaction to be added with the NPI and provider name*** Completed EDI enrollment forms may be faxed to: ed to: askedi@ask-edi.com Mailed to: ASK P.O. Box 3500 Topeka, KS Revised February
3 EDI Change of Information Form This form is to be used to: a) change trading partner or vendor information, OR b) add additional NPI or transaction To change trading partner contact information: new contact information to (only if address contains name of facility) OR fax new contact information on company letterhead to Section 1: Trading Partner Information Trading Partner Number Organization Name (legal name): Mailing Address: City: State: Zip: Telephone #: ( ) Fax #: ( ) Address: Section 2: Vendor Information Software Company Name: Mailing Address: City: State: Zip: Contact Name: Telephone #: ( ) Fax: ( ) Address: Revised February
4 Section 3: NPI and Transactions Select the appropriate transaction for the Organizational (Billing) NPI you are enrolling. * New York customers must also submit Individual (Rendering) NPI numbers Payers NPI Provider Name Blue Cross Blue Shield of Kansas (BCBSKS): 837P (professional claims) 837I (institutional claims) 837D (dental claims) 270/271 (eligibility inquiry/benefits) 276/277 (claims status) Blue Cross Blue Shield of Kansas City (BCBSKC): 837P (professional claims) 837I (institutional claims) 837D (dental claims) 270/271 (eligibility inquiry/benefits) 276/277 (claims status) New York Customers (Those submitting for HealthNow New York (HNNY) or Blue Cross Blue Shield of Western New York (BCBSWNY) or Blue Shield of Northeastern New York (BSNENY): 837P (professional claims) 837I (institutional claims) 837D (dental claims) Preferred Health Professionals (PHP): 837P (professional claims) 837I (institutional claims) EDI Midwest Electronic Clearinghouse (Requires Contract) 837P (professional claims) 837I (institutional claims) TAX ID: Required for EDI Midwest Revised February
5 General Information Please provide in writing to ASK any future changes to the information contained in this EDI setup form within 5 business days of the change. ASK will make every attempt to give 60 days notices of any material changes to the EDI system that may effect trading partner data transmissions. Updates to any system changes will be made through the list notification on the ASK Web site. Trading partners are responsible for signing up for the list notifications. In an effort to keep our records up to date, provider numbers with no activity for at least six months will be removed from a trading partner number. Once removed from a trading partner number, the EDI enrollment form will need to be completed to re-add this number. Kansas law applies to this business relationship. Completed EDI enrollment forms may be faxed to: ed to: askedi@ask-edi.com Mailed to: ASK P.O. Box 3500 Topeka, KS ***All pages of EDI enrollment form must be returned*** Revised February
6 EDI Enrollment Form Instructions Application for Electronic Remits (835) Enrollment Section 1 Request Type: Indicate whether request is for a new enrollment or to add a provider number to an existing trading partner number. Section 2 Trading Partner Information: Trading Partner Number - enter if you are an existing trading partner Organization Name - print name of the organization submitting files or trading partner Mailing Address - print the address of the organization City, State, Zip - print the city, state and zip code of the organization Contact Name(s) - print the contact name(s) for the organization (information will only be released to names on file) Telephone # - print telephone number of organization Fax # - print fax number of organization Address - print address of contact at the organization Section 3 Type of Organization (new trading partner enrollments only): Please indicate if you are a clearinghouse or billing service. Leave blank if neither description fits the organization. Section 4 Vendor Information (new trading partner enrollments only): Software Company Name - print name of software company that supports your practice management software Mailing Address - print address of software company City, State, Zip - print city, state and zip code of software company Contact Name(s) - print contact name(s) for the software company Telephone # - print telephone number of software company Fax # - print fax number of software company Address - print address for software company Section 5 Communication Type (new trading partner enrollments only): Indicate whether you will be using Internet file transfer, a network service vendor, or FTP file transfer. If using FTP, please indicate the compression and transfer type. EDI Enrollment Instructions(835) Updated Nov
