MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS
|
|
|
- Cathleen Reed
- 5 years ago
- Views:
Transcription
1 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 TIME FOR ENROLLMENT? Standard processing time is 2 weeks. HOW DO I CHECK STATUS? Call Xerox at (866) and ask if you are enrolled and linked to Office Ally s Submitter ID Once enrollment has been approved, you MUST contact Office (360) , option 1 and notify us of the approval BEFORE submitting claims for electronic transmission. Office Ally P.O. Box Vancouver, WA Phone: :
2 Xerox EDI Provider Enrollment Form Please print or type. Complete all areas of the Xerox Provider Enrollment Form, unless otherwise indicated. Section 1. Classification. Please indicate your classification. Individual Group Section 2. Submission Method. Please indicate how you plan to submit your electronic transactions. WINASAP5010 Vendor Software Billing Agent Clearinghouse x Section 3. Provider Information. Business Name (If applicable) Provider Name (Last, First, MI, and Suffix) Business Street Address City, State, and Zip Code Telephone Provider Number (Required for Individuals) Group Provider Number (Required for Groups) Address (If applicable) Section 4. Submitter/Trading Partner ID Number. If you are currently submitting electronic transactions directly to Xerox EDI Gateway, please indicate your Xerox EDI Gateway 5-digit Submitter ID or 6-digit Trading Partner ID: of 5
3 Section 5. Contact Information. Please indicate contact information. Contact Person Contact Title Business Street Address City, State, and Zip Code Telephone Address Additional Contact Information. Please indicate additional contact information. Contact Person Contact Title Business Street Address City, State, and Zip Code Telephone Address Please attach additional sheets if necessary 2 of 5
4 Section 6. Provider Using a Software Vendor, Billing Agent, or a Clearinghouse. If you have indicated that you plan to use Vendor Software, a Billing Agent, or a Clearinghouse to submit your transactions electronically to Xerox EDI Gateway, please provide the following information. (If you plan on using WINASAP5010, you do not need to complete this section.) Sub-section 6a. Type of Service that you use. Please indicate the type of service that you use to submit electronic transactions. SV/CH/BA Name Software Vendor (SV) Clearinghouse (CH) Billing Agent (BA) Contact Person Business Address Contact Title City, State, and Zip Code Telephone Number Address Number Sub-section 6b. Provider Using a Software Vendor. If you plan to use Vendor Software, please complete the following information related to your software. Software Software Version: Protocol: Name: Sub-section 6c. Software Vendor, Billing Agent or Clearinghouse Submitter ID or Trading Partner ID. Note: Your Billing Agent or Clearinghouse must be equipped with their own uniquely assigned Xerox EDI Gateway Submitter ID or Trading Partner ID to act on your behalf. Please contact your Software Vendor, Billing Agent/Clearinghouse to confirm their status with Xerox EDI. Please indicate your Software Vendor/Clearinghouse/Billing Agent s 5-digit Submitter ID or 6-digit Trading Partner ID: of 5
5 Section 7. Transactions Available for Transmission. Sub-Section 7a. WINASAP5010 (replacing WINASAP2003 software). Request for free WINASAP5010 Software: I will download a copy from the Xerox website at X12N 837P (Professional Claim) X12N 837D (Dental Claim) X12N 837I (Institutional Claim) X12N Nursing Facility Claim (X12N 837I) Sub-Section 7b. Standard Transactions (Submissions other than WINASAP5010.) X12N 837P (Professional Claim) X12N 278 (Prior Authorization) X12N 837D (Dental Claim) X12N 837I (Institutional Claim) X12N 270 (Eligibility Inquiry) X12N 276 (Claim Status Inquiry) Section 8. Delimiter Information. If you are submitting X12N transactions directly to Xerox EDI Gateway, please provide please provide an alternate delimiter if you are not using the default. (This information is not required if you are using WINASAP5010). Element Delimiter to be used: Segment Delimiter to be used: Element Delimiter to be used: Default Delimiter (asterisk) * Default Delimiter (tilde) ~ Default Delimiter (colon) : Section 9. Electronic Response Retrieval. Washington, DC Medicaid providers can retrieve their electronic responses from the Xerox EDI Gateway Internet Data Exchange (idex). If you would like to participate in this service, please complete the section below. Responses available for X12N Transactions. X12N 277CA (Claim Acknowledgement) X12N 999 (Functional Acknowledgement) X12N 271 (Eligibility Response) X12N 835 (Healthcare Claim Payment/Advice) X12N 277 (Claims Status Response) X12N 278 (Prior Authorization) 4 of 5
6 Section 10. Additional Provider List. Provider Name Provider ID Please attach additional sheets if necessary 5 of 5
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
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
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
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
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
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
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
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
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
220 Burnham Street South Windsor, CT Vox Fax OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
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
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
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)?
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.
