Fillable CONTRA COSTA HEALTH PLAN (CCHPL) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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CONTRA COSTA HEALTH PLAN (CCHPL) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• Contra Costa Health Plan Pre-enrollment Form
o Note: Payment and Provider Information must match the Payer’s system.
• Email the Contra Costa Pre-enrollment Form to Support@officeally.com
• Standard processing time for pre-enrollment is 7-10 business days.
• Call Office Ally at (360) 975-7000 Option 1 or email Support@officeally.com to ask if you have been approved
to submit your claims electronically.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
CONTRA COSTA HEALTH PLAN (CCHPL)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
Payment and Provider information must match the Payer’s system for enrollment. Payer will match on Name, Tax ID,
Zip Code and Payment Address. It is important for the Payment Name and Address to contain the correct PO Box or
File Number if applicable. This information must also be sent on electronic claims to avoid rejections.
Payment Information (Name, PO Box or File Number, if applicable) should match W-9 information.
___Professional Claims ___Institutional Claims
Pay-To Organization or Provider Name:
Address: PO Box or File Number (if applicable)
City: State: Zip Code:
National Provider Identifier (NPI):
Provider Federal Tax Identification Number (TIN):
Provider Name:
Address:
City: State: Zip Code:
National Provider Identifier (NPI):
Provider Federal Tax Identification Number (TIN):
Provider Name:
Address:
City: State: Zip Code:
National Provider Identifier (NPI):
Provider Federal Tax Identification Number (TIN):
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
CONTRA COSTA HEALTH PLAN (CCHPL)
PRE-ENROLLMENT FORM
CLAIM SUBMISSION
PAYMENT INFORMATION
PROVIDER INFORMATION (IF DIFFERENT FROM PAYMENT INFORMATION)
SERVICE FACILITY INFORMATION
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CONTRA COSTA HEALTH PLAN (CCHPL) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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