PAYER ENROLLMENT INSTRUCTIONS FOR Before enrolling please be sure your Capario contract includes the transactions you will be using. Complete the payer enrollment process BEFORE submitting claims to Capario for this payer. If you are unsure about your contract status please contact Capario Support team at: edi@capario.com or 800 792 5256. We recommend enrolling using our Portal enrollment tool. This free Portal tool allows you to enter Providers and select the payers and transactions for your enrollment as it prefills the agreement forms for you. Another advantage of the enrollment tool is the ability to follow the progress of enrollments from initial generation through to payer approval. Our team will set you up and provide a quick tutorial. Contact us at edi@capario.com If you are not enrolling with the free portal Enrollment tool, please following these instructions: If this payer does not require an agreement, go to Step 2. STEP 1: COMPLETE AGREEMENT Complete all required fields on agreement and verify that information entered is correct. If an agreement requires signatures, we recommend signing in blue ink. Do not use signature stamps. STEP 2: PROCESS
STEP 3: COMPLETE CAPARIO ENROLLMENT SPREADSHEETS Capario Provider Spreadsheet This is completed for each new provider. http://www.capario.com/downloads/xls/provider_bulk_spreadsheet.xlsx Capario Payer Enrollment Spreadsheet This is completed when requesting enrollment with a payer for providers previously added to the Capario system. Please refer to the instruction tab on each spreadsheet form for details about the information to enter in each column. **PLEASE NOTE** The fields for tracking information are key for both your record keeping of enrollments and for Capario following up with payers for approvals. Be sure to enter all tracking for each enrollment. http://www.capario.com/downloads/xls/enrollment_bulk_spreadsheet.xlsx Email the completed spreadsheet(s) to: provider.enrollment@capario.com Questions? Contact us: Phone: (800) 792 5256 Option 1 Fax: (404) 877 3324 Email: provider.enrollment@capario.com
EmdeonClaimsProviderSetupForm 1 ProviderOrganization Practice/FacilityName Email:batchenrollment@emdeon.com Fax:(615)8853713 ProviderName Provider SpecialtyCode Practice/Facility ProviderAddress ContactName 2 TaxID SiteID Street City State ZipCode Vendor(Emdeon Certified Vendor used to submit files to Emdeon) VendorName ContactPhone Number VendorSubmitterID ContactName ContactPhoneNumber 3 TSOID ReportMethod ReportType RepositoryReportOptions.pdf Human_Read_Specsv.pdf 4 Payer M=MedicalCommercialOnly CommunicationProtocol/Output ReportFormat Pleaselistadditionalpayersbelow Check the Emdeon Payer List to see if additional enrollment is required at: H=HospitalCommercialOnly Revised10.20.2008 http://www.emdeon.com/payerlists/payerlists.php PayerID GroupID IndividualID NPIID PayerID GroupID IndividualID NPIID 5 Confirmations(Enter E-mail address) Confirmations(Enter E-mail address)
THIS FORM MUST BE PROCESSED BY EMDEON PAYER ID: SKDE0 SUBMITTER ID: 345564169 1 Provider Organization Practice/ Facility Name Emdeon Claims 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 Code Contact Name E-mail Address Telephone Fax 2 Vendor (Emdeon certified vendor used to submit files to Emdeon) Vendor Name Contact Name E-mail Address 3 Payer Payer ID Vendor Submitter ID SKDE0 DELAWARE MEDICAID Division ID Group ID Individual Provider ID NPI ID 4 Confirmations Send Emdeon Claim Confirmations To: Special Instructions: All Payer Registration forms must contain original signatures, NO stamped signatures or photocopies are accepted. SUBMIT COMPLETED FORM TO: Emdeon Donelson Corporate Ctr Bldg 3 3055 Lebanon Pike Ste 1000 NASHVILLE, TN 37214-2230 #11 OF THE ENROLLMENT FORM REQUIRES A TRANSACTION TO BE CHOSEN AND EMDEON TO BE ADDED AS THE VENDOR FOR EACH OF THE TRANSACTIONS SELECTED. THIS FORM MUST BE PROCESSED BY EMDEON EMDEON REVISION FORM DATE: 03/04/15
D E L A W A R E T I T LE X I X E L E C T R O N I C C L A I M S U B M I S S I ON P R O VI D E R A G R E E M E N T TYPE OF AUTHORIZATION: (select only one) New Enrollment Change Enrollment Cancel Enrollment HP Enterprise Services, LLC has developed, under authority granted by the State of Delaware Department of Health and Social Services (DHSS), a claim processing system to facilitate business transactions by electronically transmitting and receiving data in lieu of conventional paper-based documents. This Agreement is made by and between the State of Delaware s Department of Health and Social Services, its fiscal agent, HP Enterprise Services (hereinafter referred to as HPES), and the undersigned provider (hereinafter referred to as Provider and/or Trading Partner): Provider Group Name: Group NPI: Provider Address: Contact Person: Contact Phone: Email Address: 1. HPES operates and maintains, under the authority of the Department of Health and Social Services, a paperless transaction system that allows providers to submit electronic transactions through the use of designated electronic media in compliance with current HPES electronic claim specifications and any revisions that may occur from time to time. 2. The Trading Partner agrees that it will complete, to the specifications and satisfaction of HPES, adequate testing appropriate to the electronic transactions it intends to submit, and further agrees that it will correct transaction errors or deficiencies as identified by HPES. 3. The Trading Partner attests that all services for which reimbursement will be claimed shall be provided in accordance with all federal and state laws pertaining to the Delaware Medical Assistance Program, and that all charges submitted shall not exceed the Provider s usual and customary charges for the same services and items provided to persons not entitled to receive benefits under the Delaware Medical Assistance Program. 