Instructions for Completing the Region D DMERC EDI Customer Profile
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1 Instructions for Completing the Region D DMERC EDI Customer Profile IMPORTANT: Read this before completing your application. Incomplete or incorrect applications will be returned. Application Processing All complete applications are processed within 21 business days from the date the application is received. Incomplete or incorrect applications will be returned. Applications with 100 or more supplier numbers will require an additional 10 business days for processing. Application Tips The entity performing the billing must complete this form. Sections 1, 2, and 9 must be completed for all applications. Section 9 Form Submission: If payment is not required, then mail the completed form(s) to the appropriate address indicated in this section. If payment is required, then mail the check and the customer profile to the appropriate address. Do not fax the form. Miscellaneous : This instruction sheet is for informational purposes and does not need to be returned to the EDI Department. New Submitter Tips To enroll, you must complete both the DMERC EDI Customer Profile (below) and the EDI Enrollment Form. You may access the EDI Enrollment Form at If you want to: You must complete sections: Enroll in electronic billing X X X X A A A A X X = A = Must complete this section Complete this section when applicable Revised 12/15/2003 1
2 Existing Submitter Tips Instructions for Completing the Region D DMERC EDI Customer Profile If you are upgrading to DMACS-837, Region D s HIPAA-ready free billing software You must complete sections 1, 2, and 9. DMACS-837 requires a $5.00 payment for shipping and handling. To ensure accurate processing, send the completed DMERC EDI Customer Profile and a check to Connecticut General Life Insurance Company, PO Box , Pittsburgh, PA If you are changing or adding to your existing profile - Change Customer information o Complete sections 1, 2, and 9 Claim transmission information o Complete sections 1, 2, 4, and 9 Software vendor information o Complete sections 1, 2, 4, 5, and 9 o Fill out both sections if using separate software for the ANSI and NCPDP formats. Add/Remove Supplier number o Complete sections 1, 2, 3, and 9 Additional features (ERNs, Beneficiary Eligibility, and CSI) o Complete sections 1, 2, 3, 6, 7 (if applicable), and 9. o When applying for ERNs, check test or production. o Note: If applying for both beneficiary eligibility DDE and claim status inquiry DDE, the same software (IBM Passport for Windows) is required to access both features. It is only necessary to send $5.00 to cover the shipping and handling cost of the software. o Section 7 is used to authorize a billing service, clearinghouse, or a supplier billing for multiple suppliers, to add features on the client s behalf and to authorize CIGNA Medicare to release patient and/or supplier information electronically to the billing service or clearinghouse. This section must be completed by the supplier, not the billing service or clearinghouse. If you are transmitting claims to another DMERC and want them to automatically transfer to Region D You must complete sections 1, 2, 3, 4, and 9. If applicable, complete sections 5, 6, 7, and 8. If you are transmitting claims directly to Region D, do not check this option. Upgrade to the ANSI X12N v. 4010A1 837 transaction Choose test or production. You must complete sections 1, 2, 4, 5, and 9. Upgrade to the NCPDP v. 5.1 transaction for retail pharmacy drug claims Choose test or production. You must complete sections 1, 2, 4, 5, and 9. Questions? Direct all questions about the Region D DMERC EDI Customer Profile to the EDI Department at , option 1. Revised 12/15/2003 2
3 DMERC EDI Customer Profile IMPORTANT NOTE: Make sure the entity performing the billing actually completes this form. Incomplete or incorrect applications will be returned. PLEASE PRINT (1) General Information I am a (select one) Supplier Billing Service Clearinghouse Software Vendor New Billers Existing Billers (select all that apply) Start billing electronically You must complete sections 1, 2, 3, 4, and 9. If applicable, complete sections 5, 6, 7 and 8. Upgrade to DMACS-837, Region D s HIPAA-ready free billing software** You must complete sections 1, 2, and 9. (2) Customer Information Submitter ID # (required for existing billers) Company Name Change or add to my existing profile Change Customer information complete sections 1, 2, and 9 Claim transmission information complete sections 1, 2, 4, and 9 Software vendor information comp lete sections 1, 2, 4, 5, and 9 Add/Remove Supplier number complete sections 1, 2, 3, and 9 Additional features complete sections 1, 2, 3, 6, 7 (if applicable), and 9 Transmit claims to another DMERC and have them automatically transfer to Region D You must complete sections 1, 2, 3, 4, and 9. If applicable, complete sections 5, 6, 7, and 8. Upgrade to the ANSI X12N v.4010a1 837 transaction Test Production You must complete sections 1, 2, 4, 5, and 9. Upgrade to the NCPDP v.5.1 transaction for retail pharmacy drug claims Test Production You must complete sections 1, 2, 4, 5, and 9. Mailing Address City, State, Zip Phone # ( ) Fax # ( ) Contact Name Revised 12/15/2003
