Fillable PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers)

Fill Online, Printable, Fillable, Blank PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers) Form

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

PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers)

On average this form takes 21 minutes to complete

The PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers) form is 4 pages long and contains:

0 signatures
0 check-boxes
83 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Availity Providers forms online.

BROWSE AVAILITY PROVIDERS 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



PayerInformation

CPID PayerID Payer Type EstDays MultiCH

    

SpecialEnrollmentInstructions



VendorInformation

SubmitterID SubmitterName



ProviderInformation

TaxID NPI ProviderNumber Name

 

Address City State Zip



ContactName ContactPhone



ContactEmailAddress



ConfirmationAddresses

PrimaryEmailAddress SecondaryEmailAddress



ReportMethod

TSOID ReportType CommunicationProtocol/Output ReportFormat SiteID

  



Send completed form to:

Batchenrollment@changehealthcare.com

Fax: (615) 885-3713

Claims

2456

SMDE0

DE Medicare Part B (J12 - Highmark

Professional

Yes

Only authorized personnel may sign the agreement on pg 5.

Please note: Each Line of Business has a different provider transcation access number (PTAN) and cannot be used

for more than one Medicare Enrollment.

Most Common Denial Reasons: 'Provider's Information does not match payor's system.' Please verify that the

provider's information matches the payor's system before submitting agreement.

'Someone signs the enrollment who isn't authorized to do so.' If you question who is able to sign your enrollment,

please contact payer.

Payer will accept ALL, in section G, for which submitters/receiver ID(s) (Clearinghouses) the provider wants to

maintain existing setup.

Will Change Healthcare be receiving your

Remittance?

Yes

Distribution Detail:

For Change Healthcare use only

22627

ELECTRONIC DATA

INTERCHANGE (EDI) ENROLLMENT

All fields marked with * are required and must be completed. Reference Materials are available on the last page of this document.

*Check all contracts

that apply (Required):

Part A (Institutional) Part B (Professional) J12901

DC (Part A) DCMA (Part B) DE MD

NJ PA

*PROVIDER NAME (Required) (Must match the name for the Group/Billing Provider on file with Medicare as reported on the CMS-855 Enrollment form)

PRACTICE LOCATION (Required)

*STREET

*CITY

*STATE/Province

*ZIP CODE/Postal Code

*CONTACT

*TELEPHONE #

Ext.

FAX #

*EMAIL ADDRESS FOR LISTSERV AND ENROLLMENT RESPONSE

ENVIRONMENTALLY FRIENDLY OPTION: If additional PTANs are linked to my submitter ID in the future, I do not need the

traditional paper mail response. Only mail me my initial enrollment letter.

(Required) Complete using your billing/group PTAN.

*Provider Transaction Access Number (PTAN)

*National Provider Identifier (NPI)

*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

The PTAN/NPI reported above should NOT be the Group MEMBER PTAN/NPI. PTANs may also be known as a CMS Certification

Number. For Affiliated PTANs or National Provider Identifiers (NPIs), attach a signed list on company letterhead, if needed.

If the same entity, other than the Provider, is both preparing and submitting the electronic claims, that entity must be reported on the

CMS-855

form in Section 8. Refer to the Web instructions for more information on this requirement.

*REQUEST TYPE: (Required) (Requests will be processed for the PTAN provided above in the most recent HIPAA-compliant format/version.)

Reason for submission:

New Enrollment

Change Enrollment

Add to existing submitter ID:

Assign this provider a new electronic billing submitter ID.

*Name of electronic billing software vendor:

Enroll for Claim Status and Response (for direct submitters only)

Direct Data Entry Only (DDE) (Part A only)

FISS Logon Request Form also Required

Vendor Change-no additional request should be selected in this block.

*Name of electronic billing software vendor:

ERA Change

*ELECTRONIC REMITTANCE ADVICE (ERA)

(Required)

ERA will be available on a daily basis, based on claim finalization, and is available for retrieval for 60 days. After 60 days from the ERA creation

date, the ERA is no longer available on the telecommunications platform. For Part A customers, the paper remittance will continue for thirty-

one (31) days after initial enrollment for ERA. For Part B customers, the paper remittance will continue for forty-five (45) days after initial

enrollment for ERA. You will no longer receive paper remittances after these time-frames. Designate the ID the ERA should be sent to by

selecting one of the options below. If nothing is selected, existing ERA setup will be maintained, unless you currently receive paper remittance.

Check only one:

Create a new and separate receiver ID for ERA purposes only.

Assign ERA to an existing submitter/receiver ID:

Assign ERA to the new submitter ID being requested in block E of this form.

Maintain existing ERA setup. (This option cannot be selected if currently receiving paper remittance.)

