BCBS Florida 835 (BS590)

Transcription

1 BCBS Florida 835 (BS590) Submitter ID: H3493 Payer ID: BS590 Form Instructions: Section A: To be completed by. If you are changing vendors, a letter of intent is to be included with the enrollment form. Letter of Intent Instructions: If your Tax ID number is currently set up to receive 835 remittance files from a vendor2, and you would like to change vendors, an LOI is required. An LOI is a notification from the provider on office letterhead requesting a change. The name of the current vendor, name of the new vendor and the responsible party s signature must be included in the LOI. Section B: Trading Partner Information is pre-filled with Office Ally information. Sections C1, C2 and C3 and D: To be completed by provider WHERE TO SEND FORMS: o Fax the form to or mail to: o Blue Cross and Blue Shield of Florida Attention: Sender Setup DCC Deerwood Campus Parkway Jacksonville, FL HOW LONG DOES PRE-ENROLLMENT TAKE?: 10 business days EDI Contact Information: S. Coast Highway, Laguna Beach, CA Phone:

2 Mail to: Blue Cross and Blue Shield of Florida Attention: Sender Setup DCC Deerwood Campus Parkway Jacksonville, FL Fax to: (904) Health Care Electronic Remittance Advice (ERA) Request Form This form enables providers or other entities to request a HIPAA X12N 835 version 4010A1 electronic remittance advice transaction from Blue Cross and Blue Shield of Florida through the Availity 1 Health Information Network. It may also be used to add or remove providers or update existing information. Note: s must register their National Identifier (NPI) with BCBSF prior to submitting this request form. To locate the National Identifier (NPI) Notification form online, go to Completion Instructions Section A: Type of Request (Please choose only one) Initial Request - Check the Initial Request box to receive an 835 Health Care ERA as a new receiver. Change - Check the Change box to modify existing information, such as name, Tax ID, or to add/delete a provider. Letter of Intent (LOI) - If your Tax ID number is currently set up to receive 835 remittance files from a vendor 2, and you would like to change vendors, an LOI is required. An LOI is a notification from the provider on office letterhead requesting a change. The name of the current vendor, name of the new vendor and the responsible party s signature must be included in the LOI. Section B: Trading Partner Organization Information Complete the trading partner organization information. All fields must be completed. Section C: /Facility s In the appropriate section (C1, C2, or C3), please list the provider name, BCBSF provider number, the Federal Tax ID and the National Identifier (NPI) for the individual who should receive the 835 Health Care ERA. C1: Professional Association (PA) Group Complete this section if you are a professional group. Only list the group name, BCBSF group provider number, group Tax ID number and group NPI number. C2: Professional Solo Practice Complete this section if you are a professional solo practice (individual provider, laboratory, DME supplier, etc.). C3: Facility/Institution Complete this section if you are a facility/institution. Section D: Availity Access Delegation Complete this section if you are a provider who contracts with a Business Associate authorized to access claims and eligibility data for your patients through the Availity Health Information Network Gateway. Availity Information All HIPAA X12N 835 version 4010 A1 Health Care ERA receivers must be registered with Availity prior to submitting this request form. To register with Availity, please call (800) AVAILITY ( ) or visit their website at 1 2 A vendor is defined as a billing service, clearinghouse or hardware/software support company who receives electronic remittances on behalf of BCBSF providers

3 835 Health Care Electronic Remittance Advice (ERA) Request Form Section A: Type Of Request Initial Request Change: Add Update Remove Note: A Letter of Intent is required to change vendors. See Completion Instructions Section A on the previous page. Section B: Trading Partner Organization Information (Example: Billing, Billing Service, or Clearinghouse) Organization/Sender Name: Organization Address: Contact Name (printed): Contact Signature: Telephone : Fax : Address: BCBSF Sender ID: (5 digit ID starting with G or H)

4 Section C1: Professional Association Group Professional Association Group Name BCBSF Group Group Federal Tax ID Group National Identifier (NPI) Section C2: Professional Solo Practice Professional Solo Practice Name BCBSF Federal Tax ID National Identifier (NPI) Section C3: Facility/Institution Facility/Institution Name BCBSF Federal Tax ID National Identifier (NPI) If additional space is required, please copy this page.

5 Section D: Availity Access Delegation To: From: Tax ID #: Subject: Date: Availity, L.L.C. Availity Access Delegation Authorization Agreement I am currently under contract with [Business Associate] having offices at for their medical billing and other claims-related services. I do hereby authorize [Business Associate] access to claims and eligibility data for my patients through their use of the Availity Health Information Network. I do hereby affirm that all of the necessary consents have been obtained from such patients to grant access to their claims and eligibility data to [Business Associate]. Upon the termination of services provided by [Business Associate] to my practice, I understand it is my responsibility to notify Availity through the execution of the Availity Access Termination Form, which can be provided by the Business Associate currently performing transactions on my behalf or accessed online at Physician or Group Name Title Signature Date