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MEDICAID MARYLAND MHA (PMHS) (77062) PRE-ENROLLMENT INSTRUCTIONS WHICH (Office Ally)

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• Online Provider Services Account Request Form
• Online Provider Services Intermediary Authorization Form
o The owner or other authorized personnel may sign the forms
• If you wish to receive Electronic Remittance Advice (ERA), you must create an account (free) with
PaySpan
Health
o Note: Office Ally cannot supply or access these reports. You will not be able to access your ERAs
through your Office Ally account
• If you wish to receive Claim Status Reports (aka Summary Vouchers), you must create an account with Value
Options using the following instructions:
o Go to www.valueoptions.com
o Select the Provider Tab
o Select Register under Provider Connect login on the right hand side of the screen
Call (888) 247-9311 option 2 for help
It is important to include your email address on this form since your password will be sent to
this email address.
If you do not create the account for Claim Status Reports, you risk having a rejected claim
and being unaware of it. Office Ally has no way of accessing/supplying these reports
• Fax the forms to Value Options at (866) 698-6032
• Standard processing time is 1 week
• One week after faxing your form to Value Options, you must call (888) 247-9311 option 2 and ask if your
account has been set up and linked to Office Ally.
• Once Value Options verifies that you have been linked to Office Ally, you MUST call Office Ally at (360) 975-
7000 option 1 and inform them of the approval PRIOR to submitting claims electronically.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICAID MARYLAND MHA (PMHS) (77062)
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?
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 1 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.
Special Setup: (See page 3)
Additional Login Account
Super User Account
New Combined Account
Existing Combined Account:
Login ID: ___________________
*Provider, Practice or Facility Name
*ValueOptions
assigned Provider ID. If not known, please
see page 3
*NATIONAL PROVIDER IDENTIFIER # (NPI)
*Provider, Practice or Facility Tax IDs to be associated to this online account. If more than one, please list all.
*Address
______________________________ ______________________________ ______________________________
*City *State *Zip Code
(____)__________________________________________________
(______)__________________________________________________
*Telephone Number
Fax Number
*Please check which Online Provider Services options you would like to have access to:
Electronic Batch Claims Submission
(837 HIPAA format)
Direct Claims Submission
Military OneSource Case Activity Form
Horizon Behavioral Health
Authorizations
Automatically included:
Eligibility Inquiry Claim Status Inquiry
Authorization Inquiry & Submission
Provider Summary Vouchers/EOBs
Provider has retained a 3
rd
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 accounts created to ensure the claims are processed
accurately (i.e. Medicaid vs. Commercial). Therefore, to help us in setting up your account(s) correctly, if you are located in…
Colorado, will you be submitting CO Medicaid clients?
Yes No, Commercial Only Both
Kansas, will you be submitting either KS Medicaid Claims or AAPS Block Grant clients?
Yes No, Commercial Only Both
Maryland, will you be submitting MD MHA clients?
Yes No, Commercial Only Both
Massachusetts, will you be submitting MBHP clients?
Yes No, Commercial Only Both
Pennsylvania, will you be submitting SWPA Medicaid clients?
Yes No, Commercial Only Both
Pennsylvania, will you be submitting for the Non-HealthChoices Mental Health Program?
Yes No Counties: _______________
Texas, will you be submitting TX NorthSTAR clients?
Yes No, Commercial Only Both
Illinois, will you be submitting Batch Registration Files for Illinois Mental Health
Collaborative or ICG clients?
Yes No
____________________________@__________________________________________________________________________
*Provider’s Contact e-mail address – Please print
____________________________@_________________________________________________________________________
E-mail address where you would like to receive your batch submission file feedback. - Please print.
*Contact Name at Provider’s Office
Ext.
✔
✔
✔
✔
✔
✔
✔
✔
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 2 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.
Agreement Terms:
A. The undersigned submitter authorizes ValueOptions to receive and process claims or batch registration submissions via
the ValueOptions Electronic Transport System (ETS) or ValueOptions 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 ValueOptions 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 ValueOptions.
E. This is to certify that an exact copy of any claim files submitted via the ValueOptions 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
OR
____I am office staff of a Provider, and am authorized to sign on their behalf.
Signatures:
____________________________________________ _________________________________________
Legal name of Organization Title of individual signing for organization
_______________________________________ _________________________________________________ _____________
*Name of Individual Signing for Organization *Authorizing Signature *Date
For Super User Accounts Only:
________________________________________________________
____________________________
*First and Last Name of Initial Managed User
*Managed Users Phone
____________________________@___________________________________________________
*
Managed Users e-mail address – Please print
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:
http://www.valueoptions.com/providers/ProCompliance.htm
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
numbers)
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.
Online Provider Services
Intermediary Authorization Form
Required fields are marked with an asterisk. *
Please fax completed form to 866-698-6032.
Questions on this form? Call 888-247-9311
INSTRUCTIONS:
This form should be completed by providers who contract with a third party to submit claims. If the Billing Intermediary will submit claims for
multiple providers, an Account Request Form and an Intermediary Authorization Form is required for each provider. Forms that are incomplete,
incorrect or illegible may delay or prevent proper processing.
Billing Agent/Clearinghouse/Intermediary Information Provider Information:
*
Billing Intermediary Name
*
Provider Name
*
Billing Intermediary’s Submitter ID (if already established)
*
Provider NPI number
*
Contact name at billing intermediary
*
ValueOptions assigned provider ID number
*
Email address at billing intermediary
*
Phone number at intermediary
*
Please check those options for which you have been authorized by the below-signed provider.
Electronic Batch Claims Submission
(837 HIPAA format)
Online Claims Adjustment
Direct Online Functions:
Direct Claims Submission
Online Claims Adjustment
Automatically included:
Eligibility Inquiry Claim Status Inquiry
Authorization Inquiry & Submission
Provider Summary Vouchers/EOBs
Agreement Terms:
A.
The undersigned Provider authorizes the above Billing Intermediary to submit claims to ValueOptions on his/her/its behalf in accordance
with any applicable regulations.
B.
The provider warrants that he/she/it has entered into a written agreement with above named Billing Intermediary. The provider
understands and agrees that its use of this Billing Intermediary does not in any manner relieve the provider of full responsibility and
liability for any violations of the laws, regulations and rules which govern the ValueOptions EDI program.
C.
The provider accepts full liability for all actions of the above named Billing Intermediary within its actual or apparent authority to act on
behalf of the provider, notwithstanding any contrary provisions in the agreement between the provider and the Billing Intermediary. In the
case of any violations of applicable laws, rules and regulations governing the ValueOptions EDI program, which arise out of the actions of
the Billing Intermediary, the provider accepts full liability as though these actions were the provider’s own actions.
D.
The provider agrees to notify ValueOptions in writing at least ten (10) days prior to the effective date of the revocation of
this Intermediary
Authorization Form. In such event, the provider’s liability for the acts of the
Billing Intermediary will continue until the tenth day after the
receipt of such notification or the effective date of the revocation, whichever is later.
Signatures:
*
Billing Intermediary’s Signature
*
Provider or provider’s staff signature
Date Date
Office Ally, LLC
Customer Service
support@officeally.com
360-975-7000 Option 1
x
7/21/14
Brian Oneill CEO
OFFICEALMD
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Completed 8 April 2021

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