4 DMERC EDI Customer Profile (Continued) (3) Supplier Number(s) List each individual supplier number for which this application applies. Additional supplier numbers may be added by attaching a separate page to this form. Supplier # Supplier # Supplier # Supplier # Supplier # Supplier # Supplier # Supplier # Supplier # (4) Claim Transmission Information (direct communication only) If you are using both the ANSI and NCPDP formats for your claim submission, please mark both boxes below. Format Billing Software ANSI X12N 837 v. 4010A1 (HIPAA-compliant format) Vendor Software (See # 5) Program In-House NCPDP (HIPAA-required format for retail pharmacy drug claims ) DMACS-837 (+ $5.00 S & H)** (5) Software Vendor Information If you marked Vendor Software in the section above, this section must be completed. If you are using a different software vendor for ANSI and NCPDP, please fill out both sections. Company Name Mailing Address Phone # ( ) Fax # ( ) Contact Name Software Name Transaction Format ANSI X12N v. 4010A1 Software Version NCPDP v. 5.1 (for retail pharmacy drug claims) Company Name Mailing Address Phone # ( ) Fax # ( ) Contact Name Software Name Transaction Format ANSI X12N v. 4010A1 Software Version NCPDP v. 5.1 (for retail pharmacy drug claims) Revised 12/15/2003 2
5 DMERC EDI Customer Profile (Continued) (6) Additional Features (to be completed by billing service, clearinghouse or supplier billing for multiple suppliers) NOTE to Billing Services, Clearinghouses, and Suppliers Billing for Multiple Suppliers: If applying for additional features on behalf of your client, then your client must complete and sign section 7*. Electronic Remittance Notice* (ERN) Test Production Format: ANSI X12N 835 v. 4010A1 Suppliers must purchase an ERN software program or develop their own software in order to convert the file into a readable format. This software is not provided by CIGNA Medicare. If a supplier has both Electronic Funds Transfer (EFTs) and ERNs, the supplier will no longer receive paper remittance notices. 1. Would you like to download your file Daily or Weekly? Beneficiary Eligibility Direct Data Entry (DDE)** Format: ANSI X12N 270/271 v. 4010A1 The DDE version is only available through the AT&T Global Network using the communication software provided by CIGNA. The software, IBM Passport for Windows, may be issued to you upon receipt of $5.00 for shipping and handling costs. NOTE: The same software (IBM Passport for Windows) is used for both the Beneficiary Eligibility DDE and Claim Status Inquiry DDE features. If applying for both features, it is only necessary to send $5.00 to cover the shipping and handling cost for the software. Do not send $ EMC Logon ID#: MB 2. RCD # ( complete only if previously assigned) Real Time Mode (Currently unavailable) Suppliers must purchase a software program for this version. This software is not provided by CIGNA Medicare. Claim Status Inquiry (CSI) Direct Data Entry (DDE)** Format: ANSI X12N 276/277 v. 4010A1 The DDE version is only available through the AT&T Global Network using the communication software provided by CIGNA. The software, IBM Passport for Windows, may be issued to you upon receipt of $5.00 for shipping and handling costs. NOTE: The same software (IBM Passport for Windows) is used for both the Beneficiary Eligibility DDE and Claim Status Inquiry DDE features. If applying for both features, it is only necessary to send $5.00 to cover the shipping and handling cost for the software. Do not send $ EMC Logon ID#: MB 2. RCD # ( complete only if previously assigned) Batch Mode Suppliers must purchase a software program for this version. This software is not provided by CIGNA Medicare. Revised 12/15/2003 3
6 DMERC EDI Customer Profile (Continued) (7) Third-Party Authorization for Additional Features (to be completed by client) *NOTE to Billing Services, Clearinghouses, and Suppliers Billing for Multiple Suppliers: If applying for additional features on behalf of your client, then your client must complete and sign this section. If this section is not signed, your application will be returned. I hereby authorize Name of Billing Service/Clearinghouse/Supplier Billing for Multiple Numbers Check all that apply: to receive Electronic Remittance Notices (ERNs) on my behalf. I understand that these transactions contain payment information concerning my processed DMEPOS claims. I also understand that if I am receiving Electronic Funds Transfer (EFTs), my paper remits will be discontinued. to perform any and all functions of Beneficiary Eligibility (DDE or real time mode) on my behalf. I understand that this allows access to information regarding patient eligibility. to perform any and all functions of Claims Status Inquiry (DDE or batch mode) on my behalf. I understand that these transactions allow access to information on both pending and processed DMEPOS claims. I am authorized to endorse this Third-Party Authorization on behalf of the supplier; and acknowledge that it is my responsibility to notify CIGNA Medicare in advance and in writing if I wish to make any changes or revoke this authorization. The supplier or a representative from each supplier's office must sign this form. Other signatures may result in a delay in processing this application. Supplier or Authorized Representative Signature / Supplier # / Date (8) Additional Instructions (9) Form Submission All applications are processed within 21 business days from the date the application is received. Please note that applications with 100 or more supplier numbers will require an additional 10 business days for processing. Please do not include the instruction sheet with this application. If you are not purchasing software, then mail the completed form to: CIGNA Medicare Attn: EDI Department PO Box 49 Boise, ID DO NOT MAIL CHECKS TO THIS ADDRESS. Do not fax this form. If you are purchasing software, mail the completed form and your check to: Connecticut General Life Insurance Company PO Box Pittsburgh, PA Make check payable to CIGNA. **Payment is required. Send both the completed EDI Customer Profile and your check to the address above. To ensure accurate processing, all checks must be accompanied by a completed EDI Customer Profile. Revised 12/15/2003 4
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