Fillable CENTRAL CALIFORNIA ALLIANCE FOR HEALTH (CCA01) PRE-ENROLLMENT WHICH (Office Ally)

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CENTRAL CALIFORNIA ALLIANCE FOR HEALTH (CCA01) PRE-ENROLLMENT WHICH (Office Ally)

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  • 19 other fields

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File type: PDF

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• EDI Claims Enrollment Form
• Email the form to edisupport@ccah-alliance.org; OR
• Fax to (831) 430-5895 Attn: EDI Analyst
• Email edisupport@ccah-alliance.org or call (800) 700-3874 ext 5510.
• Once the enrollment is complete, CCAH will notify both Office Ally and the provider.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
CENTRAL CALIFORNIA ALLIANCE FOR
HEALTH (CCA01) PRE-ENROLLMENT
INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
HOW CAN I CHECK THE STATUS?
CREATING HEALTH CARE SOLUTIONS
www.ccah-alliance.org
EDI CLAIMS ENROLLMENT FORM
IDENTIFICATION OF PROVIDER/TRADING PARTNER
AND TRANSACTION INFORMATION
All Trading Partners, whether covered entities or business associates of covered entities, agree to abide by all HIPAA Privacy and
Security requirements as they apply to communications with The Alliance.
Reminder: Prior to setting up Electronic Data Interchange (EDI) claims submission with the Alliance, a minimum of one paper
claim must have been submitted to the Alliance so that a record for the office can be configured.
PROVIDER INFORMATION (All fields required)
Provider Name
Provider Federal Tax Identification Number (TIN)
Doing Business As Name (DBA)
National Provider Identifier (NPI)
Provider Address – Street
City
State/Province
Provider Contact Name
Telephone Number
(
)
Email Address
CLEARINGHOUSE INFORMATION (Required field)
Are you planning to use a clearinghouse for electronic
transmissions with the Alliance?
Clearinghouse Name
SUBMISSION INFORMATION (Required field)
Reason for Submission:
New Enrollment
Change Enrollment
Cancel Enrollment
TRANSMISSION INFORMATION (Select appropriate fields)
Professional (837)
(ASC X12N 005010X222)
Institutional (837)
(ASC X12N 005010X0223)
AUTHORIZED SIGNATURE (Person submitting form)
Name
Signature
Submission Date
Please EMAIL completed form to
edisupport@ccah-alliance.org
Or FAX to (831) 430-5895, ATTN: EDI Analyst
To enroll in electronic claims submissions,
please contact our EDI Support Unit by
emailing a completed EDI Claims Enrollment
form edisupport@ccah-alliance.org
July 2020
To enroll in Electronic Remittance Advice(ERA),
contact our partner ECHO Health at
EDI@echohealthinc.com or call (888) 983-5574.
Office Ally, Inc (330897513)
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CENTRAL CALIFORNIA ALLIANCE FOR HEALTH (CCA01) PRE-ENROLLMENT WHICH (Office Ally)

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Completed 8 April 2021

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