hhh medicare (a) edi form for claims & erase... · title: hhh medicare (a) edi form for claims...
TRANSCRIPT
EDI APPLICATION FORM - Instructions
Section Data to Enter into the Form DATE (Prefilled)
REASON FOR SUBMISSION Select: ADD PROVIDERS
LINE OF BUSINESS Select: HHH 15004
SUBMITTER INFORMATION
Please complete only the following required fields (*) Submitter ID Number: Enter IA002522 Type of Submitter: Select CLEARINGHOUSE Submitter Entity Name: Enter HEALTH-E-WEB INC EDI Contact Person: Enter ENROLLMENT GROUP Submitter Phone Number: Enter 877-565-5457 Submitter E-mail Address: Enter [email protected] Submitter Address 1: Enter 2525 COLONIAL DRIVE SUITE A Submitter Address 2: Enter PO BOX 1540 Submitter City: Enter HELENA Submitter State: Select MT Submitter Zip: Enter 59624
ELECTRONIC REMITTANCE ADVICE (ERA) INFORMATION
Please complete only the following required fields (*) Report Response Format: Select Report Data Compression: Select PKZIP
PROVIDER INFORMATION
Please complete all required provider information fields (*), however you can complete at your discretion the non-required fields in this section.
Group Practice/Provider Name Provider Email Address Group Provider Number (this is the Medicare PTAN) Group NPI (this is the NPI linked to the PTAN listed) Address 1 City State Zip
REQUEST TYPE
For Claims ONLY, check mark both: 1. Submit Claims 2. Receive Reports
For Claims & ERAs, check mark all three of the following:
1. Submit Claims 2. Receive Reports 3. Receive Electronic Remittance
ADD ANOTHER PROVIDER
Check mark only if you have more than one Billing Provider to complete EDI paperwork.
WOULD YOU LIKE TO ORDER SOFTWARE
Select NO
PRESS the “Submit” button PRINT the form SIGN FAX the completed signed form to HHH 15004. Fax number is listed on the first page of our instructions within this document.