Fillable MEDICAID VERMONT (MCDVT) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

Fill Online, Printable, Fillable, Blank MEDICAID VERMONT (MCDVT) PRE-ENROLLMENT INSTRUCTIONS (Office Ally) Form

Use Fill to complete blank online OFFICE ALLY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MEDICAID VERMONT (MCDVT) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

On average this form takes 35 minutes to complete

The MEDICAID VERMONT (MCDVT) PRE-ENROLLMENT INSTRUCTIONS (Office Ally) form is 5 pages long and contains:

  • 0 signatures
  • 155 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Office Ally forms online.

BROWSE OFFICE ALLY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
• Vermont Medicaid EDI Registration Form
o If you would like Office Ally to receive Electronic Remittance Advice on your behalf, you must
authorize Office Ally to see your weekly remittance advice in Part 1b on page 2 of the registration
form. You also need to check the 835 Remittance (ERA in X12N format) under Transactions and Part 2
• 835 ERA Enrollment Form
o To activate ERAs, this form is required in addition to the ERA selections made on the EDI enrollment
form
• Email to vtedicoordinator@dxc.com
; OR
• Mail to:
Gainwell Technologies
Attn: EDI Coordinator
PO Box 888
Williston, VT 05495
NOTE: Both documents must be signed by the provider
• Standard processing time is 7-14 business days
• You may call Medicaid Vermont at (802) 879-4450 option 3 and ask if your Provider ID has been linked to
Office Ally’s Trading Partner ID 701101732
• 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 VERMONT (MCDVT)
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?
103/2021
EDI Registration
Vermont Medicaid EDI Registration
Purpose
Registration of Vermont Medicaid Trading Partners to allow access to the Vermont Medicaid Web Portal for test
and production claim transaction uploads, and downloads of functional acknowledgements, submitted claim

Who Must Register

Requirements



• Utilization of the Vermont Medicaid Companion Guide to ensure that the transactions meet the




Instructions










information will be used to route transactions to the Claims Processing System and back to Trading Partner

203/2021
EDI Registration
Part 1a.
Electronic Transactions
Trading Partner Name:
Address:
City: State: Zip Code:
Primary Contact Name:
Primary Contact Phone:
Part 1b.
Pre-Certification (please check one)


Translator Compliance Check:

Other (describe):


Transactions (Check all that apply)
837 Institutional Inpatient
**835 Remittance (ERA in X12N format)
837 Institutional Outpatient
999 Functional Acknowledgement
837 Institutional Nursing Home

837 Institutional Home Health

837 Professional

837 Dental


***Gainwell Internal Use Only***
Date: 
Trading Partner ID: 
Office Ally, Inc
Customer Service
(360) 975-7000 Option 1
Office Ally, Inc
303/2021
EDI Registration
Part 2.
Vermont Medicaid Provider List

Trading Partner ID:
Provider ID Provider Name Provider Signature
837 I
837 P
837 D
999
Claim Accept/
Reject Rpt
835
270/271
276/277
Remove
✔
✔
✔
101/2021
835 ERA Enrollment Form
835 ERA Enrollment Form
Provider Information (Completion Required)
Provider Name: VT Medicaid ID:
Address:
City: State: Zip Code:
TIN/EIN: NPI:
Trading Partner ID: Taxonomy Code:
Contact Information (Completion Required)
Contact Name:
Telephone Number (w/ Ext):
Email Address:
Billing Agent Information (If Applicable)
Name of Provider’s Authorized Agent:
Address:
City: State: Zip Code:
Provider Agent Contact Name:
Telephone Number (w/ Ext):
Email Address:
Electronic Remittance Advice Clearinghouse Information (If Applicable)
Clearinghouse Name:
Electronic Remittance Advice Vender Information (If Applicable)
Vendor Name:
Submission Information (Completion Required)
Reason for Submission: New Enrollment Change Enrollment
Cancel Enrollment
Signature
Authorized Signature:
Printed Name: Title:
Electronic Remittance Advice Information

• Method of Retrieval: Download from VT Medicaid Portal Website at http://www.vtmedicaid.com/#/home
Return by E-mail vtedicoordinator@dxc.com

Office Ally, Inc
201/2021
835 ERA Enrollment Form
835 ERA Enrollment Form Instructions
Provider Information
Provider Name: Enter the individual provider name or group name (if billing under a group).
Provider Address: Enter your physical address information.
TIN/EIN: Enter your Tax ID Number.
NPI:

Trading Partner ID:
Clearinghouse or Billing Service, you must enter their Trading Partner ID. If you are downloading to your
account then it should be your Provider Trading Partner ID. If you are establishing your own new account

Provider Taxonomy Code: Enter your ten position alphanumeric taxonomy code.
Contact Information
Enter the name and contact information for the EDI Coordinator to use if there are questions about the information
on this form.
Billing Agent Information
If you are using a billing agent other than that supplied in the Provider Address and Contact information sections,
please enter agent information in this section.
Electronic Remittance Advice Clearinghouse Information

Electronic Remittance Advice Vendor Information

Submission Information
Enter the reason for the form subission.
Signature
Authorized Signature: The provider or a provider representative (not a vendor or clearinghouse) must sign this

Name: The provider or a provider representative should print their name
Title: The provider or a provider representative should print their title
Return by E-mail vtedicoordinator@dxc.com


Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICAID VERMONT (MCDVT) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document