Fillable AVAILITY E_TREST_TricareEast_835

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AVAILITY E_TREST_TricareEast_835

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© Availity, LLC, all rights reserved. | Confidential and proprietary.
Page 1 of 1 | Updated 2/28/2019
AVAILITY ENROLLMENT FORM
PAYER ID: TREST
PAYER NAME: TRICARE EAST
Required: Submission of this form indicates the completion of the enrollment instructions.
Enter Provider Information (print or type)
Provider Organization Name
Provider Tax ID
Provider/Group NPI
Availity Customer ID (Required)
Provider Legacy ID (if available)
Provider Billing Address
City
State
Zip
Authorized Name
Phone
Email Address
Choose which transaction you are enrolling (Claims, Remits, or Both): Remits
Enrollment Instructions
To begin enrollment please click the link. https://www.caqh.org/solutions/enrollhub
Select EnrollHub on the rightside of the screen.
Clearinghouse: Availity LLC
Trading Partner / Submitter ID: 70000
Please be aware WPS will follow up with the provider office to validate the enrollment. If WPS
is unable to validate, they will reject the enrollment. Only the provider can check for status
with CAQH and receive approval.
Enrollment Questions: Please Contact CAQH EnrollHub Helpline at 1-844-815-9763
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AVAILITY E_TREST_TricareEast_835

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Completed 26 September 2019

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