ODS Health Plan EDI Form - Health-e-Web

13350
ODS HEALTH PLAN
PAYER ENROLLMENT INSTRUCTIONS
✔ Professional
Institutional
Claims
✔ ERAs
Important - HeW provides the EDI paperwork pre-populated with our submitter information as a courtesy to our clients.
Please note that even though we make all attempts to have the most current form available, we are not always notified
by the carriers when their EDI forms are updated.
FORM INSTRUCTIONS
The paperwork is designed for you to type into while opened in Adobe Reader. Please use your Tab key on your
keyboard to move to the next field.
* This form requires an authorized individual signature on two pages.
* EFT is required. Please contact Moda Health for information on enrolling for EFT (www.modahealth.com).
* Only one Tax ID is allowed per form
If you are not already receiving ERAs through HeW for the provider on the form, please contact our Support Center at
877-565-5457, option 1, or [email protected], to verify ERAs have been authorized on your account and for this
provider.
PAPERWORK SUBMISSION
Email the completed form to the HeW Enrollment department at [email protected] If a SSN number is being
reported please contact HeW Enrollment at 1-877-565-5457, Option 6, for submission instructions. DO NOT EMAIL.
Updated: 03/24/2014
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Page 1 of 3
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
PAYER INFORMATION
Refer to the Availity Health Plan Partner List for payer IDs.
13350
Payer Name: ODS HEALTH PLAN
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
RECEIVER INFORMATION
* If different than provider contact information.
Who will receive your ERA files?
Receiver Name:
ET&T / HeW
Contact Name*:
Enrollment Group
Telephone Number*:
Provider
Clearinghouse
Vendor
Availity Customer ID:
(877) 565-5457
Ext: 1
E-mail Address*:
12614
[email protected]
PROVIDER INFORMATION
PROVIDER IDENTIFIERS INFORMATION
Provider Name:
Provider Federal Tax Identification Number
(TIN) or Employer Identification Number (EIN):
Street:
City:
State/Province:
ZIP Code/Postal Code:
National Provider Identifier (NPI):
Provider Federal Tax Identification Number
(TIN) or Employer Identification Number (EIN):
Provider Name:
Street:
City:
State/Province:
ZIP Code/Postal Code:
National Provider Identifier (NPI):
PROVIDER CONTACT INFORMATION
Provider Contact Name:
Telephone Number:
ext.
E-mail Address:
ELECTRONIC REMITTANCE ADVICE INFORMATION
Preference for Aggregation
of Remittance Data
Provider Tax Identification Number (TIN):
National Provider Identifier (NPI):
SUBMISSION INFORMATION
Reason for Submission:
Authorized Signature:
New Enrollment
Change Enrollment
Cancel Enrollment
(Print & Sign Here)
Important: By typing or signing a name in this field, you acknowledge and agree that you have been authorized by the provider or its agent to initiate,
modify, or terminate an enrollment. You further acknowledge and agree that you have the legal authority to perform such action on behalf of your
organization. In no event will Availity be liable for any losses or damages including without limitation, indirect or consequential losses or damages, or
any loss or damage whatsoever arising from loss of data or profits arising out of, or in connection with this submission.
Printed Name of Person Submitting Enrollment:
SEND THE
FORM VIA:
E-mail: [email protected]
Submission Date:
Fax: 904.470.4773
Mail:
Avality LLC
P.O. Box 550857
Jacksonville, FL 32255-0857
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
Page 2 of 3
11
Moda Health/ODS / ODS Community Health Electronic Remittance Advice (ERA) Enrollment
Form
EFT is required to receive ERAs. Please contact Moda Health for information (www.modahealth.com)
PROVIDER INFORMATION
Provider Name:
Doing Business As Name (DBA):
Provider Address:
Street
City
State/Province
ZIP Code/Postal Code
PROVIDER CONTACT INFORMATION
Provider Contact Name:
Telephone Number:
Telephone Number extension:
Email Address:
ELECTRONIC REMITTANCE ADVICE INFORMATION
Preference for Aggregation of Remittance Data (e.g.
