Agreement to send electronic Colorado Medicare

Size: px
Start display at page:

Download "Agreement to send electronic Colorado Medicare"

Transcription

1 Agreement to send electronic Colorado Medicare This agreement must be completed and approved by Medicare prior to receiving electronic remittance advice from Colorado Medicare through Secure EDI. Instructions for completing this form: 1. Page 4 1. Provider Data Fill out the Demographic information. Make sure they include the NPI # and check the correct state. 2. EDI Software Data LEAVE BLANK! 3. EDI Billing Service/ CLEARINGHOUSE DATA THIS SHOULD BE PRE FILLED IN OUR INFORMATION. 4. Provider must sign and date. If signed be anyone other than provider, this must be for a group, and they must be authorized by the payer (in other words on file with the payer as authorized to sign) 5. Page 5, 6 only writing but MUST be mailed in. 6. Page 7 Again pretty much a copy of page 4 s information. Add the Medicare group # here (if they are a group) and use the Group NPI # (if they are a group) 7. Page 8 only writing but MUST be mailed in. 8.Page 9 - LEAVE BLANK!! 9. Page 10, 11 only writing but MUST be mailed in 10. Page 12 this should be OUR information, Under Software LEAVE BLANK 11 Page 13 LEAVE BLANK If the Provider fills this in they will be rejected and ask to fill in additional paper work! And the last page is OURS please fill out with all of the providers you will billing for this is the only place we get the tax id. After completing the agreement mail the original agreement to: Secure EDI ATTN: Enrollment Dept. 200 S. Tryon St Suite 1700 Charlotte, NC If you have questions concerning this agreement, call Secure EDI at CO_Mcare ERA/ENS: Rev. 03/08

2 Colorado Medicare Provider List Although the Payer does not request this information, ENS must have each provider s individual number for set-up. Please complete the requested information below. Provider numbers are required prior to completing this agreement. Do not list provider numbers as pending. Group Name: Group Tax ID: Group Medicare Provider Number: Please all providers billing under the group number listed above: Provider Name: Individual Medicare Number: Noridian Provider list ENS*3/06

3 A CMS Contracted Intermediary and Carrier Medicare Electronic Data Interchange Department Dear Provider: Thank you for your interest in Electronic Media Claims (EMC). Enclosed is a summary of the available electronic claims services for Medicare Part A/B providers. Also enclosed are the necessary applications, enrollment forms and instructions for their completion. Section 1 - General EDI Enrollment Documents contains the required enrollment documents that must be completed, signed and returned to our office prior to initiation of electronic claims submission or inquiry. Section 2 - Free Billing Software Section 3 - Testing Requirements The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from Medicare must be submitted electronically as of October 16, 2003, with limited exceptions. TrailBlazer Health Enterprises, LLC accepts Medicare claims submitted electronically using the ANSI ASC X12N 837 v4010a1 format. We are committed to making your transition to EMC as smooth as possible. If you have any questions regarding the information contained in this package, please feel free to contact the TrailBlazer EDI Technology Support Center toll free at (866) Be Compliant: Take Control of your Accounts Receivable Sign up today to receive your remittances electronically and be ahead of the game. Download and print your remittances more quickly. CMS is focused on increasing the number of providers who receive their remittances electronically and on decreasing the printing and mailing costs associated with hard copy remittances. Complete your forms today! Important Note on Staying Up-To-Date Online Register on the TrailBlazer Web site ( to receive EDI news electronically. By selecting Listserv (which displays at the top of all pages) and completing a user profile, you will be notified via when new or important EDI information is added to our Web site. If you have already registered, please ensure your profile has been updated for all new applicable EDI categories. TrailBlazer Health Enterprises, LLC Revision 13, January 2008 SY-QSF GEDI TrailBlazer Part A/B EDI Enrollment Packet

4 TRAILBLAZER HEALTH ENTERPRISES, LLC SECTION 1 GENERAL EDI ENROLLMENT DOCUMENTS The following documents are required to enroll for EDI: Medicare Electronic Data Interchange Application The purpose of the EDI application is to enroll providers, software vendors, clearinghouses and billing services as electronic submitters. Please follow the instructions carefully when completing the application. Incomplete forms will be returned to the applicant, thus delaying processing. Medicare Electronic Data Interchange Enrollment Agreement The EDI enrollment agreement should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the provider to ensure each is knowledgeable of the enrollment request and the associated requirements: o If the submitter will be submitting for multiple providers, each provider whose claim data will be submitted must complete this form. o The entire form must be read carefully and then dated with the day, month and year. o The name of the provider (an authorized officer s name) must be printed in the space provided and that authorized officer s title and signature must also be included. o When completed, all three pages of the properly executed EDI enrollment agreement must be returned with the EDI application form. Providers who have contracted with a third party (clearinghouse/network service vendor or a billing agent) are required to have that third party sign an agreement in which they agree to meet the same Medicare security and privacy requirements that apply to the provider in regard to viewing or use of Medicare Beneficiary data. These agreements are not to be submitted to Medicare, but are to be retained by the providers. Providers are obligated to notify Medicare by fax or hard copy of: Any changes in their billing agents or clearinghouses. The effective date they will discontinue using a specific billing agent or clearinghouse. If they want to begin using additional types of EDI transactions. Other changes that might impact their use of EDI. Providers are not required to notify Medicare if their existing clearinghouses begin to use alternate software. The clearinghouses are responsible for notification in this instance. Note: The binding information in an EDI Enrollment Form does not expire if the person who signed the form for a provider is no longer employed by the provider. The EDI Application Process Step 1: Complete the EDI application. Step 2: Complete and sign the Medicare Electronic Data Interchange Enrollment Agreement.The Medicare provider must complete and sign this form. Step 3: Complete documents and fax or mail to the following address: Fax Number MAILING ADDRESS DELIVERY ADDRESS (410) TrailBlazer Health Enterprises, LLC TrailBlazer Health Enterprises, LLC EDI Department EDI Department P.O. Box 4898 Timonium II 6 th floor Timonium, MD Greenspring Drive Timonium, MD TrailBlazer Health Enterprises, LLC Page 2

