Please return this form via fax to 866.698.6032
Beacon Health Options, Inc. | EDI Helpdesk | PO Box 1287, Latham, NY 12110 | Phone#:
888.247.9311
Incomplete, incorrect or illegible forms may delay or prevent proper
processing
ProviderConnect Account Request Form
Access to Multiple Provider Files
__________________________________________________________________________
Name of staff
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_____________________________________________________________________________________________________
Address
City State Zip
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Please check which Online Provider Services options you would like to have access to:
Electronic Batch Claims (837)
Direct Claim Submission
277CA Acknowledgement File
999 Acknowledgement File
__________________________________________________________________________
Staff member’s contact e-mail address – Please print
__________________________________________________________________________
E-mail address where you would like to receive your batch submission file feedback.
This is for a new login ID
We are adding a provider number to an existing multi-user account. Existing Login ID
:
Please list the names and provider number of all the providers you will need access to with this account (ProviderConnect registration
for each of these providers must have been completed prior to submission of this form):
You must also indicate what specific tax IDs that this user should be allowed access to under that provider number. All fields are
required. Additional sheets may be included to accommodate linking more than 5 providers at one time.
Beacon Health Options
Assigned ID
Depending on the state in which you are practicing, you may need multiple logins created to ensure the claims are processed
accurately (i.e.Medicaid vs. Commercial). If you intend to submit batch transactions for one of the states below please mark the
appropriate box:
1. Colorado, batch claims for Colorado Medicaid clients? Yes No Both
2. Kansas, batch claims for Kansas Medicaid or AAPS Block Grant clients? Yes No Both
3. Maryland, batch claims Maryland BHA clients? Yes No Both
4. Massachusetts, batch claims for Massachusetts Behavioral Health Partnership (MBHP)? Yes No Both
5. Pennsylvania, batch claims for SWPA Medicaid clients? Yes No Both
6. Pennsylvania, batch claims for Non-HealthChoices Mental Health Program? Yes No Both
7. Texas, batch claims for Texas NorthSTAR clients? Yes No Both
8. Illinois, batch registration for Illinois Mental Health Collaborative or ICG clients? Yes No
9. Georgia, batch registration, authorization, discharge or claims for Georgia Collaborative ASO? Yes No
Automatically included:
Eligibility Inquiry
Claim Status
Authorization Inquiry
Provider Summary Vouchers
