Online Provider Services
Account Request Form
Required fields are marked with an asterisk. *
Fax pages 1 & 2 of completed form to 866-698-6032.
Questions on this form? Read instructions on page 3.
Page 3 of 3
ValueOptions, Inc / EDI Helpdesk / PO Box 1287, Latham, NY 12110/Phone#: 888-247-9311
Forms that are incomplete, incorrect or illegible may delay or prevent proper processing.
Instructions for Account Request Form
The Account Request Form is only for activating online access on ValueOptions ProviderConnect website. If you need to update your
address, tax ID or NPI information, you will need to contact our ProviderRelations area at 800-397-1630. Please do not make additional
notations on the Account Request Form unless advised to do so by these instructions or by the EDI Helpdesk.
For guides on Direct Claim Submission and Authorization Submission, visit the Compliance page at:
Additional Login Account:
If a ProviderConnect account already exists for the provider or facility, and an office staff member needs their own unique ID/password, you
can check this box. If this secondary account needs to be disabled or deleted for any reason, it will be the provider’s responsibility to contact
the EDI Helpdesk immediately.
Super User Account:
Only check this box if you are registering to access ProviderConnect as an administrator to manage other users of your account.
New Combined Account:
Only check this box if you are registering multiple provider numbers, you want them accessible from a single user ID and password, and if
you currently do not have a login ID for ProviderConnect. In the area for Provider Number, you can write “See Attached List,” and include
an additional list containing the provider’s name, ValueOptions provider #, NPI, and tax ID. This information must be complete and accurate.
Existing Combined Account:
Only check this box if you currently have a Combined account login ID for ProviderConnect, and you want to include an additional provider
number to be accessible from this account. Please write your existing login ID on the blank line. Make sure you put the new provider number
in the appropriate field, or send a list as described above.
Provider ID number:
You can retrieve your ValueOptions assigned provider number by reviewing any Provider Summary Vouchers/EOBs you have previously
received; the Provider # will be present at the beginning of each claim. Or, depending on what state and type of claims you will be
submitting, the following service centers will be able to best assist you:
For all commercial accounts or states not listed below: 800-397-1630
Colorado Medicaid: 800-397-1630
Illinois Mental Health Collaborative or ICG: 800-397-1630
Kansas Medicaid or AAPS Block Grant: 800-397-1630
Maryland MHA: 800-888-1965
Massachusetts MBHP: 800-495-0086 (If submitting for both Commercial and MBHP clients, please provide both provider
Pennsylvania SWPA Medicaid or Non-HealthChoices Mental Health Program: 800-397-1630
Texas NorthSTAR: 800-397-1630
Batch vs. Direct Claim Submission:
Direct Claim Submission: If you are a smaller practice, or happen to have a low volume of Professional claims (normally submitted on a
HCFA-1500 or CMS-1500), Single Claim Submission may be best and easiest. With this option, you can submit each claim directly on the
website, the member and provider information are verified, and you receive a claim number right away.
Batch Claim Submission
: If you have to submit Institutional claims (submitted on a UB-92 or UB-04 form), and/or if you have a larger
volume of Professional Claims, you can select Batch Claim submission. With this feature, you will create your claims using either our EDI
Claims Link Software, or any practice management software that can create an 837 HIPAA file. You will then upload a batch file via our
website for processing. Claim numbers are usually available in about 1 business day. All new accounts are set up in test mode. A successful
test batch must be submitted, and the EDI Helpdesk contacted to switch to production mode.
Claim Adjustment: The ProviderConnect Online Adjustment Module allows users to electronically submit changes (adjustments) to
previously processed claims. This feature allows users to correct claims where the original result of the claim’s processing is not the correct
outcome for the services rendered or where information was submitted incorrectly on the original claim.
Commercial and Medicaid Claims:
We may need to create more than one online account for you if you need to submit both commercial and Medicaid claims.
If you only select commercial or Medicaid for now, and you need to add the other in the future, please contact the EDI Helpdesk and we can
make the appropriate updates for you. If no option is checked, the default will be Commercial Only.