Fillable HEALTH SOURCE MSO (HSMSO) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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HEALTH SOURCE MSO (HSMSO) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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  • 4 check-boxes
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File type: PDF

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• Electronic Claims Submission Request Form
• Email the form to HSMSOEDI@HealthsourceMSO.com
• Standard processing time is 1-3 business days
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
HEALTH SOURCE MSO (HSMSO)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
Electronic Claims Submission Request Form
Instructions
• Electronic Claims Submission is only available to contracted providers
• ALL FIELDS ARE REQUIRED
• Form must be filled out and signed by an authorized representative for the provider
• Please email all completed forms to HSMSOEDI@HealthsourceMSO.com
• Once the provider has been approved, HSMSO will email the contacts below with instructions on how to submit
electronic claims to HSMSO
Vendor Information
Provider Name:
Provider Tax ID:
Provider NPI:
Which IPA/Hospital is the Provider Contracted With:
Authorized Representative Information
Title:
Phone Number:
Email:
EDI/Technical Contact Information
Title:
Phone Number:
Email:
Claim Submission Information
Claim Submission Type?
UB04
CMS 1500
Will This Provider Submit Attachments?
YES
NO
Authorized
Signature: Date:
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HEALTH SOURCE MSO (HSMSO) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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