5 Step 4: Retain the completed forms for your records. Processing an EDI application will take five business days from the date of receipt. When processing is complete, you will receive a notification by fax or mail. New electronic submitters and software vendors will be informed of any testing requirements. Electronic Data Interchange Application Instructions Please retain a copy of this completed form for your records. You must submit a completed EDI application form when submitting additional EDI forms. The field descriptions listed below will aid in properly completing the application. Please follow these instructions closely. The Medicare Electronic Data Interchange Application is required. The Multiple Provider List should be used if you are listing additional providers on your application. Providers are not permitted to share their personal EDI access number (submitter ID) or password with: Any billing agent, clearinghouse/network service vendor. To anyone on their staffs who has no need to see the data for completion of a valid electronic claim, to process a remittance advice for a claim, to verify beneficiary eligibility or to determine the status of a claim. Any non-staff individual or entity. The EDI submitter ID and password act as an electronic signature; therefore, the provider would be liable if any entity performed an illegal action while using that EDI submitter ID and password. Likewise, a provider s EDI submitter ID and password is non-transferable, meaning it may not be given to a new owner of the provider s operation. New owners must obtain their own EDI submitter ID and password. Form Field Name Instructions for Field Completion 1. Provider Data Complete the date, provider s name, address, primary contact, phone, fax and address. Check the Part A or Part B Provider indicator box. Check the appropriate state indicator box. Indicate the National Provider Identifier (NPI). Action Requested: Please indicate appropriate request below: o Provider is Submitter Provider submits claims directly from his office). o Provider is with billing service/clearinghouse. o Provider is with other providers (list provider numbers). o Remove provider from Submitter ID (provide Submitter ID). 2. EDI Software Vendor Data 3. EDI Billing Service/Clearing house Data Indicate the name of the software vendor you will use for electronic claim submission to TrailBlazer. If you will use our free PC-ACE Pro32, write PC-ACE Pro32 in this field. If the vendor ID is known, enter the assigned ID; PC-ACE users may leave this field blank. Indicate the name, primary contact, phone, fax and submitter/password of the billing service or clearinghouse that will be communicating with TrailBlazer. Do not forget to sign and date the bottom of the form. TrailBlazer Health Enterprises, LLC Page 3

6 Г Г Medicare Part A/B EDI Enrollment Packet EDI Provider Information Form 1. Provider Data (to be completed by Provider) Date: Name: Address: City, State, ZIP: Primary Contact: Phone Number: Fax Number: Address: Please Check One: Part A Provider Part B Provider Please Check Applicable State: CO DC DE MD NM OK TX VA NPI (National Provider Identifier): Provider Number: Action Requested: Provider is Submitter (Provider submits claims directly from their office) Provider is with Billing Service/Clearinghouse (Section 3 must be completed) Provider is with other Providers (list NPI # s: ) Remove Provider from Submitter id: 2. EDI Software Vendor Data (to be completed by Vendor) Company Name: Primary Contact: Phone: Fax: Vendor Code: 3. EDI Billing Service/Clearinghouse Data (to be completed by Billing Service/Clearinghouse) Company Name: Primary Contact: Phone: Fax: Submitter ID: Password: I certify that I am legally empowered to sign this form on behalf of the Legal Business Name identified on this form. I acknowledge that in signing this, I bind this company or unincorporated organization to notify the Medicare contractor in advance and in writing if changes have occurred to information reported in this form or if it is necessary to revoke any designations made in the form. I certify that the information I have supplied is accurate. As a Medicare provider/supplier, I understand that in signing this form I am responsible for payment of any fees for EDI services charged by a designated EDI submitter/receiver with whom I have elected to conduct business. I also understand that any acknowledgement, error reports, or query responses related to submitted transactions will be returned to any designated EDI submitter/receiver with whom I have authorized on this form and that Medicare contractors are not permitted to send duplicate copies of outbound transactions to my organization as well as to the designated EDI submitter/receiver. Signature Printed Name Date Title TrailBlazer Health Enterprises, LLC Page 4

7 Medicare Electronic Data Interchange Enrollment Agreement The undersigned provider agrees to the following provisions for submitting Medicare claims electronically to CMS or its contractors. A. The Provider Agrees: 1. That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contactor by itself, its employees, or its agents. 2. That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS and/or its carriers, DMERC, FIs or another contractor if so designated by CMS, without the express written permission of the Medicare beneficiary or his/her parent or legal guardian, or where required for the care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to Medicare, or as required by State or Federal law. 3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file. 4. That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect the following information: Beneficiary s name. Beneficiary s health insurance claim number. Date(s) of service. Diagnosis/nature of illness. Procedure/service performed. 5. That the Secretary of Health and Human Services or his/her designee and/or the carriers, DMERC, FIs or other contractor if designated by CMS has the right to audit and confirm information submitted by the provider and shall have access to all original source documents and medical records related to the provider s submissions, including the beneficiary s authorization and signature. All incorrect payments that are discovered as a result of such an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and CMS guidelines. 6. That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that Medicare is the primary payer. 7. That it will submit claims that are accurate, complete, and truthful. 8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid. 9. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically transmitted to the carriers, DMERC, FIs or another contractor if so designated by CMS. TrailBlazer Health Enterprises, LLC Page 5

8 10. That the CMS-assigned unique identifier number (submitter identifier) constitutes the provider s legal electronic signature and constitutes an assurance by the provider that services were performed as billed. 11. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access. 12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim for payment under the Medicare program, and that anyone who misrepresents or falsifies or causes to be misrepresented or falsified any record or other information relating to that claim that is required pursuant to this Agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law. 13. That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from CMS or its carrier, DMERC or FI or other contractors if designated by CMS, shall not be used by agents, officers, or employees of the billing service except as provided by carrier, DMERC or FI or other contractors if designated by CMS (in accordance with 1106(a) of the Social Security Act (the Act). 14. That it will research and correct claim discrepancies. 15. That it will notify the carrier, DMERC or FI or other contractors if designated by CMS or CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form. B. The Centers for Medicare & Medicaid Services will: 1. Transmit to the provider an acknowledgement of claim receipt. 2. Affix the FI/carrier/DMERC or other contractor if designated by CMS number, as its electronic signature, on each remittance advice sent to the provider. 3. Ensure that payments to providers are timely in accordance with CMS s policies. 4. Ensure that no carrier, DMERC, FI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from the carrier, DMERC, FI, or other contractor if designated by CMS or from any subsidiary of the carrier, DMERC, FI, or other contractor if designated by CMS or from any company for which the carrier, DMERC, or FI has an interest. The carrier, DMERC, FI, or other contractor if designated by CMS will make alternative means available to any electronic biller to obtain such services. 5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare carrier, DMERC, FI, or other contractor if designated by CMS to make available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal access will be granted to any services the carrier, DMERC, FI, or other contractor if designated by CMS sells directly, indirectly, or by arrangement. 6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form. TrailBlazer Health Enterprises, LLC Page 6

