Fillable PENN BEHAVIORAL HEALTH (53226) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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PENN BEHAVIORAL HEALTH (53226) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• Emdeon EDI Enrollment Form
o Note: This form is emailed to Office Ally, not Emdeon.
• Penn Behavioral Health Corporate Services Electronic Claims Request
• Email the Emdeon EDI Enrollment Form to EnrollmentAdmin@officeally.com
o Email Subject should include “Emdeon EDI Enrollment”
• Fax the Penn Behavioral Health request form to (215) 746-2695
• Standard processing time is 24-48 business hours.
• If you have not received confirmation of your enrollment within 24-48 business hours, you can call
(888) 321-5533 to check enrollment status.
• Once you have received confirmation that you have been linked to Office Ally, you may start
submitting right away.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
PENN BEHAVIORAL HEALTH (53226)
PRE-ENROLLMENT INSTRUCTIONS
WHAT FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
In order to send claims electronically to this payer, please fill out this form and return it via email
to EnrollmentAdmin@officeally.com, the Email Subject should read: Emdeon EDI Enrollment.
Provider Name:
Provider Address:
Provider Federal Tax Identification Number (TIN)
OR Employer Identification Number (EIN):
National Provider Identifier (NPI):
Provider Contact Name:
Telephone Number:
Email Address:
Reason for Submission:
Authorized Signature:
Note: Electronic Signature (typed name) of Person Submitting ERA Enrollment.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
EMDEON EDI ENROLLMENT FORM
PAYER NAME AND PAYER ID:
PROVIDER INFORMATION:
PROVIDER IDENTIFIER INFORMATION:
PROVIDER CONTACT INFORMATION:
SUBMISSION INFORMATION:
New EDI Enrollment
Penn Behavioral Health Corporate Services
Electronic Claims Request
Date
Client/Account Information
Billing Contact Person Business name
Street address Street address line 2
City State Zip code
E-mail address NPI Number
Billing Address
Same as above
Contact person Business name
Street address Street address line 2
City State Zip code
Please allow 5 to 10 business days for your request to be processed. A representative will be in contact.
*Penn behavioral health requires the use of modifiers and place of service codes for the submission of
electronic claims. Electronic Claims submission is for PBH credentialed providers. Please email a saved copy to
pbhcs@mail.med.upenn.edu or fax to 215746-2695
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PENN BEHAVIORAL HEALTH (53226) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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