Online Provider Services Account Request Form
Online Provider Services Intermediary Authorization Form
If you wish to receive Electronic Remittance Advice (ERA), you must create an account with PaySpan Health
o Click here for instructions.
Fax the forms to Beacon Health Options (Value Options) at (866) 698-6032
Standard processing time is approximately 1 week
One week after faxing in your enrollment, you must call Beacon Health Options at (888) 247-9311 and ask if
your account has been set up and linked to Office Ally
Once enrollment has been approved you MUST email
with the below information
PRIOR to submitting claims electronically
Email Subject: Medicaid MA Behavioral Health (MCMAB) EDI Approval
Body of Email:
Please log my EDI approval for Medicaid MA Behavioral Health.
o Provider Name
o Tax ID
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
Page 1 of 3
Please return this form via fax to 866.698.6032
Beacon Health Options, Inc. | EDI Helpdesk | PO Box 1287, Latham, NY 12110 | Phone#:
Incomplete, incorrect or illegible forms may delay or prevent proper
ProviderConnect Online Services Account Request Form
Provider, Practice or Facility Name
Special Setup:
Additional User Account
Super User Account
Military OneSource
Horizon Behavioral Health
Beacon Health Options Assigned ID
National Provider Identifier (NPI)
Provider, Practice or Facility Tax IDs to be associated to this online account. If more than one, please list all.
City State Zip Code
( )
( )
Telephone Number
Fax Number
Please check which Online Provider Services options you are requesting:
Electronic Batch Claims (837)
Direct Claims Submission
277CA Acknowledgement File
999 Acknowledgement File
Provider has retained a 3
party Billing Agent or Clearinghouse to submit claims on their behalf.
(Other than office staff) (If yes, please complete the Billing Intermediary Authorization Form)
Yes No
Depending on the state in which you are practicing, you may need multiple logins created to ensure the claims are processed
accurately (i.e.Medicaid vs. Commercial). If you intend to submit batch transactions for one of the states below please mark the
appropriate box:
Colorado, batch claims for Colorado Medicaid clients? Yes No Both
Kansas, batch claims for Kansas Medicaid or AAPS Block Grant clients? Yes No Both
Maryland, batch claims Maryland BHA clients? Yes No Both
Massachusetts, batch claims for Massachusetts Behavioral Health Partnership (MBHP)? Yes No Both
Pennsylvania, batch claims for SWPA Medicaid clients? Yes No Both
Pennsylvania, batch claims for Non-HealthChoices Mental Health Program? Yes No Both
Texas, batch claims for Texas NorthSTAR clients? Yes No Both
Illinois, batch registration for Illinois Mental Health Collaborative or ICG clients? Yes No
Georgia, batch registration, authorization, discharge or claims for Georgia Collaborative ASO? Yes No
Contact Name (ProviderConnect Account User)
Contact’s e-mail address
E-mail address where you would like to receive your batch submission file feedback
Automatically included:
Eligibility Inquiry
Claim Status
Authorization Inquiry
Provider Summary Vouchers
Page 2 of 3
Please return this form via fax to 866.698.6032
Beacon Health Options, Inc. | EDI Helpdesk | PO Box 1287, Latham, NY 12110 | Phone#:
Incomplete, incorrect or illegible forms may delay or prevent proper
Agreement Terms:
A. The undersigned submitter authorizes Beacon Health Options, Inc. to receive and process claims or batch registration, authorization
and/or discharge submissions via the Beacon Health Options Electronic Transport System (ETS) or Beacon Health Options Online
Provider Services Program on his/her/its behalf in accordance with the applicable regulations.
B. All submitted information must be true, accurate and complete. I/We understand that payment of any claim submitted in falsification
or concealment of a material fact may be prosecuted under any applicable state and/or federal laws.
C. The Submitter agrees to comply with any laws, rules and regulations governing the Beacon Health Options Online Provider
Services/EDI program.
D. The Provider agrees to accept, as payment in full, the amounts paid in accordance with the fee schedules provided for under
previously established agreements with Beacon Health Options.
E. This is to certify that an exact copy of any claim files submitted via the Beacon Health Options ETS system or Online Provider
Services program will be stored in an electronic medium and held by the originator for a period of 90 days or until the
submission has been finalized as to reimbursement or denial of payment, whichever comes first.
This is to certify that the following is true:
I am a provider
I am office staff of a Provider, and am authorized to sign on their behalf.
Legal name of Organization Title of individual signing for organization
Name of Individual Signing for Organization Authorizing Signature Date
For Super User Accounts Only; Managed User Information:
First and Last Name of Initial Managed User Managed User’s Phone
(Must differ from Contact Name on page 1)
Managed Users e-mail address (Please print)
(Must differ from Contact Email on page 1)
Page 3 of 3
Please return this form via fax to 866.698.6032
Beacon Health Options, Inc. | EDI Helpdesk | PO Box 1287, Latham, NY 12110 | Phone#:
Incomplete, incorrect or illegible forms may delay or prevent proper
Instructions for Account Request
The Account Request Form is only for activating online access on Beacon Health Options ProviderConnect website. If you need to update
your address, tax ID or NPI information, you will need to contact our Provider Relations 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 User 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.
Provider ID number:
You can retrieve your Beacon Health Options 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 %HA: 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
Georgia Collaborative: 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 claims 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.
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