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
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
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
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
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:
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
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
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
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
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
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;
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
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;
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
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
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
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
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
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
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
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
Standard Companion Guide
Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X224A2 Health Care Claim Dental (837D) Companion Guide Version Number 2.0 September 25, 2018 Page 1 of 15 CHANGE LOG
THANK YOU FOR INTEREST IN OFFICE ALLY
THANK YOU FOR INTEREST IN OFFICE ALLY I have attached Office Ally s Enrollment Instructions for enrolling online to start sending electronic claims. Below is information and direction on how to get started.
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
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
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
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,
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
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
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
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
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
837 Health Care Claim Companion Guide. Professional and Institutional
837 Health Care Claim Companion Guide Professional and Institutional Revised December 2011 Table of Contents Introduction... 3 Purpose... 3 References... 3 Additional information... 4 Delimiters Supported...
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
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
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
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
ANSI ASC X12N 835 Healthcare Claim Institutional, Professional and Dental Department of Labor-OWCP Companion Guide. May 31, 2017
Institutional, Professional and Dental Department of Labor-OWCP Companion Guide May 31, 2017 TABLE OF CONTENTS Table of Contents At a Glance... 3 Chapter 1 Introduction... 4 Chapter 2 EDI Operations...
Mississippi Medicaid Companion Guide to the X279A1 Benefit Inquiry and Response Conduent EDI Solutions, Inc. ANSI ASC X12N 270/271
Mississippi Medicaid Companion Guide to the 005010X279A1 Benefit Inquiry and Response Conduent EDI Solutions, Inc. ANSI ASC X12N 270/271 OCT 2017 TABLE OF CONTENTS AT A GLANCE II CHAPTER 1: INTRODUCTION
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
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
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
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
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
ANSI ASC X12N 837 Healthcare Claim (Version X222A1-June 2010) Professional Companion Guide
ANSI ASC X12N 837 Healthcare Claim (Version 005010X222A1-June 2010) Pruitt Health Premier Missouri Medicare Select Signature Advantage September 2015 TABLE OF CONTENTS AT A GLANCE II CHAPTER 1: INTRODUCTION
Guide to the X214 Claim Acknowledgement Conduent EDI Solutions, Inc.
Mississippi Medicaid Companion Guide to the 005010X214 Claim Acknowledgement Conduent EDI Solutions, Inc. ANSI ASC X12N 277CA October 2017 TABLE OF CONTENTS AT A GLANCE II CHAPTER 1: INTRODUCTION 3 Audience
837D Health Care Claim: Educational Guide
837D Health Care Claim: Educational Guide January 2011 - Version 3.0 Disclaimer INGENIX is still under development stages and frequent changes within this document are expected. This documentation was
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
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
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
BLUE CROSS AND BLUE SHIELD OF LOUISIANA PROFESSIONAL CLAIMS COMPANION GUIDE
BLUE CROSS AND BLUE SHIELD OF LOUISIANA Table of Contents I. Introduction...3 II. General Specifications...4 III. Enveloping Specifications...5 IV. Loop and Data Element Specifications...7 V. Transaction
Blue Shield of California
Blue Shield of California HIPAA Transaction Standard Companion Guide Section 1 Refers to the Implementation Guides Based on X12 version 005010 Companion Guide Version Number: 1.0 June 6,2011 [OCTOBER 2010
Ohio Medicare Part B Change Form
Ohio Medicare Part B Change Form Change form for currently enrolled providers changing to new clearinghouse(ltc). Complete the form, sign, and mail original to: CGS 1 Cameron Hill Cir STE 0061 Chattanooga,
Excellus BCBS of New York is divided into three payers, SB804, SB805 and SB806. Each payer is setup based on New York counties.
Excellus BCBS of New York is divided into three payers, SB804, SB805 and SB806. Each payer is setup based on New York counties. Submit the form that is applicable to your county only. enrollments under
BLUE CROSS AND BLUE SHIELD OF LOUISIANA INSTITUTIONAL CLAIMS COMPANION GUIDE
BLUE CROSS AND BLUE SHIELD OF LOUISIANA Table of Contents I. Introduction...3 II. General Specifications...4 III. Enveloping Specifications...5 IV. Loop and Data Element Specifications...7 V. Transaction
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
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
Statement of HIPAA Readiness February 2003
Statement of HIPAA Readiness February 2003 Copyright 2003 WebMD Envoy Corporation. All Rights Reserved. Rev. 02/03 Table of Contents 1 Meeting the HIPAA Challenge...1 Overview...1 WebMD Envoy HIPAA Readiness...2
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:
< A symbol to indicate a value is less than another. For example, 2 < 3. This symbol is used in some BCBSNC proprietary error messages.
Glossary < A symbol to indicate a value is less than another. For example, 2 < 3. This symbol is used in some BCBSNC proprietary error messages. > A symbol to indicate a value is greater than another.