PAGE 1 of 4

22627

8292 (R05-18)

(R05-18)

Submitter ID Name:

*MAINTAIN EXISTING SUBMITTER/RECEIVER ID SETUP

(Required for existing customers)

Providers are required to notify Novitas Solutions of changes involving billing agents or clearinghouses used by the provider. If the PTAN listed

above is associated to any other non-Novitasphere Portal submitter or receiver ID(s), Novitas Solutions will remove the other submitter/receiver

ID(s) immediately, unless indicated below.

Type the submitter/receiver ID(s) or name(s) to be maintained. All other submitter/receiver IDs will be removed. Do not enter PTAN/NPIs in

this box.

✘

1926617

CHANGE HEALTHCARE

Maintain All

SOFTWARE TERMS:

z Novitas Solutions, Inc. (Novitas) is authorized to distribute PC-ACE/PRINTLINK/ETRA (herein referred to as the "Program") to authorized users.

PC-ACE and PRINTLINK software programs are copyrights of ABILITY. The Program is distributed for the purpose of creating electronic Medicare

claim files only. Any use not authorized herein is strictly prohibited, including but not limited to, making copies of any part of the Program,

reselling or transferring copies to any party, or creating any modified or derivative work.

z The Program is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of 

merchantability or fitness for particular purpose.

z In no event will Novitas be liable for any loss or damage, including but not limited to incidental or consequential damages, arising out of the use or 

inability to use the Program even if Novitas has been advised of the possibility of such damages, or for any claim by any other party.

z The authorized user will upgrade this Program within 90 days of upgrade availability. This is a CMS requirement.

z The authorized user will provide the necessary office space, all electrical and telephone connections, hardware, telecommunication software and 

equipment that adhere to the technical requirements located at:

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004599

z Internet download is the preferred method of software installation. Internet download instructions will be provided upon processing of this enrollment. 

There is no fee for software installation via Internet download. To receive the Program in CD-ROM format, visit

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004595

for ordering instructions. A non-refundable $100

annual service fee is required. This service fee covers four quarterly PC-ACE releases.

ADDITIONAL INFORMATION (Optional)

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)

Provider Tax Identification Number (TIN)

National Provider Identifier (NPI)

AGREEMENT

The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS A/B MACs or CEDI:

The Provider Agrees:

1. That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contractor by itself, its employees, or its agents.

2. That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS and/or its A/B MACs,

DME MACs or CEDI without the express written permission of the Medicare beneficiary or his/her parent or legal guardian, or where required for the

care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to Medicare, or as required

by State or Federal law.

3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required

beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file.

4. That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must

reflect the following information: Beneficiary's name, beneficiary's health insurance claim number, date(s) of service, diagnosis/nature of illness, and

procedure/service performed.

5. That the Secretary of Health and Human Services or his/her designee and/or the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS

has the right to audit and confirm information submitted by the provider and shall have access to all original source documents and medical records

related to the provider's submissions, including the beneficiary's authorization and signature. All incorrect payments that are discovered as a result of

such an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and CMS guidelines.

6. That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that Medicare is the primary

payer.

7. That it will submit claims that are accurate, complete, and truthful.

8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years,

3 months after the bill is paid.

9. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically transmitted to the A/B

MAC, CEDI, or other contractor if designated by CMS.

10. That the CMS-assigned unique identifier number (submitter identifier) or NPI constitutes the provider's legal electronic signature and constitutes an

assurance by the provider that services were performed as billed.

11. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all

transmissions of documents are authorized and protect all beneficiary-specific data from improper access.

12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim for payment under the Medicare

program, and that anyone who misrepresents or falsifies or causes to be misrepresented or falsified any record or other information relating to that claim

that is required pursuant to this Agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law.

13. That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from

CMS or its A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS, shall not be used by agents, officers, or employees of the billing

service except as provided by the A/B MAC, DME MAC, or CEDI (in accordance with §1106(a) of the Social Security Act) (the Act).

14. That it will research and correct claim discrepancies.

15. That it will notify the A/B MAC, CEDI or other contractor if designated by CMS within 2 business days if any transmitted data are received in an

unintelligible or garbled form.

PAGE 2 of 4

8292 (R05-18)

(R05-18)

When checking the box to enroll, you are agreeing to the software terms listed below

ENROLL FOR ABILITY | PC-ACE

ABILITY | PC-ACE ENROLLMENT (Optional)

The Centers for Medicare & Medicaid Services (CMS) agrees to:

1. Transmit to the provider an acknowledgement of claim receipt.

2. Affix the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS number, as its electronic signature, on each remittance advice sent to

the provider.

3. Ensure that payments to providers are timely in accordance with CMS's policies.

4. Ensure that no A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from the

A/B MAC, CEDI or from any subsidiary of the A/B MAC, CEDI, other contractor if designated by CMS, or from any company for which the A/B

MAC, CEDI has an interest. The A/B MAC, CEDI, or other contractor if designated by CMS will make alternative means available to any electronic

biller to obtain such services.

5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare A/B MACs, CEDI, or other contractor if

designated by CMS to make available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal

access will be granted to any services sold directly, indirectly, or by arrangement by the A/B MAC, CEDI, or other contractor if designated by CMS.

