Fillable OPTUM 835 ENROLLMENT REQUEST

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OPTUM 835 ENROLLMENT REQUEST

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The OPTUM 835 ENROLLMENT REQUEST form is 2 pages long and contains:

  • 0 signatures
  • 40 check-boxes
  • 12 other fields

Country of origin: OTHERS
File type: PDF

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Email this form to Support@officeally.com
or Fax to (360) 896-2151. Once your form is received and processed, Office Ally will
email you a confirmation. If you do not receive a confirmation email from us within 2-3 business days or faxing or emailing this form, please
send it again. Please make sure to print legibly and to complete this form in its entirety. You risk delaying enrollment if the application is
unreadable or incomplete. All fields in bold are required.
Provider Name:
Provider Address: City: State: Zip:
Provider Federal Tax Identification Number
Employer Identification Number (EIN): National Provider Identifier (NPI):
Contact Name: Telephone Number/Extension:
Email Address: Fax Number:
Reason for Submission:
Authorized Signature:
Note: Electronic Signature (Typed Name) of Person Submitting ERA Enrollment.
NOTE: If you have received ERA's from these payers through another clearinghouse, you may be prompted via email
from your previous clearinghouse to confirm the change. If you do not confirm the change, enrollment will be delayed.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
OPTUM 835 ENROLLMENT REQUEST
PROVIDER INFORMATION
PROVIDER IDENTIFIERS INFORMATION
PROVIDER CONTACT INFORMATION
SUBMISSION INFORMATION
New ERA Enrollment
Submit by Email
Clear Form
This form can be used to enroll for ERAs from any of the following payers. Check all that apply.
Payer ID
Payer Name
Payer ID
36273
AARP (Insured by UnitedHealthcare)
37602
77799 AmeriHealth Caritas Delaware
81400 United HealthOne / UnitedHealthcare Life Insurance
87726
Care Improvement Plus (CIP) / XL Health
87726
10629
Christus Health Medicare Advantage
81400
13285 Clover Health
87726 UnitedHealthcare / MAHP - MD IPA - Optimum - MLH (MAMSI)
PROH1
Dignity Health - Mercy MG / Woodland
03432
44054
GEHA / Texas Dental Plan
04567
96475 Healthlink HMO
95378 UnitedHealthcare Community Plan / IA, MS CAN & CHIP, TN
68024 IlliniCare Health Plan – Medical
96385 UnitedHealthcare Community Plan / KS
3135M
Mdwise Healthy Indiana Plan
95467
3519M
Mdwise Hoosier Healthwise
86050
94265 Medica and Medica UHC
UFNEP UnitedHealthcare Community Plan / NE
78857
Medica HealthCare Plans / FL
86047
MAHP1
Medical Associates Health Plan
NYU01
75190 NCAS - Fairfax Virginia
TEX01 UnitedHealthcare Community Plan / TX
87726
Neighborhood Health Partnership
WID01
41194
OptumHealth Complex Medical Conditions (CMC)
95378
41161 OptumHealth Physical (Includes Oxford)
00773 UnitedHealthcare Vision / Spectera
76342
Sierra Health Services / Health Plan of NV
95959
39026
UMR (formerly Wausau/UHIS)
VACCN
2020-10-29
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OPTUM 835 ENROLLMENT REQUEST

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Completed 18 December 2020

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