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
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.