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
Page 1 of 2
ProviderConnect Account Request Form
Access to Multiple Provider Files
__________________________________________________________________________
Name of staff
m
e
m
b
e
r
_____________________________________________________________________________________________________
Address
City State Zip
C
o
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e
( )
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Telephone Number
Fax Number
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.
Provider/Facility
N
a
m
e
Beacon Health Options
Assigned ID
Tax
I
D(s)
NPI
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 MHA 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
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
Page 2 of 2
Agreement Terms:
A. The undersigned submitter authorizes Beacon Health Options, Inc. (Beacon) to receive and process claims, batch registration,
authorization and/or discharge submissions via the Beacon Electronic Transport System (ETS) or Beacon Online Provider Services
Program on his / her / its behalf in accordance with the applicable regulations.
B. All submitted information must be true, accurate and complete. I / We understand that payment of any claim submitted in falsification
or concealment of a material fact may be prosecuted under any applicable state and/or federal laws.
C. The Submitter agrees to comply with any laws, rules and regulations governing the Beacon Online Provider Services / EDI program.
D. The Provider agrees to accept, as payment in full, the amounts paid in accordance with the fee schedules provided for under
previously established agreements with Beacon.
E. This is to certify that an exact copy of any claim files submitted via the Beacon ETS system or Online Provider Services program will
be stored in an electronic medium and held by the originator for a period of 90 days or until the submission has been finalized as to
reimbursement or denial of payment, whichever comes first.
Signatures:
Legal name of Organization Title of individual signing for organization
Name of Individual Signing for Organization Authorizing Signature Date