9 Notice: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by the CMS under this document. This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to carrier, DMERC, FI, or other contractor if designated by CMS. Either party may terminate this arrangement by giving the other party (30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal. C. Signature I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and acknowledge same by signing below. Provider/Supplier Name: Address: City/State/ZIP: Phone: Authorized Signature: By (Print Name): Title: Date: Medicare Provider Number National Provider Identifier (NPI) Complete this form and mail or fax to: TrailBlazer Health Enterprises, LLC EDI P.O. Box 4898 Timonium, MD (410) (fax) TrailBlazer Health Enterprises, LLC Page 7

10 TRAILBLAZER HEALTH ENTERPRISES, LLC SECTION 2 FREE BILLING SOFTWARE AND OTHER SERVICES PC-ACE Pro32 Claim Submission Software Medicare provides free electronic claims submission software PC-ACE Pro32. Features of PC-ACE Pro32 include: User-friendly system with extensive help screens and a manual providing step-by-step instructions. No charge when downloaded from or for a nominal charge when requested via CD-ROM. Transmission of claims via telephone lines with modem speeds ranging from 9600 bps to 56k bps. Transmission lines are available 24 hours a day, seven days a week. Minimum system requirements: 133 MHz processor (Pentium II-350 for larger claim volume). SVGA monitor resolution (800 x 600)*. Windows 95, 98, 2000, Me, XP or NT 4.0 operating system. 64 MB system memory (128 MB recommended). CD-ROM Drive. Adobe Acrobat Reader Version 4.0 or later (for overlaid claim printing). When the Windows Large Fonts display setting is enabled, the screen resolution must be 1024 x 768 or greater. The UB-92 / UB-04/HCFA 1500 Claim Form(s) will not display properly at lower screen resolutions. Notice: PC-ACE Pro32 was not developed for network use. Technical support will not be provided for users who install Pro32 on a network. You must obtain all assistance from your network administrator. Pro32 software may be obtained from the TrailBlazer Web site at: %20Manuals/. If unable to obtain software from the TrailBlazer Web site, complete the order form and send it, along with a check for $25 made payable to TrailBlazer Health Enterprises to: TrailBlazer Health Enterprises, LLC EDI P.O. Box 4898 Timonium, MD Gateway Production Network (GPNet) Communication Instructions The GPNet Communications Manual is available for download from Adobe Acrobat Reader must be installed on your PC to view and print the manual. To print or save the file, use the Acrobat toolbar inside the browser window. The GPNet Edit Manual includes a list of GPNet edit codes and descriptions that may appear on the GPNet Response Report. The GPNet Edit Manual is also available for download from the TrailBlazer Web site. Adobe Acrobat Reader must be installed on your PC to view and print the manual. To print or save the file, use the Acrobat toolbar inside the browser window TrailBlazer Health Enterprises, LLC Page 8

11 PC-ACE Pro32 Software CD Request Form I have read and understand the system requirements for the free PC-ACE Pro32 software and I have verified that my system meets the minimum equipment requirements to submit my claims electronically using the Pro32 software. Submitter Name: Date: Provider NPI: Provider Name: Type Of Submitter: Provider is submitter (Provider submits own claims) Provider is with other providers: Billing Service/Clearinghouse Contact Person: Address: City: State: ZIP: Phone: Fax: Address: Application cannot be processed without the EDI Provider Information Form and EDI agreement. To order PC-ACE Pro32 software, complete this form and send it, along with a check for $25 made payable to TrailBlazer Health Enterprises to: TrailBlazer Health Enterprises, LLC Attn: EDI P.O. Box 4898 Timonium, MD TrailBlazer Health Enterprises, LLC Page 9

12 TRAILBLAZER HEALTH ENTERPRISES, LLC SECTION 3 TESTING REQUIREMENTS New EDI Submitters and Software Vendors New EDI vendors and submitters, including providers who have programmed their own systems, are required to complete a testing phase to ensure accurate format and claims data quality before production status can be granted. Once the vendor or submitter is granted approved status, they can enroll new providers without additional testing. Test files should contain a minimum of 25 claims representative of the types of claims the provider would normally submit to Medicare. Test claims will be validated against production files; therefore, all claims must contain valid data. Since test claims will not be processed for payment, live claims may be used. Testing validates the ability of a file to pass the Gateway Production Network (GPNet) edits. Format testing checks for the following: Layout of file. Password to submitter ID. Version numbers. Record sequencing. Balancing. Batch types. Batch type to files. Batch ID. Duplicate batches. Numeric fields. Date fields. Relationship edits. Field values. The submitter of the test file must monitor the response file after each test submission to determine format and/or data elements to be corrected and retested. Test results for telecommunicated submissions will be returned at the time of transmission. You will not receive any other form of notification for initial test results. Testing Procedure Submit an appropriate test file to GPNet using your assigned vendor or submitter ID number. Download and monitor the 997 Functional Acknowledgement and GPNet Claim Response reports after submission of the test file. Once a test file has been accepted with no errors, complete the enclosed Production Request Form. An EDI analyst will verify the test submissions for accuracy and send a fax confirmation of your status within three (3) business days. Do not attempt to submit production claims until you receive this notification. For Part B Providers: In addition to the fields required for specific specialties, we request that test files include (where applicable): Multiple Place of Service (11, 12, 21, 22, 32 ). Referring Universal Provider Identification Numbers (UPINs) (X-ray, lab, consults, physical therapy). Medigap for participating providers. TrailBlazer Health Enterprises, LLC Page 10

13 Secondary insurance (BCBS, Med. Assistance, Commercial). Medicare Secondary Payer (MSP) claims (paid and allowed amounts, insurance type code). Narratives. Modifiers. Assistant surgery (Mod 80 with facility ID). Multiple surgeries. Solo practice. Group practice (with performing National Provider Identifier (NPI)). Purchased test (with indicator, amount, NPI). Twelve detail lines. Anesthesia/Certified Registered Nurse Anesthetist (CRNA) (with modifiers, minutes). Independent labs. Independent radiology. Reference labs. Ambulance Must include mileage, supplies, round trip, transfers and special billings (e.g., waiting time) if these services are routinely rendered. Podiatry. Chiropractic. Physical therapy. Exclusive Provider Organization (EPO) (with initial EPO visits). Existing EDI System Vendors and Submitters Testing Although we do not require approved system vendors and submitters to test new providers, we encourage all vendors and submitters to test new versions, formats and/or enhancements to their software programs to ensure their electronic claims software continues to meet format and quality standards. Vendors can use their six-digit vendor IDs as the submitter IDs to transmit a file for test purposes. TrailBlazer Health Enterprises, LLC Page 11