Account Number Linkage to Provider Identifier)
Provider Federal Tax Identification
Number (TIN):
Enter only one based on your preference.
National Provider Identifier (NPI):
Method of Retrieval:
Clearinghouse
1
Page 3 of 3
12
ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
Clearinghouse Name
Clearinghouse
SUBMISSION INFORMATION
Reason for Submission:
New Enrollment
Change Enrollment
Cancel Enrollment
Authorized Signature
Written Signature
(Print & Sign Here)
Printed Name
Printed Title
Submission Date
(ccyymmdd)
2
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
Field Descriptions
Section
PAYER
INFORMATION
RECEIVER
INFORMATION
PROVIDER
INFORMATION
PROVIDER
IDENTIFIERS
INFORMATION
PROVIDER
CONTACT
INFORMATION
ELECTRONIC
REMITTANCE
ADVICE
INFORMATION
Field
Payer Name
Payer ID
Who will receive your ERA files?
Description
The name of the payer sending/issuing the X12 835 files.
The payer’s unique identifier.
The type of organization that will receive the X12 835 files: Provider,
Clearinghouse, or Vendor.
Receiver Name
The name of the organization that will receive the X12 835 files.
Availity Customer ID
The receiving organization’s customer ID assigned by Availity. To
determine your customer ID, click Who controls my access? at the
top of any page in the Availity Web Portal.
Contact Name
Name of a contact at the receiving organization (if different than the
provider contact).
Telephone Number/Ext
Telephone number of the receiving organization’s contact.
E-mail Address
E-mail address of the receivng organization’s contact.
Provider Name
Complete legal name of institution, corporate entity, practice or
individual provider.
Street
The number and street name where a person or organization can be
found.
City
City associated with provider address field.
State/Province
ISO 3166-2 Two Character Code associated with the
State/Province/Region of the applicable Country.
ZIP Code/Postal Code
System of postal-zone codes (zip stands for "zone improvement plan")
introduced in the U.S. in 1963 to improve mail delivery and exploit
electronic reading and sorting capabilities.
Provider Federal Tax Identification
A Federal Tax Identification Number, also known as an Employer
Number (TIN) or Employer Identification Identification Number (EIN), is used to identify a business entity.
Number (EIN)
National Provider Identifier (NPI)
A Health Insurance Portability and Accountability Act (HIPAA)
Administrative Simplification Standard. The NPI is a unique
identification number for covered healthcare providers. Covered
healthcare providers and all health plans and healthcare
clearinghouses must use the NPIs in the administrative and financial
transactions adopted under HIPAA. The NPI is a 10-position,
intelligence-free numeric identifier (10-digit number). This means that
the numbers do not carry other information about healthcare providers,
such as the state in which they live or their medical specialty. The NPI
must be used in lieu of legacy provider identifiers in the HIPAA
standards transactions.
Provider Contact Name
Name of a contact in provider office for handling ERA issues.
Telephone Number
Associated with contact person.
E-mail Address
An electronic mail address at which the health plan might contact the
provider.
Preference for Aggregation of
Provider preference for grouping (bulking) claim payment remittance
Remittance Data (e.g., Account
advice – must match preference for EFT payment.
Number Linkage to Provider Identifier)  Provider Tax Identification Number (TIN) – Enter a TIN in the field
provided if you select this option.
 National Provider Identifier (NPI) – Enter an NPI in the field provided
if you select this option.
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
Field Descriptions (cont.)
Section
SUBMISSION
INFORMATION
Field
Reason for Submission
Authorized Signature
Printed Name of Person Submitting
Enrollment
Submission Date
Description
Select one of the following options: New Enrollment, Change
Enrollment, or Cancel Enrollment.
The signature of an individual authorized by the provider or its agent to
initiate, modify or terminate an enrollment. May be used with electronic
and paper-based manual enrollment
The printed name of the person signing the form; may be used with
electronic and paper-based manual enrollment.
The date on which the enrollment is submitted.
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.