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DENTI-CAL (94146) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• EDI Application Agreement
• Provider Service Office Electronic Data Interchange Option Selection Form (See Page 2)
• ERA Enrollment Form (Required for EDI Submission)
• Mail the original forms to (DO NOT FAX OR EMAIL):
Medi-Cal Dental Program
Provider Enrollment
P.O. Box 15609
Sacramento, CA 95852-0609
• Requires provider’s signature or President, CEO, or Owner of a group in ! BLUE INK
o Signature must be original
o Signature must be in BLUE INK
o Signature must be given by provider or owner on file at Medi-Cal as authorized to sign
o Medi-Cal will not accept signatures in black ink or signatures from office managers or billers
o DO NOT use white out
• Standard processing time is approximately 4-6 weeks.
• For assistance in completing forms or checking on status, contact EDI Support at (916) 853-7373 or by email
to denti-caledi@delta.org. Ask if your EDI Application has been approved and that your NPI is linked to Office
Ally’s Submitter ID OFFICEALLY.
• Once approved you MUST call Office ally at (360) 975-7000 Option 1 and let us know PRIOR to submitting
claims.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
DENTI-CAL (94146)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHO CAN SIGN THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
B-EDI-FRM-031.H Page 1 of 3
PROVIDER SERVICE OFFICE ELECTRONIC DATA INTERCHANGE
OPTION SELECTION FORM
1. Reason for Submission: New Enrollment Change Enrollment Cancel Enrollment
2.Provider Name:
3.National Provider Identifier (NPI):
4.Business Name:
5.Provider Address – Street:
City:
ZIP Code:
6.Provider Contact Name:
Telephone Number:
7.Software/Practice Management System:
8.Email Address:
EDI INPUT/OUTPUT OPTIONS
Identify the INPUT FROM and RETURN OUTPUT OPTIONS for your office in the fields below.
For assistance, contact EDI Support at (916) 853-7373 or by email to denti-caledi@delta.org.
INPUT FROM:
9a.
Service Office
9b.
Billing Office
9c.
Clearinghouse Name:
You will submit Claims, TARs and Adjustments (ANSI X 12 837).
Will you also submit:
10. NOAs electronically?
YES
NO
11. Claim Status Inquiry (ANSI X 12 276)?
YES
NO
RETURN OUTPUT OPTIONS: Standard options are shaded:
12. Electronic RTDs
YES
NO
13. Electronic NOAs
YES
NO
14. Electronic EOB Supplemental Claim Data
(If YES:
SUMMARY or DETAIL)
YES
NO
15. Would you like to stop receiving Explanations of Benefits (EOBs) by mail?*
YES*
NO
*If YES, EDI Support will contact your office to determine the effective date.
NOTE: Opting not to receive paper EOBs by mail is an option only if either the 835 ERA and/or Supplemental
EOB file in the Detail format are received.
Mandatory options are pre-selected:
16. Electronic X-Ray/Attachment Labels (CP-O-971-P2 & CP-O-971-P)
YES
(1-UP or 3-UP)
17. Report of Documents Awaiting Return Information (CP-0-978-P)
YES
18. Report of EDI Documents Received (CP-0-973-P)
YES
19. Claim Status Inquiry Response (ANSI X 12 277)
YES
NO
20. Print the name of the provider
(last) (first) (middle)
21. Signature of provider
Signature Date
Return completed form to:
Medi-Cal Dental Program
Provider Enrollment
P.O. Box 15609
Sacramento, CA 95852-0609
DENTI-CAL
CALIFORNIA MEDI-CAL DENTAL PROGRAM
P.O. BOX 15609
SACRAMENTO, CALIFORNIA 95852-0609
Phone 800-423-0507 Web www.denti-cal.ca.gov
Print Form
Reset Form
Office Ally
B-EDI-FRM-031.H Page 2 of 3
INSTRUCTIONS FOR COMPLETION OF THE PROVIDER SERVICE OFFICE
ELECTRONIC DATA INTERCHANGE OPTION SELECTION FORM
Type or print clearly in ink. Return completed form to: Medi-Cal Dental Program
Provider Enrollment
P.O. Box 15609
Sacramento, CA 95852-0609
1. Reason for Submission: Check the enrollment action requested:
New Enrollment – check if applicant is not currently enrolled to submit electronically to Denti-Cal.
Change Enrollment – check if applicant is requesting to modify existing EDI enrollment options.
Cancel Enrollment – check if applicant is requesting to deactivate EDI enrollment.
2. Provider Name: Enter the provider’s legal name.
3. National Provider Identifier (NPI): Enter the Billing provider’s National Provider Identifier (NPI) for the business
address indicated in item 5.