14 EDI Systems Vendor/Submitter Enrollment Form Fax Completed Form To: (410) Add Update Business Name: Part A Provider Part B Provider Vendor Billing Service Submitter Clearinghouse Provider(s) - More than one provider billing independent from same office. List all providers at bottom. Address: City, State, ZIP: Vendor/Submitter #: Primary Contact s Name: Password: Phone: ( ) Fax: ( ) Vendor Name: Address: City, State, Zip: Contact: SOFTWARE Phone: ( ) Fax: ( ) Requested Response Format GPNet Claim Acceptance Response: File Format Report Format ANSI X12 997* * This response is sent in addition to the GPNet Claim Acceptance Response in report format. Mode: ASYNC NDM Data Compression To receive files compressed for faster transmission, please indicate which data compression utility you support: PKZIP version 2.04g or compatible UNIX-Compress TrailBlazer Health Enterprises, LLC Page 12

15 EDI Production Request Form I have completed claims testing and received a response file with no rejected claims or warnings. Fax completed form to: (410) Date: Please complete the information requested below to update your status from test to production. You will be notified within three (3) business days by fax confirmation. EDI Submitter/Vendor ID(s): Contact Person: Office Phone: Fax: Date(s) of Test Transmission(s): File ID(s): Please List the NPI (s) used for Testing: Name of EDI Analyst (if known): Technology Support Center (toll free): (866) TrailBlazer Health Enterprises, LLC Page 13

Dear Provider, Vendor, Clearinghouse or Billing Service:

Dear Provider, Vendor, Clearinghouse or Billing Service: Dear Provider, Vendor, Clearinghouse or Billing Service: Thank you for your interest in Electronic Media Claims (EMC). Enclosed is a summary of the available electronic claims services for Medicare Part

More information

MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085

MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085 MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 5 business days after receipt. WHAT FORM(S) SHOULD I COMPLETE? IF you have

More information

Payer Agreement Instructions for Trailblazer Medicare Payers

Payer Agreement Instructions for Trailblazer Medicare Payers Capario EDI 1901 E. Alton Ave. #100 Santa Ana, CA. 92705 Phone: (800) 792-5256 Option 1 Fax: (404) 877-3324 provider.enrollment@capario.com Payer Agreement Instructions for Trailblazer Medicare Payers

More information

CO & TX Medicare. Complete the form, sign, and mail original to: EDI Operations, AG-507 PO Box 100249 Columbia, SC 29209-3249

CO & TX Medicare. Complete the form, sign, and mail original to: EDI Operations, AG-507 PO Box 100249 Columbia, SC 29209-3249 CO & TX Medicare Complete the form, sign, and mail original to: EDI Operations, AG-507 PO Box 100249 Columbia, SC 29209-3249 Blank forms may be copied. Call Lindsay Technical Consultants, Inc. (888)941-8967,

More information

Agreement to Send Electronic Florida Medicare

Agreement to Send Electronic Florida Medicare Agreement to Send Electronic Florida Medicare Instructions for completing this form: 1. Complete one agreement for the group. 2. Please complete the following: EDI Enrollment Form, Section C Complete the

More information

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name Tax ID

More information

J1 EDI Application Form Instructions

J1 EDI Application Form Instructions J1 EDI Application Form Instructions The purpose of the J1 EDI Application Form is to enroll providers, software vendors, clearinghouses and billing services as electronic submitters and recipients of

More information

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS Notification Secure EDI provides this agreement as a courtesy for our customers. We make every effort to keep these forms updated however; the payer may not always notify us when changes have been made

More information

MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002

MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002 MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is approximately 4 6 weeks. WHAT FORM SHOULD I DO? EDI Enrollment Agreement

More information

Dear Provider, Thank you for your interest in Electronic Data Interchange (EDI).

Dear Provider, Thank you for your interest in Electronic Data Interchange (EDI). A CMS Contracted Intermediary and Carrier Dear Provider, Thank you for your interest in Electronic Data Interchange (EDI). Section 1 contains the required enrollment documents that must be completed, signed

More information

Attention: Please Read Before Completing Paperwork. Take Control of your Accounts Receivable and Become Compliant Now!

Attention: Please Read Before Completing Paperwork. Take Control of your Accounts Receivable and Become Compliant Now! A RRB-Contracted Specialty Medicare Administrative Contractor Technology Support Center 866-749-4301 RAILROAD MEDICARE PART B EDI ENROLLMENT PACKET Attention: Please Read Before Completing Paperwork Enrollment

More information

Railroad Medicare Palmetto GBA 837 and 835

Railroad Medicare Palmetto GBA 837 and 835 Payer ID: RRMCR Palmetto GBA 837 and 835 EDI Enrollment Instructions: Please save this document to your computer. Open the file in the Adobe Reader program and type directly onto the form. Complete the

More information

EDI Change Form Instructions

EDI Change Form Instructions EDI Change Form Instructions The change form is to be used to: a) change trading partner or vendor information, OR b) add additional provider numbers or transactions Section 1 Trading Partner Information:

More information

Agreement to send electronic Southern California Medicare Claims

Agreement to send electronic Southern California Medicare Claims Agreement to send electronic Southern California Medicare Claims This agreement must be completed and approved by Southern California Medicare prior to sending electronic Southern California Medicare claims

More information

NHIC EDI PROFILE FORM

NHIC EDI PROFILE FORM NHIC Document Name: DME EDI Profile Form Doc. Number: FRM-EDI-0019 Release Date: 6/15/2007 Version: 3.0 Please complete and MAIL with an: EDI PROFILE FORM 1) EDI Enrollment Form (Original Signature Required)

More information

Blank forms may by copied. Be sure to use blue ink for signatures.

Blank forms may by copied. Be sure to use blue ink for signatures. Montana Blue Cross Blue Shield/Medicare Complete form, sign and mail original to: Health-e-Web Attn: Marketing P.O. Box 4309 Helena, MT 59604 Blank forms may by copied. Be sure to use blue ink for signatures.