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
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
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
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
USVI HEALTH ELIGIBILITY/BENEFIT INQUIRY 5010 Companion Guide 270
USVI HEALTH ELIGIBILITY/BENEFIT INQUIRY 5010 Companion Guide 270 Date of Publication: 12/04/2012 Version: 1.1 DISCLAIMER The DXC Technology Companion Guide for USVI Medicaid is subject to change prior
DentaQuest HIPAA Transaction Standard Companion Guide
DentaQuest HIPAA Transaction Standard Companion Guide 837D 005010X224A2 Version 1.0 January 2016 January 18, 2016 1 Disclosure Statement 2015 DentaQuest, LLC. All rights reserved. This document may be
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
Administrative Services of Kansas (ASK)
Administrative Services of Kansas (ASK) HIPAA 276/277 005010X212 Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 January 2016 1 Disclosure Statement This document
VI. CLAIMS EDI PROCESSING PROCEDURES A. General Information
A. General Information Electronic submission of claims helps to speed the processing and ensure accuracy and security. While direct submission of claims is allowed, this option is more practical for large
Kentucky HIPAA HEALTH CARE CLAIM: DENTAL Companion Guide 837
Kentucky HIPAA HEALTH CARE CLAIM: DENTAL Companion Guide 837 Version 1.4 Final RECORD OF CHANGE VERSION NUMBER DATE REVISED DESCRIPTION OF CHANGE PERSONS INVOLVED 1.0 10/25/02 Creation and first view by
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
MI Health Plan Benefits: Users and Applications Application User Guide
MI Health Plan Benefits: Users and Applications Application User Guide August 28, 2017 MI Health Plan Benefits User Guide Page 1 of 17 Table of Contents 1 MI Health Plan Benefits Overview... 3 2 Accessing
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
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
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
837 Dental Health Care Claim
Companion Document 837D 837 Dental Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for dental claims. The remaining
HIPAA TRANSACTION STANDARD 837 HEALTH CARE CLAIM: PROFESSIONAL COMPANION GUIDE APRIL 21, 2004 VERSION X098A1
HIPAA TRANSACTION STANDARD 837 HEALTH CARE CLAIM: PROFESSIONAL COMPANION GUIDE APRIL 21, 2004 VERSION 004010X098A1 837 Health Care Claim: Professional Below is a summary of the fields that have additional
EMBLEMHEALTH HIPAA Transaction Standard Companion Guide
EMBLEMHEALTH HIPAA Transaction Standard Companion Guide Refers to the X12N Implementation Guide 005010X222A1: 837P Health Care Claim Professional Transaction HIPAA Readiness Disclosure Statement The Health
Mississippi Medicaid Companion Guide to the ASC X12N 837 Professional Conduent EDI Solutions, Inc. ANSI ASC X12N 837
Mississippi Medicaid Companion Guide to the ASC X12N 837 Professional Conduent EDI Solutions, Inc. ANSI ASC X12N 837 October 2017 TABLE OF CONTENTS AT A GLANCE II CHAPTER 1: INTRODUCTION 3 Audience 3 CHAPTER
Refers to the Technical Reports Type 3 Based on ASC X12 version X223A2
HIPAA Transaction Standard Companion Guide For Availity Health Information Network Users Refers to the Technical Reports Type 3 Based on ASC X12 version 005010X223A2 837 Health Care Claim Institutional
837 Professional Health Care Claim
Section 2A 837 Professional Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional claims. The tables
835 Health Care Claim Payment and Remittance Advice Companion Guide X091A1
835 Health Care Claim Payment and Remittance Advice Companion Guide 004010 X091A1 Version 1.3 March 1, 2008 1-March-2008 TABLE OF CONTENTS 1 Introduction... 1 1.1 Purpose... 1 2 Transmission and Data Retrieval
West Virginia HEALTH ELIGIBILITY/BENEFIT INQUIRY Companion Guide 270
West Virginia HEALTH ELIGIBILITY/BENEFIT INQUIRY Companion Guide 270 Date of Publication: 01/01/2014 Document Number: Version: 2.0 DISCLAIMER The Molina Healthcare Companion Guide for West Virginia is
BULLETIN BOARD SCREENS for HIPAA (BBS) UPDATED JULY 22, Once connected, the first screen displays the node number that you are connected to.
BULLETIN BOARD SCREENS for HIPAA (BBS) UPDATED JULY 22, 2010 The following provides information and screen instructions on: 1. Transmitting 837 Transactions 2. TA1 Acknowledgement Retrievals 3. 997 Acknowledgement
270/271 Health Care Eligibility, Coverage, or Benefit Inquiry and Response
Companion Document 270/271 270/271 Health Care Eligibility, Coverage, or Benefit Inquiry and Response Basic Instructions This section provides information to help you prepare for the ANSI ASC X12.281 Eligibility,
Anthem Blue Cross and Blue Shield. 834 Companion Guide
Anthem Blue Cross and Blue Shield 834 Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance Transactions Incoming to the Electronic Enrollment System (EES) Anthem Blue Cross and Blue