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

Transcription

1 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 processing and claims submission. This agreement must be completed on the NGS Website. IMPORTANT: Please advise the ABILITY Network (Enrollment Helpdesk) of your packet ID number. Please make note of the packet ID and be sure to or fax it us for processing. Please reference the (Tax ID, NPI, PTAN) in your message. Please be advised that we need this information in order to properly set-up your enrollment on our systems. Print these instructions. Refer to them as you complete the online registration process. Please return the Contact Information Sheet with your agreement for Enrollment s reference. ABILITY Network submitter information for all Jurisdiction 6 payers is listed below. This submitter information is state-specific. Refer to the information below when completing enrollment forms for your state. SMNY0 / Empire/Downstate Medicare: Submitter ID CH Contractor Code Part B NY (Downstate) 13202

2 CONTRACT SMNY1 / Upstate Medicare: Submitter ID CHBU01563 Contractor Code Part B NY (UPSTATE) SMNY2 / Queens/GHI Medicare: Submitter ID NYBQ11469 Contractor Code Part B NY (QUEENS) Go to: - If attestation screen comes up, click Accept - Select second box I need to complete a Registration Form - Method of Electronic Submission Select Clearinghouse - Approved Entities List (See pages 2 & 3 to identify Entity ABILITY Network) - Clearinghouse Contact Information: - Contact Name Kim Scro - setup@abilitynetwork.com

3 CONTRACT EDI Guided Enrollment - Entity Name (Group or Ind. Provider), Address and Phone information that were submitted on the CMS-855 form when applying with Medicare. - Entity Contact Name, Title, for your site. - Contractor Code = Select the state for which you are enrolling from the drop down - Enter PTAN & NPI - Enter Provider/Facility Name, Address, Phone - Select Next - Choose Transaction Status 837 (Claims), 835 (Electronic Remittance Advice) or 267/277 - Submit EDI ERA Enrollment Form - Once the General Enrollment Information section is complete and submitted, the necessary enrollment forms will be presented. All information previously answered will be auto-populated on each individual EDI form. - Verify all fields displayed the correct information. - Enter Tax/EIN ID - Trading Partner ID/Submitter ID: (Refer to the grid on pages 2 & 3 for this information) - If selecting ERA, Electronic Remittance Advice Information Method of Retrieval: Clearinghouse - Electronic Remittance Advice Vendor Information - Vendor Name (See Grid on pages 2 & 3) - Vendor Contact Kim Scro - Vendor address setup@abilitynetwork.com - Authorized Signature - Authorized Name, Title - Read the Terms and Conditions on each form, check boxes if you agree

4 CONTRACT EDI Registries Form - Verify information is correct. - Read the Terms and Conditions on each form, check boxes if you agree. - Action; Link to Third Party - Trading Partner ID/Submitter ID: (Refer to the grid on pages 2 & 3 for this information) - Select Transaction Authorized for This submitter Read the Terms and Conditions on each form, check boxes if you agree. - EDI Enrollment Complete - Look your Packet ID is: (Important Make note of or print down Packet ID Number) - Print for your records - Finish and Exit IMPORTANT: Please or call the ABILITY Network Enrollment Helpdesk with your Packet ID Number. We ll utilize this information to track your enrollment to completion. Please call Enrollment at to confirm that we received your fax to avoid time-out rejections.

5 CONTRACT Submit the completed Payer Request Form to: Complete one Payer Request Form per Tax ID. Return this request form to ABILITY Network Enrollment with your EDI documentation. All information is required unless you are not using a billing service ABILITY Network is not a billing service. Note: Some payers require additional enrollment forms- please review our payer list for additional requirements. BILLING INFORMATION Please type provider information on this form for ease of processing at ABILITY Network. If you use a third-party billing service to prepare your claims, complete top section (if not, skip to provider info section): Please type your responses directly into the form. Billing Service Name TIN or ABILITY ID: Contact Name: Phone:( ) Group/Provider Name: Billing Tax ID: Indicate Tax ID SSN Billing NPI: Address on file with Payer(s): City: State: Zip+4: PRINT Authorized signature name, title (CEO, etc): Contact Full Name: Phone:( ) Contact Fax: ( ) PROVIDER INFORMATION List carriers/providers with which you wish to enroll below. Please refer to the ABILITY Network Payer List for enrollment requirements. Payer ID Payer Name PTAN Indiv Provider Name Rendering NPI Claims ERA