7 Section 6 Billing Provider Numbers: Enter all billing provider numbers you will be requesting remits under. *** As of 12/1/07 Requests to add provider numbers must include a valid NPI. Forms received without the NPI will be returned. Blue Cross and Blue Shield of Kansas 6-digit group number Blue Cross and Blue Shield of Kansas City 8-digit group number HealthNow New York, Blue Cross and Blue Shield Western New York, Blue Shield Northeastern New York Submit 12 digit payee numbers only. NPI 10 digit billing number Section 7 Provider Information (only if different than trading partner information) Provider/Organization - print name of provider/organization Address - print address of provider/organization City, State, Zip Code - print city, state and zip code of provider/organization Attention/Contact Name - print attention or contact name (optional) Telephone # - print telephone number Fax # - print fax number Address - print address (optional) Section 8 Signatures: A signature is required from the provider or an authorized provider representative. By signing this agreement it is understood that any previous 835 enrollment for the indicted provider number(s) will be overridden. Completed EDI enrollment forms may be sent to: ASK, Inc. P.O. Box 3500 Topeka, KS Fax number: ***All pages of EDI enrollment form must be returned*** EDI Enrollment Instructions(835) Updated Nov
8 EDI Enrollment Form ANSI 835 Payment/Advice (004010X091A1) Section 1: Request Type: New enrollment (request for a new trading partner number) Existing trading partner adding additional provider numbers Section 2: Trading Partner Information: Trading Partner Number: (for existing trading partner) Organization Name: (legal name) Mailing Address: City: State: Zip: Contact Name(s): Telephone #: Fax #: Address: Section 3: Type of Organization (new trading partner enrollment only): Clearinghouse Billing Service (Leave blank if neither description fits the organization) Section 4: Vendor Information (new trading partner enrollment only): Software Company Name: Mailing Address: City: State: Zip: Contact Name: Telephone #: ( ) Fax #: ( ) Address: EDI Enrollment Instructions(835) Updated Nov
9 Section 5: Communication Type (New Trading Partner enrollment only): Internet Network Service Vendor (i.e.: IVANS or Vision Share) FTP - choose compression type and transfer type if using FTP Compression Type Transfer Type: Encryption ASCII PKZip Binary UnixComp None UnixTar UnixZip None Section 6: Billing Provider Numbers: ***As of 12/1/07 Requests to add provider numbers must include a valid NPI. Forms received without the NPI will be returned. Payer Blue Shield and Blue Cross of Kansas Blue Shield and Blue Cross of Kansas City HealthNow NY BCBSWNY BSNENY Payer Provider Number(s) NPI Provider Name Note: Payer provider numbers and NPI can only be loaded under one trading partner number for the 835 (electronic remittance). Setup will be completed within 3-5 business days of receipt. If interested in submitting 837(claims) complete EDI Enrollment Form for 837, or the EDI change form, if you are an existing trading partner. NPI must be reported to payers before completing EDI enrollment. Section 7: Provider Information: Provider will be notified of 835 enrollment(s). Please submit provider information below if different than trading partner information: * = Required Provider/Organization: * Address: * City, State, Zip: * Attention/Contact Name: Telephone #: Fax#: * Address: EDI Enrollment Instructions(835) Updated Nov
10 Section 8: Signatures A signature is required from either the provider or an authorized provider representative. Only one billing provider may be enrolled per form. **Signing this agreement will override any previous 835 enrollments for the indicated provider numbers. Provider or Providers Representative: (Sign) (Date) (Print Name) (Print Title) General Information Please provide in writing to ASK any future changes to the information contained in this EDI setup form within 5 business days of the change. ASK will make every attempt to give 60 days notice of any material changes to the EDI system that may effect trading partner data transmissions. Updates to any system changes will be made through list notification on the ASK Web site. Trading partners are responsible for signing up for the list notifications. In an effort to keep our records up to date, provider numbers with no activity for at least six months will be removed from a trading partner number. Once removed from a trading partner number, the EDI enrollment form will need to be completed to re-add this number. Kansas law applies to this business relationship. Completed forms can be sent to: ASK, Inc. P.O. Box 3500 Topeka, KS Fax number: ***All pages must be returned*** EDI Enrollment Instructions(835) Updated Nov
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