Excellus BCBS of New York is divided into three payers, SB804, SB805 and SB806. Each payer is setup based on New York counties.

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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 multiple regions. Only ancillary providers will need to submit The list below shows the counties for each payer. SB804 New York BCBS Rochester Covers the following counties only. Monroe, Ontario, Wayne, Seneca, Livingston & Yates SB805 New York BCBS Central Covers the following counties only. Oswego, Onondaga, Cayuga, Corland, Chenango, Broome, Tioga, Tompkins, Schuyler, Cheemung & Steuben SB806 New York BCBS Utica/Watertown Covers the following counties only. Clinton, Essex, Franklin, St. Lawrence, Jefferson, Lewis, Oneida, Madison, Herkimer, Hamilton, Fulton, Montgomery, Otsego & Delaware When approved, the payer will notify Change Healthcare via email. The email will list the region that the provider was setup under. In case the wrong payer id was selected, we will setup the correct payer id in Wizard and add a note to incorrect payer to see payer id.

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 Tax ID Client ID Site ID Address City STATE ZIP Contact Name E-mail Address Telephone Fax 2 Vendor (Change Healthcare certified vendor used to submit files to Change Healthcare) Vendor Name Vendor Submitter ID Contact Name E-mail Address 3 Payer Payer ID Group ID Individual Provider ID NPI ID 4 Confirmations Send Change Healthcare Claim Confirmations To: Special Instructions: All Payer Registration forms must contain signatures when applicable, stamped signatures or photo copies are accepted. SUBMIT COMPLETED FORM TO: Change Healthcare Donelson Corporate Ctr Bldg 3 3055 Lebanon Pike Ste 1000 Nashville, TN 37214-2230 PROVIDERS MUST BE SENDNG ELECTRONIC CLAMS TO RECEIVE ELECTRONIC REMITTANCE THIS PAYER ONLY COVERS THE FOLLOWING COUNTIES MONROE, ONTARIO, WAYNE SENECA, LIVINGSTON & YATES CHANGE HEALTHCARE REVISION FORM DATE:

SCHEDULE CR TO CONSENT TO RECEIVE ELECTRONIC REMITS AGENT ADDENDUM This Addendum to the attached Agreement of Consent to Submit Claims Electronically ( Agreement ) acknowledges that Trading Partner has entered into an arrangement with, with it principle place of business at ( Agent ) to provide third party services to Trading Partner. 1. APPOINTMENT. Trading Partner has appointed an Agent to provide certain services to Trading Partner that necessitate Agent being able to take advantage of the electronic services as described in the attached Agreement is being made available to Trading Partner in accordance. 2. ACCESS. Health Plan shall provide the electronic services to Agent upon the same terms and conditions of the Agreement to be provided to Trading Partner. 3. OBLIGATION OF AGENT. Agent shall have the same duties, rights and obligations as Trading Partner has agreed to under the terms of the Agreement. 4. NOTICES. Any notices required or permitted to be given pursuant to this Addendum shall be in writing and addressed to the following mailing address or such other address as may be provided to the other in writing: AGENT Excellus Health Plan, Inc. EDI Solutions P.O. Box 22999 Rochester, NY 14692 5. INCORPORATION. All terms and conditions of the Agreement are incorporated by reference into this Addendum. The Parties hereby agree to the provisions of the Addendum. 6. SIGNATURES (REQUIRED): PHYSICIAN (S): Title: Dated: AGENT S NAME: Title: Dated:

Mail to: Excellus Health Plan, Inc. EDI Solutions P.O. Box 22999 Rochester, NY 14692 Practice Information Practice Practice Address: City: State: Zip: Practice Contact Practice NPI: Practice Tax Id Number: Billing Service: Yes ( ) No ( ) *If yes, please be sure to complete the following. If no, please skip to Software Vendor Billing Service/Clearinghouse Information Billing Service: Clearinghouse: Submitter ID: Effective Date: Signature: **Signature required by physician or authorized person to sign on behalf of practice

Software Vendor Submitter ID: Effective Date: Signature: **Signature required by physician or authorized person to sign on behalf of practice

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