Fillable PHYSICAL ADDRESS REGISTRATION LETTER INSTRUCTIONS AND TEMPLATE (Office Ally)

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PHYSICAL ADDRESS REGISTRATION LETTER INSTRUCTIONS AND TEMPLATE (Office Ally)

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Office Ally | PO Box 872020 | Vancouver, WA 98687
www.officeally.com
Phone: 360-975-7000
Fax: 360-896-2151
Office Ally offers the ability for Providers to Register Physical Address Information with Office Ally in order to meet
5010 requirement for CMS1500 Box 33 Billing Provider Address.
With the implementation of the 5010 format, PO or Lock Box addresses are no longer allowed in the Billing Provider
loop (CMS1500 Box 33).
DOES THIS AFFECT YOU?
If you are not sure whether this affects you, check what address you are currently sending Office Ally in Box 33 of the
CMS1500.
- If you are sending a physical address in Box 33, this notice does not affect you.
- If you are sending a PO Box address in Box 33, this notice is for you.
I AM SENDING A PO BOX IN BOX 33, WHAT DOES THIS MEAN FOR ME?
Providers who currently send their Pay-To Address (that is a PO Box) in CMS1500 Box 33 could receive claim rejections
from Payers that enforce the 5010 rule that PO Boxes are not allowed in the Billing Provider loop.
WHAT CAN I DO?
Office Ally has set up the ability for providers to register their Physical Address (by Billing NPI) with Office Ally.
To take advantage of this new ability, providers can fax/email an authorization letter to Office Ally; it must be on the
Provider/Practice letterhead and contain:
- Billing Provider NPI the request is in reference to
- Physical Address to be registered under the Billing Provider NPI above (make sure to include the full 9 digit zip
code, which is another possible requirement under the 5010 format)
- W
ording authorizing Office Ally to register the physical address under the Billing Provider NPI provided, so that,
for claims that have a PO Box address sent in CMS1500 Box 33, Office Ally will copy that PO Box address to the
Pay
-T
o Provider loop and populate the registered physical address into CMS1500 Box 33 (Billing Provider Loop)
- O
ffice Ally Username
- Email address that a confirmation can be sent to once registration complete
- Signature of the Provider/Owner of the practice with name and title listed
A template letter that can be filled out electronically, and then printed on your letterhead, can be found on the last
page.
T
he letter can be faxed to Office Ally at (360) 896-
2151
or emailed to support@officeally.com
NOTE: Emailed letters MUST be scanned letters that contain actual signatures.
PHYSICAL ADDRESS REGISTRATION LETTER
INSTRUCTIONS AND TEMPLATE
Office Ally | PO Box 872020 | Vancouver, WA 98687
www.officeally.com
Phone: 360-975-7000
Fax: 360-896-2151
WHAT HAPPENS NEXT?:
O
nce the request is received, it will be processed within 5
-
7 business days. Once the request is processed a
confirmation/rejection email will be sent to the email provided in the letter. For confirmed requests, future claims that
contain a PO Box in Box 33 will have that PO Box address moved to the Pay
-
To Provider loop and the registered
physical address populated into CMS1500 Box 33 (Billing Provider Loop).
Note that this will NOT affect claims going out via paper claim. This is so that paper claims will be printed with
whatever address you submit in Box 33.
I
t is your responsibility to make sure your request is processed, if you do not receive a confirmation/rejection email
within 5
-
7 business days, please contact Office Ally Customer Support by emailing us at support@officeally.com or call
us at (360) 975-7000 option 1.
HELP IS AVAILABLE FOR YOU:
I
f you have any questions regarding this, please feel free to contact Office Ally Customer Support by emailing us at
support@officeally.com or call us at (360) 975-
700
0 option 1.
Office Ally | PO Box 872020 | Vancouver, WA 98687
www.officeally.com
Phone: 360-975-7000
Fax: 360-896-2151
RE: Physical Address Registration Letter (Must be printed on Company Letterhead
)
Today’s Date: _______________
To Whom It May Concern:
I
hereby authorize Office Ally to r
egister the physical address under the Billing Provider NPI provided, so that,
for claims that have a PO Box address sent in CMS1500 Box 33, Office Ally will copy that PO Box address to
the Pay
-T
o Provider loop and populate the registered physical address into CMS1500 Box 33 (Billing Provider
Loop)
.
B
illing Provider NPI: __________________
Physical Address to be registered: ________________________________________________
NOTE: The PO BOX cannot be the address to be registered, please only add the Physical Address. Zip Code must be 9 digits.
Office Ally Username: ___________________
Email Address: ___________________________________
By signing below, I certify that I am an authorized individual for the Provider/Group NPI(s) listed above and that I
am authorized to sign on their behalf.
___________________________________
Authorized Individual’s Signature
___________________________________
Printed Name of Authorized Individual
___________________________________
Title of Authorized Individual (Must be
CEO, CFO, COO, President or Owner)
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Completed 8 April 2021

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