4. The Trading Partner agrees that any payments made in satisfaction of claims submitted electronically will be delivered from federal and state funds and that any false claims, statements or documents, or concealments of a material fact may be subject to prosecution under federal and state law. Delaware Title XIX Electronic Claim Submission Provider Agreement Page 1 of 3 01/2014
5. The Trading Partner shall allow HPES access to its claims data. Further, the Trading Partner shall take reasonable steps to insure that the claims data will be submitted only by authorized personnel. 6. The Trading Partner will institute and adhere to security procedures to prevent unauthorized access to data, data transmissions, security access codes, and any and all other private or protected data or records. Further, the Trading Partner will promptly notify HPES of any unlawful use or unintended disclosure of Protected Health Information or any unauthorized attempt to obtain access to or otherwise tamper with any protected data. In the event that any litigation arises concerning the unlawful or unauthorized disclosure or use of Protected Health Information, the Trading Partner will comply with requests for cooperation from HPES and the Department of Health and Social Services. 7. The Trading Partner agrees that electronic transmission of all data shall be in strict accordance with the standards set forth in this agreement; Electronic Claim Submission guidelines as put forth by HPES; and as defined by the Health Insurance Portability and Accountability Act. In the event that electronic transmission of data fails to comply with the above stated specifications, HPES may, with the approval of the Department of Health and Social Services, terminate this agreement upon written notice to the Trading Partner. 8. The Provider may modify its election to use, not use, or change a third-party service provider such as a billing agent or authorized vendor but understands that in the event that any such modification is made, it is incumbent upon the Provider to give written notice to HPES by submitting a new Trading Partner Agreement specifying that said change is being authorized. Regardless of any such change to a third-party service provider, all elements of this Trading Partner Agreement shall remain in effect and apply to all electronic transactions. 9. The Trading Partner understands and agrees that all other terms and conditions of participation in the Delaware Medical Assistance Program remain in effect and are unchanged by this Trading Partner Agreement. 10. Please specify if a billing agent or an authorized vendor will be used to submit claims: A P P R O V E D T R A D I N G P A R T N E R Name of Vendor: Address: Contact: Telephone: Submitter ID: EMDEON 3055 LEBANON PIKE ENROLLMENT HELP DESK 866.924.4634 345564169 11. Please specify below the type(s) of electronic transaction(s) you intend to submit and specify for each of those transactions if a third-party service provider will be submitting or receiving electronic data on your behalf. Delaware Title XIX Electronic Claim Submission Provider Agreement Page 2 of 3 01/2014
SPECIFY TRANSACTION(S) PLEASE SPECIFY WHO WILL BE SENDING OR RECEIVINGTRANSACTIONS. 837 Dental Provider Trading Partner 837 Institutional Provider Trading Partner 837 Professional Provider Trading Partner 276/277 Provider Trading Partner 270/271* Provider Trading Partner *270/271 transactions require completion and approval of the Eligibility Benefit Inquiry and Response Addendum. Approved Trading Partner list: http://www.dmap.state.de.us/downloads/software/approved%20vendors.pdf AUTHORIZATION TO SUBMIT ELECTRONIC CLAIMS I hereby certify that I have examined this agreement and that the representations that are contained herein are true and correct. I hereby authorize the below stated individuals to submit electronic claims on my behalf to the State of Delaware Medicaid Program. I agree to notify HPES, in writing, of any changes to this agreement. Signature: Date: Printed Name: PERSONS AUTHORIZED TO SUBMIT CLAIMS ELECTRONICALLY: I accept responsibility for the accuracy of electronic claims submitted to Medicaid and understand that any and all identification numbers used to submit electronic transactions are to remain confidential. I understand that failure to maintain confidentiality may result in falsified claims and may lead to criminal prosecution. Signature: Printed Name: Signature: Printed Name: DEPARTMENT OF HEALTH AND SOCIAL SERVICES: Approved by: Date: Return Completed Form With Original Ink Signatures To: HPES Enterprise Services, LLC Suite 100, 248 Chapman Road Newark, DE 19702 PLEASE CONTACT PROVIDER RELATIONS ECS TEAM AT 800-999-3371 OR DEXIX-PR-ECS@HP.COM WITH ANY QUESTIONS. Delaware Title XIX Electronic Claim Submission Provider Agreement Page 3 of 3 01/2014