More information

MEDICARE MAINE PRE-ENROLLMENT INSTRUCTIONS - 14102

MEDICARE MAINE PRE-ENROLLMENT INSTRUCTIONS - 14102 MEDICARE MAINE PRE-ENROLLMENT INSTRUCTIONS - 14102 HOW LONG DOES PRE-ENROLLMENT TAKE? Approximately 3 weeks WHERE SHOULD I SEND THE FORMS? Fax the forms to NHIC Corp. at 781-741-3523, or; Mail the forms

More information

MEDICARE MASSACHUSETTS PRE-ENROLLMENT INSTRUCTIONS - 14202

MEDICARE MASSACHUSETTS PRE-ENROLLMENT INSTRUCTIONS - 14202 MEDICARE MASSACHUSETTS PRE-ENROLLMENT INSTRUCTIONS - 14202 HOW LONG DOES PRE-ENROLLMENT TAKE? Approximately 3 weeks WHERE SHOULD I SEND THE FORMS? Fax the forms to NHIC Corp. at 781-741-3523, or; Mail

More information

MEDICARE PART B - North Carolina PRE-ENROLLMENT INSTRUCTIONS 11052

MEDICARE PART B - North Carolina PRE-ENROLLMENT INSTRUCTIONS 11052 MEDICARE PART B - North Carolina PRE-ENROLLMENT INSTRUCTIONS 11052 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 4-6 weeks. WHERE SHOULD I SEND THE FORMS? Mail the form to: Palmetto GBA

More information

Jurisdiction D EDI Customer Profile Instructions

Jurisdiction D EDI Customer Profile Instructions Jurisdiction D EDI Jurisdiction D EDI Customer Profile Instructions IMPORTANT: Read the instructions before completing your applications. Incomplete or incorrect applications will be returned. The entity

More information

DMERC EDI ENROLLMENT PACKET

DMERC EDI ENROLLMENT PACKET MEDICARE Part A Intermediary Part B Carrier DME Regional Carrier DMERC EDI ENROLLMENT PACKET Attention: Please Read Before Completing Paperwork There are two addresses for the submission of paperwork.

More information

Advanced Billing Consultants, Inc. New Client Workbook. New Client Worksheet & Technical Information Worksheet

Advanced Billing Consultants, Inc. New Client Workbook. New Client Worksheet & Technical Information Worksheet Advanced Billing Consultants, Inc. New Client Workbook New Client Worksheet & Technical Information Worksheet New Client Worksheet **Please fill out this form completely and email it to forms@advancedbillingconsultants.com

More information

Chapter 4: Electronic Data Interchange

Chapter 4: Electronic Data Interchange Electronic Billing NOTE: ELECTRONIC CLAIM SUBMISSION IS REQUIRED UNDER SECTION 3 OF THE ADMINISTATIVE SIMPLIFICATION COMPLIANCE ACT (ASCA), PUB.L. 107-105, AND THE IMPLEMENTING REGULATION AT 42 CFR 424.32.

More information

BlueCross BlueShield of Tennessee Electronic Provider Profile

BlueCross BlueShield of Tennessee Electronic Provider Profile Date: Business Name: SECTION 1 PURPOSE FOR PROFILE Please PLACE A CHECK MARK using blue or black ink by the purpose for completing the. The chart below indicates with an X the sections that need to be

More information

Instructions for Completing the Region D DMERC EDI Customer Profile

Instructions for Completing the Region D DMERC EDI Customer Profile 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

More information

J11 EDI Application Form Instructions

J11 EDI Application Form Instructions J11 Instructions The purpose of the J11 is to enroll providers, software vendors, clearinghouses and billing services as electronic submitters and recipients of electronic claims data. It is important

More information

Agreement to send electronic Colorado Medicaid medical claims

Agreement to send electronic Colorado Medicaid medical claims Agreement to send electronic Colorado Medicaid medical claims This agreement must be completed and approved by Colorado Medicaid prior to sending electronic Colorado Medicaid claims through Secure EDI.

More information

Electronic Data Interchange Agreement

Electronic Data Interchange Agreement Electronic Data Interchange Agreement F00021 DO NOT FAX ALL ATTACHED FORMS MUST BE SENT BY MAIL TO TMHP AT THE FOLLOWING ADDRESS: Texas Medicaid & Healthcare Partnership Attention: EDI Help Desk, MC B14

More information

Companion Guide Trading Partner Information

Companion Guide Trading Partner Information Companion Guide Trading Partner Information ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) v.5010 Table of Contents Preface... 2 1. Getting Started... 3 1.1 Where to Get

More information

Electronic Data Interchange

Electronic Data Interchange West Region Electronic Data Interchange Electronic Data Services 1717 W. Broadway P.O. Box 8128 Madison, WI 53708-8128 www.wpsic.com/edi/edi_home.shtml Table of Contents Getting Started with Electronic

More information

Medicare Claims Processing Manual

Medicare Claims Processing Manual Medicare Claims Processing Manual Chapter 24 General EDI and EDI Support Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims Transmittals for Chapter 24 Table of Contents

More information

EDI Support Services. PC-ACE Pro32 User Guide. Welcome to PC-ACE Pro32. System Requirements. Connectivity Options

EDI Support Services. PC-ACE Pro32 User Guide. Welcome to PC-ACE Pro32. System Requirements. Connectivity Options EDI Support Services PC-ACE Pro32 User Guide Welcome to PC-ACE Pro32 The PC-ACE Pro32 Claims Management System, Electronic Data Interchange Support Services (EDISS) free/low-cost billing software, is a

More information

Electronic Data Interchange (EDI) Enrollment Packet

Electronic Data Interchange (EDI) Enrollment Packet Electronic Data Interchange (EDI) Enrollment Packet This enrollment packet consists of the following: 1. Delta Dental State Government Programs Telecommunications Provider and Biller Application/ Agreement

More information

Request to Send Electronic North Carolina Medicaid Claims

Request to Send Electronic North Carolina Medicaid Claims Request to Send Electronic North Carolina Medicaid Claims This agreement must be completed and approved by Medicaid prior to sending claims through Secure EDI Instructions for completing this form: PLEASE

More information

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS Notification Secure EDI provides this agreement as a courtesy for our customers. We make every effort to keep these forms updated however; the payer may not always notify us when changes have been made

More information

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS. Select if this is a new application, change of submitter, update.

SECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS. Select if this is a new application, change of submitter, update. Notification Secure EDI provides this agreement as a courtesy for our customers. We make every effort to keep these forms updated however; the payer may not always notify us when changes have been made

More information

Enrollment Guide for Electronic Services

Enrollment Guide for Electronic Services Enrollment Guide for Electronic Services 2014 Kareo, Inc. Rev. 3/11 1 Table of Contents 1. Introduction...1 1.1 An Overview of the Kareo Enrollment Process... 1 2. Services Offered... 2 2.1 Electronic

More information

Please look for comments in yellow boxes below to see how your service with RemitDATA is protected under this latest CMS communication.

