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MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS WHICH (Office Ally)

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• Provider Conduent EDI Gateway Authorization Form for Billing Agents and Clearinghouses
• Fax the form to (202) 906-8399; OR
• Mail to:
Conduent
Technical Support/Enrollment
PO Box 34734
Washington DC 20043-4761
• Standard processing time is 2 weeks
• Call Conduent at (866) 407-2005 and ask if you are enrolled and linked to Office Ally’s Submitter ID 91168
• Once the enrollment has been approved, you MUST call Office Ally at (360) 975-7000 Option 1 and notify us
of the approval PRIOR to submitting claims electronically
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICAID DISTRICT OF COLUMBIA (77033)
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?
Washington, DC Conduent EDI Provider Enrollment Form
Please return to:
Conduent
Technical Support/Enrollment
PO Box 34734
Washington DC 20043-4761
Fax to: (202) 906-8399
(866) 407-2005 (phone) / (202) 906-8399 (fax)
www.dc-medicaid.com
Provider Conduent EDI Gateway Authorization Form for Billing Agents and Clearinghouses
Section A. Provider Information.
Please indicate your classification (required): Individual Provider Group Provider/Practice
Business Person
Provider Name (Last, First, MI and Suffix)
Provider Number (Required for Individuals)
Group Provider Number (Required for Groups)
Business Address
City, State, and Zip
Telephone Number
Fax Number
Contact Name
E-mail Address
Section B. Authorization Signature (required).
Provider, ______________________________________________________________________ hereby appoints
Provider name /Provider Representative Name (please print)
__________________________________________________________, ________________________________________________
Billing Agent/Clearinghouse name (please print) Billing Agent/Clearinghouse Conduent Trading Partner/Submitter ID
to act as the authorized agent for the purpose of retrieving health care responses electronically from Conduent EDI Gateway,
Inc. Provider also authorizes the Billing Agent/Cleringhouse’s access to the following X12N transaction responses if selected
below:
277-Claims Status Response 271-Eligibility Response
277CA-Claim Acknowledgement 835-Healthcare Claims Payment Advice
278-Prior Authorization Response 999-Functional Acknowledgement
_____________________________________________________________
Provider/Provider Representative name (Please print)
_____________________________________________________________
Provider/Provider Representative Signature
_____________________________________________________________
Date
Office Ally, Inc
91168
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MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS WHICH (Office Ally)

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Completed 8 April 2021

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