4. Business Name: Business name if different than the provider's legal name listed in item 2.
5. Provider Address: Enter the actual business location including the street name and number, room or suite number or
letter, City, State, and ZIP Code. A post office or commercial box is not acceptable.
6. Provider Contact Name: Enter the name and telephone number of the individual who can be contacted by EDI Support
staff to answer questions regarding the application.
7. Software/Practice Management System: Enter the name of the provider’s software vendor or practice management
system used for billing.
8. Email Address: Enter the provider’s email address.
EDI INPUT/OUTPUT OPTIONS:
9a. Service Office: Check if applicant will submit directly to Denti-Cal for the business location noted in item 5.Note:
certification testing is required.
9b. Billing Office: Check if the applicant will submit directly to Denti-Cal from a central location for more than one business
location. Note: certification testing is required and each location must be enrolled to submit electronically.
9c. Clearinghouse Name: Check if the applicant will submit through a certified clearinghouse. Next to Name, enter the
name of the clearinghouse.
10. Will you also submit NOAs electronically?: Check YES if the applicant will respond to EDI Notices of Authorization
(NOAs) electronically to submit them for payment or request reevaluation. Check NO if the applicant will respond to
EDI NOAs only by mail.
11. Will you also submit Claim Status Inquiry (ANSI X 12 276)? Check YES if the applicant will submit the 276 Health
Care Claim Status Request transaction. Check NO if the applicant will not submit the 276 transaction.
INPUT FROM: Refers to the source and type of EDI data the provider will submit electronically to Denti-Cal.
B-EDI-FRM-031.H Page 3 of 3
12. Electronic RTDs*: Check YES if the applicant wants to receive Resubmission Turnaround Documents (RTDs) for
electronically submitted documents. Check NO if the applicant wants to receive RTDs by mail.
13. Electronic NOAs*: Check YES if the applicant wants to receive Notices of Authorizations (NOAs) for electronically
submitted Treatment Authorization Requests (TARs). Check NO if the applicant wants to receive NOAs by mail.
14. Electronic EOB Supplemental Claim Data*: Check Yes if the applicant wants to receive electronic Explanation of
Benefits (EOBs). Please check with your clearinghouse to see if this is an option they offer and if so whether they
support receipt in a Summary or Detail format. Check No if the applicant does not wish to receive Supplemental
EOBs.
15. Would you like to stop receiving Explanation of Benefits (EOBs) by mail?: Check YES if the applicant wants to
discontinue receiving EOBs by mail. This is only an option if the provider is receiving either the 835 ERA and/or
Supplemental EOB data in the Detail format. Check NO if the applicant wants to continue receiving EOBs by mail.
16. Electronic X-Ray/Attachment Labels: Electronic X-Ray/Attachment Labels: This is a mandatory option to enable the
applicant to receive Denti-Cal EDI report CP-O-971-P2 (Office X-Ray/Attachment Request Label) and associated
Denti-Cal EDI report CP-O-971-P (X-Ray/Attachment Request Report). Labels can be provided 1-up (four labels per
page in a single column) or 3-up (12 labels per page in three columns).
17. Report of Documents Waiting Return Information: This is a mandatory option to enable the applicant to receive Denti-
Cal EDI report CP-O-978-P (Provider/Service Office Daily EDI Documents Waiting Return Information > (greater
than) 7 Days).
18. Report of EDI Documents Received: This is a mandatory option to enable the application to receive Denti-Cal EDI
report CP-O-973-P (Provider/Service Office Daily EDI Documents Received Today).
19. Claim Status Inquiry Response: Check YES if the applicant wants to receive the 277 Health Care Claim Status Inquiry
transaction in response to the 276 Health Care Claim Status Request transaction (mark YES if item 11 was also
marked YES). Check NO if the applicant does not want to receive the 277 transaction or if item 11 was marked NO.
20. Print name of provider: Print the last, first and middle name of the person who is signing the application. The
application must be signed by a person who is authorized to legally bind the provider or applicant.
21. Signature of provider: An original signature of the individual named in item 20 is required. Include the Signature Date.
*EDI RTDs, NOA, Supplemental EOBs and ERAs are considered standard options by various clearinghouses.
Providers should check with their clearinghouse, if applicable, to verify whether availability is supported. See
separate Electronic Remittance Advice (ERA) Enrollment Form to receive the X12 835 transaction.
RETURN OUTPUT OPTIONS: Refers to EDI reports and data the provider will receive electronically from Denti-
Cal through the same source selected in item 9a-c. Some options are standard or are determined by the
provider’s software and/or clearinghouse noted in item 7 and 9c. Providers are required to receive EDI reports
noted in item 16, 17 and 18. Refer to the Denti-Cal EDI How-To Guide for samples and descriptions of these
reports.
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DENTI-CAL (94146) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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