Please look for comments in yellow boxes below to see how your service with RemitDATA is protected under this latest CMS communication. Please look for comments in yellow boxes below to see how your service with RemitDATA is protected under this latest CMS communication. Related Change Request (CR) #: N/A Medlearn Matters Number: SE0461

More information

EPS EFT Enrollment Authorization Agreement

EPS EFT Enrollment Authorization Agreement EPS EFT Enrollment Authorization Agreement Optum is improving service to you by replacing paper checks and Explanation of Benefits (EOBs) with the Optum EPS solution. Get a head start by enrolling today!

More information

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS CHAPTER 7 (E) DENTAL PROGRAM CHAPTER CONTENTS 7.0 CLAIMS SUBMISSION AND PROCESSING...1 7.1 ELECTRONIC MEDIA CLAIMS (EMC) FILING...1 7.2 CLAIMS DOCUMENTATION...2 7.3 THIRD PARTY LIABILITY (TPL)...2 7.4

More information

Mail the form to MDOL with original authorized provider signature in blue ink only. Forms not signed in blue ink will reject.

Mail the form to MDOL with original authorized provider signature in blue ink only. Forms not signed in blue ink will reject. CALIFORNIA MEDICAID / MEDI-CAL EDI CONTRACT INSTRUCTIONS (SKCA0) MAIL the completed and signed forms to: MD On-Line ATTN: Enrollment 6 Century Drive 2 nd Floor Parsippany, NJ 07054 DO NOT MAIL THIS FORM

More information

National Government Services, Inc. Durable Medical Equipment Common Electronic Data Interchange. Vendor and Trading Partner Frequently Asked Questions

National Government Services, Inc. Durable Medical Equipment Common Electronic Data Interchange. Vendor and Trading Partner Frequently Asked Questions National Government Services, Inc. Durable Medical Equipment Common Electronic Data Interchange Vendor and Trading Partner National Government Services, Inc. was awarded the Durable Medical Equipment (DME)

More information

SOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0)

SOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0) SOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0) Please carefully read all instructions before beginning. The documents in this top section must be completed and sent to MD On-Line with your contract.

More information

How to Complete the Medicare CMS-855I Enrollment Application. Presented by Provider Outreach & Education and Provider Enrollment

How to Complete the Medicare CMS-855I Enrollment Application. Presented by Provider Outreach & Education and Provider Enrollment How to Complete the Medicare CMS-855I Enrollment Application Presented by Provider Outreach & Education and Provider Enrollment Welcome Welcome to the Computer-Based Training (CBT) module for Provider

More information

Request to Send Electronic Dean Health Plan (DEAN1) Claims

Request to Send Electronic Dean Health Plan (DEAN1) Claims Request to Send Electronic Dean Health Plan (DEAN1) Claims This agreement must be completed and approved prior to sending electronic Dean Health Plan claims through Secure EDI. Instructions for completing

More information

SECTION 4. A. Balance Billing Policies. B. Claim Form

SECTION 4. A. Balance Billing Policies. B. Claim Form SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing

More information

INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM

INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM Entity / Business Louisiana s Medicaid Program INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM Prior to submitting

More information

MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032

MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032 MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? EDI Provider Agreement and Enrollment Form

More information

GETTING STARTED WITH EDISS AND TOTAL ONBOARDING (TOB)

GETTING STARTED WITH EDISS AND TOTAL ONBOARDING (TOB) GETTING STARTED WITH EDISS AND TOTAL ONBOARDING (TOB) Table of Contents What is an electronic transaction?...2 What forms will be required for EDISS registration now that TOB is effective for most lines

More information

MEDICAID MARYLAND MHA (PMHS) PRE ENROLLMENT INSTRUCTIONS 77062

MEDICAID MARYLAND MHA (PMHS) PRE ENROLLMENT INSTRUCTIONS 77062 MEDICAID MARYLAND MHA (PMHS) PRE ENROLLMENT INSTRUCTIONS 77062 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 week. Medicaid Maryland PMHS is administered by Value Options. WHAT FORMS

More information

COLORADO MEDICAL ASSISTANCE PROGRAM

COLORADO MEDICAL ASSISTANCE PROGRAM COLORADO MEDICAL ASSISTANCE PROGRAM DSH Electronic Data Interchange (EDI) Submitter Enrollment & Agreement The Colorado Medical Assistance Program PO Box 1100 Denver, Colorado 80201-1100 1-800-237-0757

More information

****************************************** **************ATTENTION************** ******************************************

****************************************** **************ATTENTION************** ****************************************** 4/4/2006 Cover Page 1 PAYER ID: SKNJ0 SUBMITTER: 9902201 NEW JERSEY MEDICAID MEDICAL **************ATTENTION************** THIS PAYER EDI AGREEMENT MUST BE PROCESSED THROUGH EMDEON S PAYER ENROLLMENT DEPARTMENT.

More information

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name Tax ID

More information

Wyoming Medicaid EDI Application

Wyoming Medicaid EDI Application Wyoming Medicaid EDI Application Please type or block print the requested information as completely as possible. If any field is not applicable, please enter N/A. An incomplete form may delay the approval

More information

DENTAL COLORADO MEDICAID EDI UPDATE

DENTAL COLORADO MEDICAID EDI UPDATE 220 Burnham Street South Windsor CT 06074 Vox 888-255-7293 Fax 860-289-0055 DENTAL COLORADO MEDICAID EDI UPDATE PAYER ID NUMBER CKCO1 ELECTRONIC REGISTRATIONS Agreements Required PROVIDER ENROLLMENT FORM

More information

RAILROAD MEDICARE PRE- ENROLLMENT INSTRUCTIONS MR018

RAILROAD MEDICARE PRE- ENROLLMENT INSTRUCTIONS MR018 RAILROAD MEDICARE PRE- ENROLLMENT INSTRUCTIONS MR018 TO COMPLETE THIS FORM YOU WILL NEED to use Internet Explorer to Open Links. Railroad Medicare Provider Number (PTAN) Billing NPI on file with Palmetto

More information

Louisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Entity/Business Providers

Louisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Entity/Business Providers Louisiana Medicaid Program Louisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Entity/Business Providers (Enrollment packet is subject to change without notice) Entity / Business