6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form.

NOTE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made

by CMS under this document.

This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as

long as Medicare claims are submitted to the A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS. Novitas reserves the right to

terminate this agreement if there is no EDI activity within a six (6) month period. You agree that Novitas will be entitled to damages, court costs and

reasonable attorney's fees if you breach this agreement. Either party may terminate this agreement by giving the other party thirty (30) days written notice

of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of

mailing, as established by the postmark or other appropriate evidence of transmittal.

ATTESTATION

Any provider who submits Medicare claims electronically to CMS or its contractors remains responsible for those claims as those

responsibilities are outlined on the EDI Enrollment. In accepting claims submitted electronically to the Medicare Program from any

billing service or through the use of a particular product which accomplishes this process, neither CMS, nor any other Medicare

contractors are attesting to the appropriateness of the methods used by the billing service/clearinghouse or to the accuracy of a particular

vendor's product used to facilitate such electronic submissions. The provider furnishing the item or service for whom payment is claimed

under the Medicare Program retains the responsibility for any claim regardless of the format it chooses to use to submit the claim.

Prior to signing this agreement, please carefully review the technical requirements for electronic billing in Chapter 3 of the

Electronic

Billing Guide. New EDI submitters must connect to Novitas within 90 days of receiving the logon ID by using the Secure File Transfer

Protocol (SFTP) software provided by your Network Service Vendor.

I understand that any individual who knowingly and willfully makes or causes to be made any false claim or false statement of

false representation of a material fact in any application to the federal government for benefits or payment with respect to the Medicare

program may be subject to civil and/or criminal enforcement action which may result in fines, penalties, damages and/or imprisonment.

AUTHORIZED/DELEGATED OFFICIAL SIGNATURE REQUIREMENTS

I certify that I have been appointed an authorized individual to whom the provider has granted the legal authority to enroll it in the

Medicare Program, to make changes and/or updates to the provider's status in the Medicare Program (e.g., new practice locations, change

of address, etc.), and to commit the provider to abide by the laws, regulations, and the program instructions of Medicare. I authorize the

above listed entities to communicate electronically with Novitas Solutions on my behalf.

By signing below, the provider confirms they have read and agree to the Agreement, the Attestation, and the above signature

requirements.

The Authorized Official signing this form must be an AUTHORIZED OR DELEGATED OFFICIAL that was listed on the

Medicare Enrollment Application (CMS-855).

*WRITTEN SIGNATURE OF PERSON SUBMITTING ENROLLMENT (add after you print out the form) *DATE (add after you print out the form)

*PRINTED NAME OF PERSON SUBMITTING ENROLLMENT *PRINTED TITLE OF PERSON SUBMITTING ENROLLMENT

COMPLETE FORM, PRINT, SIGN, DATE AND MAIL OR FAX ALL PAGES TO:

Novitas Solutions, Inc. - EDI, P.O. Box 3011, Mechanicsburg, PA 17055-1801

or Fax: 1 (877) 439-5479

PAGE 3 of 4

8292 (R05-18)

If Providers elect to submit/receive transactions electronically using a third party such as a billing agent or a clearinghouse, the A/B MACs or CEDI must

notify these providers that they are required to have an agreement singed by that third party. The third party must agree to meet the same Medicare security

and privacy requirements that apply to the provider in regard to viewing or use of Medicare beneficiary data. (These agreements are not to be submitted to

Medicare, but are to be retained by the providers.)

(R05-18)

Complete agreement, print, and obtain signature.

REFERENCE MATERIALS

Instructions for completing this form may be found at

http://www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/

dDocName:00024714.

To request the status of your EDI enrollment form, complete the EDI Enrollment Status Inquiry Tool at

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/page/pagebyid?contentId=00004524

For questions, please contact an EDI Analyst at 1-877-235-8073, Option 3.

PAGE 4 of 4

8292 (R05-18)

(R05-18)

NOVITASPHERE PORTAL

Get instant access to the world of online Medicare transactions with Novitasphere!

Novitasphere is a FREE, secure internet portal for Part A and B customers to easily connect directly to Novitas Solutions. Novitasphere

provides quick access to beneficiary eligibility, claim submission, claim corrections (Part B), electronic remittance advice, appeals

requests, and many other time saving features. It's free, easy, and secure to perform transactions online, saving your office valuable time.

We encourage everyone to explore and discover the online world of Novitasphere!

To find out more, including how to enroll for Novitasphere, visit the Novitasphere Center at

http://www.novitas-solutions.com/webcenter/

portal/Novitasphere_JL.

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers)

View Audit Log
Print With Audit Log
Duplicate Document

Fillable PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers)

Fill Online, Printable, Fillable, Blank PayerInformation CPID PayerID Payer Type EstDays MultiCH SpecialEnrollmentInstructions (Availity Providers) Form

Related forms

First 20 documents completely FREE!