More information

ActivHealthCare EDI User Guide

ActivHealthCare EDI User Guide ActivHealthCare EDI User Guide Table of Contents Page Enrollment 2 Preparing Your Management Software 3 Claims Submission for AHC Network Affiliates 4 Online Entry Tool 7 Claims Follow-Up 8 Frequently

More information

NJ MEDICAID EDI CONTRACT INSTRUCTIONS (SKNJ0)

NJ MEDICAID EDI CONTRACT INSTRUCTIONS (SKNJ0) 092014 NJ MEDICAID EDI CONTRACT INSTRUCTIONS (SKNJ0) Please MAIL the completed forms with original signature to: MD On-Line ATTN: Enrollment 6 Century Drive 2 nd Floor Parsippany, NJ 07054 Do not mail

More information

Electronic Data Interchange (EDI) Registration for Oregon Medicaid

Electronic Data Interchange (EDI) Registration for Oregon Medicaid Electronic Data Interchange (EDI) Registration for Oregon Medicaid Learn how to complete the following forms: Oregon MMIS Trading Partner Agreement ( 2080) Exhibit A Application for Authorization ( 2081)

More information

Please type provider information on the form for ease of processing at MD On-Line.

Please type provider information on the form for ease of processing at MD On-Line. COLORADO MEDICAID EDI CONTRACT INSTRUCTIONS (SKCO0) Please MAIL the completed and signed agreement to: MD On-Line ATTN: Enrollment 6 CENTURY DR 2ND FL PARSIPPANY, NJ 07054 Do not fax the agreement to MD

More information

COLORADO MEDICAL ASSISTANCE PROGRAM

COLORADO MEDICAL ASSISTANCE PROGRAM COLORADO MEDICAL ASSISTANCE PROGRAM Electronic Data Interchange (EDI) Submitter Enrollment & Agreement The Colorado Medical Assistance Program PO Box 1100 Denver, Colorado 80201-1100 1-800-237-0757 ELECTRONIC

More information

EZClaim Advanced 9 ANSI 837P. Gateway EDI Clearinghouse Manual

EZClaim Advanced 9 ANSI 837P. Gateway EDI Clearinghouse Manual EZClaim Advanced 9 ANSI 837P Gateway EDI Clearinghouse Manual EZClaim Medical Billing Software February 2014 Gateway EDI Client ID# Gateway EDI SFTP Password Enrollment Process for EDI Services Client

More information

HIPAA Transaction ANSI X12 835 Companion Guide

HIPAA Transaction ANSI X12 835 Companion Guide HIPAA Transaction ANSI X12 835 Companion Guide HIPAA ASC x12 V5010X279A1 Version: 1.0 11/1/2013 Document History DOCUMENT VERSION HISTORY TABLE Version Sections Revised Description Revised By Date 2 Table

More information

Background. What You Need to Do to Get Ready for Electronic Billing

Background. What You Need to Do to Get Ready for Electronic Billing 9645 Granite Ridge Drive Suite 230 San Diego, California 92123 support@e- dsi.com http://www.e- dsi.com Electronic Transactions Enrollment Step by Step A guide to the steps necessary for new clients to

More information

Medicaid of Colorado Dental Electronic Claims Payer Enrollment

Medicaid of Colorado Dental Electronic Claims Payer Enrollment Medicaid of Colorado Dental Electronic Claims Payer Enrollment Payer Enrollment Requirements: Restrictions: Secure EDI Payer Enrollment Request form In-State non-participating providers may NOT submit

More information

Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication

Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication In This Unit Topic See Page Unit 1: Benefits of Electronic Communication Electronic Connections 2 Electronic Claim Submission Benefits

More information

State of Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP)

State of Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP) Hewlett Packard Enterprise for HIPAA Compliant Electronic Transactions Nevada Medicaid Management Information System (NV MMIS) State of Nevada Department of Health and Human Services (DHHS) Division of

More information

! Claims and Billing Guidelines

! Claims and Billing Guidelines ! Claims and Billing Guidelines Electronic Claims Clearinghouses and Vendors 16.1 Electronic Billing 16.2 Institutional Claims and Billing Guidelines 16.3 Professional Claims and Billing Guidelines 16.4

More information

SD MEDX South Dakota Medical Electronic Data Exchange SD Department of Social Services

SD MEDX South Dakota Medical Electronic Data Exchange SD Department of Social Services GENERAL INFORMATION Q. Is SD MEDX specifically for medical claims and prior authorizations or what will a dental provider use SD MEDX for? A. Delta Dental is still contracted with Medical Services for

More information

HIPAA ASC X12N Version 5010. Inbound 837 Transactions. Companion Document

HIPAA ASC X12N Version 5010. Inbound 837 Transactions. Companion Document HIPAA ASC X12N Version 5010 Inbound 837 Transactions Companion Document Version 1.2 Release Date: April 1, 2014 Purpose This document has been prepared as a PerformCare companion document to the ASC X12N

More information

KENTUCKY MEDICAID EDI CONTRACT INSTRUCTIONS (SKKY0)

KENTUCKY MEDICAID EDI CONTRACT INSTRUCTIONS (SKKY0) KENTUCKY MEDICAID EDI CONTRACT INSTRUCTIONS (SKKY0) Please carefully read all instructions before beginning. The documents in this top secion must be completed and sent to MD On-Line with your contract.

More information

National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096)

National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096) National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096) DMC Managed Care Claims - Electronic Data Interchange

More information

Submitter/Provider Relationship EDI Agreement Agreement Submitter/Provider Relationship EDI Agreement (Form EDI-201)

Submitter/Provider Relationship EDI Agreement Agreement Submitter/Provider Relationship EDI Agreement (Form EDI-201) Submitter/Provider Relationship EDI Submitter/Provider Relationship EDI (Form EDI-201) All New Jersey Medicaid and Charity Care Providers desiring to submit HIPAA formatted electronic claims must complete

More information

Glossary of Insurance and Medical Billing Terms

Glossary of Insurance and Medical Billing Terms A Accept Assignment Provider has agreed to accept the insurance company allowed amount as full payment for the covered services. Adjudication The final determination of the issues involving settlement

More information

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Approved GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Table of Contents Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Section 9: Section

More information

Colorado Medical Assistance Program DSH EDI UPDATE FORM

Colorado Medical Assistance Program DSH EDI UPDATE FORM Current DSH EDI Trading Partner ID: DSH EDI UPDATE FORM DSH EDI Submitters may change/update the following sections of the DSH Electronic Data Interchange (EDI) Submitter Enrollment & Agreement I no longer

More information

If you will be submitting claims through a Billing Service/Clearinghouse, please indicate their name below.

If you will be submitting claims through a Billing Service/Clearinghouse, please indicate their name below. Insurance Corporation 1717 W. Broadway P.O. Box 8128 Madison, WI 53708-8190 Phone: (608) 221-4711 Reminders: Please be sure to sign Item 16, Exhibit A! Complete and return all 5 pages Dear EPIC Provider:

More information

The benefits of electronic claims submission improve practice efficiencies

The benefits of electronic claims submission improve practice efficiencies The benefits of electronic claims submission improve practice efficiencies Electronic claims submission vs. manual claims submission An electronic claim is a paperless patient claim form generated by computer

More information

EDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi

EDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi EDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi 00175NYPEN Rev. 12/11 This brochure is a helpful EDI reference for both new and experienced electronic

More information

EDI Support Frequently Asked Questions

EDI Support Frequently Asked Questions EDI Support Frequently Asked Questions Last revised May 17, 2011. This Frequently Asked Question list is intended for providers or billing staff who may or may not have a technical background. General

More information

Change Healthcare Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account

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

More information

Combined Insurance Company of America

Combined Insurance Company of America Combined Insurance Company of America Companion Guide Combined Insurance Company of America HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on X12 version 004010 Companion

More information

MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT

MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT FORM APPROVED OMB NO. 0938-0373 Name(s) and Address of Participant*

More information

Quick Reference Guide for Part B Providers

Quick Reference Guide for Part B Providers Quick Reference Guide for Part B Providers 621_0813_Professional Table of Contents 621_0110 Minimum System Requirements...3 Online Help Feature...3 Getting Started Using PC-ACE PRO 32...4 Submitter Setup...4

More information

Coventry receives claims in two ways:

Coventry receives claims in two ways: Coventry receives claims in two ways: Paper Claims Providers send claims to the specific Coventry PO Box, which are keyed by our vendor and sent via an EDI file for upload into IDX. Electronic Claims -

More information

EDI Enrollment Status Messages and Descriptions

EDI Enrollment Status Messages and Descriptions EDI Enrollment Status Messages and Descriptions APPROVALS Approved Claims Approved Remits Approved - Claims/Remits Approved Provider Approved DDE/PPTN Approved -New vendor Approved - Production Completed

More information

EDI Solutions Your guide to getting started -- and ensuring smooth transactions bcbsga.com/edi

EDI Solutions Your guide to getting started -- and ensuring smooth transactions bcbsga.com/edi EDI Solutions Your guide to getting started -- and ensuring smooth transactions 00175GAPENBGA Rev. 12/11 This brochure is a helpful EDI reference for both new and experienced electronic submitters. It

More information

Getting Started with EDISS and Total OnBoarding (TOB)

Getting Started with EDISS and Total OnBoarding (TOB) Getting Started with EDISS and Total OnBoarding (TOB) Teleconference Number: (866) 699-3239 Note: Today's presentation will also be available at www.edissweb.com under the Workshop section of the Training

More information

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format Overview The Claims department partners with the Provider Relations, Health Services and Customer Service departments to assist providers with any claims-related questions. The focus of the Claims department

More information

EDI REGISTRATION FORM Blue Cross of Idaho 3000 E Pine Ave Meridian, Id 83642 Fax 208-331-7203

EDI REGISTRATION FORM Blue Cross of Idaho 3000 E Pine Ave Meridian, Id 83642 Fax 208-331-7203 DATE: EDI REGISTRATION FORM Blue Cross of Idaho 3000 E Pine Ave Meridian, Id 83642 Fax 208-331-7203 Enrollments will be completed with 5-7 Business Days from Date Received Business Name: Provider Information:

More information

. NOTE: See Chapter 5 - Medical Management System for conditions that must be met in CHAPTER 6. ELECTRONIC CLAIMS PROCESSING MODULE

. NOTE: See Chapter 5 - Medical Management System for conditions that must be met in CHAPTER 6. ELECTRONIC CLAIMS PROCESSING MODULE Electronic Claims Processing Module 6-1 CHAPTER 6. ELECTRONIC CLAIMS PROCESSING MODULE Processing claims electronically is an option that may be selected in place of or in conjunction with the processing

More information

Program Memorandum Intermediaries

Program Memorandum Intermediaries Program Memorandum Intermediaries Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal A-02-051 Date: JUNE 18, 2002 CHANGE REQUEST 2128 SUBJECT: Health

More information

EPS EFT Enrollment Authorization Agreement

EPS EFT Enrollment Authorization Agreement EPS EFT Enrollment Authorization Agreement Optum is improving service to you by replacing paper checks and Explanation of Benefits (EOBs) with the Optum EPS solution. Get a head start by enrolling today!

More information

COMMONWEALTH of VIRGINIA

COMMONWEALTH of VIRGINIA COMMONWEALTH of VIRGINIA Department of Medical Assistance Services HCBCS - Consumer Directed Service Coordination VIRGINIA MEDICAID PROVIDER ENROLLMENT PACKAGE Thank you for your interest in becoming a

More information

ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER INSTRUCTIONS

ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER INSTRUCTIONS ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER INSTRUCTIONS State Form 51400 (R/8-07) The (ISDH) is committed to conducting its business transactions with the health care provider community as efficiently

More information

CHAPTER 2 Quick Start Guide

CHAPTER 2 Quick Start Guide CHAPTER 2 Quick Start Guide 07/03/2014 1 Administrative Services of Kansas is proud to release PC-ACE Pro32 as our free-billing software solution. PC-ACE Pro32 is a windows-based electronic claims filing

More information

WPS Health Insurance

WPS Health Insurance WPS Health Insurance HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010X222A1 and 005010X223A2 Companion Guide Version Number: V2.2 November

More information

Home Health & Hospice Interactive Voice Response (IVR) System User Guide

Home Health & Hospice Interactive Voice Response (IVR) System User Guide Home Health & Hospice Interactive Voice Response (IVR) System July 2014 2014 Copyright, CGS Administrators, LLC Table of Contents Introduction... 3 Required Information... 3 Menu Options... 4 Claim Status

More information

Colorado Medical Assistance Program

Colorado Medical Assistance Program Provider ID: Colorado Medical Assistance Program EDI UPDATE FORM Provider s Current Trading Partner ID: Providers may change/update the following sections of the ELECTRONIC DATA INTERCHANGE PROVIDER ENROLLMENT

More information