Fillable ProviderConnect Online Services Account Request Form Provider, Practice

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ProviderConnect Online Services Account Request Form Provider, Practice

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The ProviderConnect Online Services Account Request Form Provider, Practice form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 30 other fields

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File type: PDF

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Page 1 of 3
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 Online Services Account Request Form
Provider, Practice or Facility Name
Special Account Setup:
Additional User Account
Super User Account
Military OneSource
Beacon Health Options Assigned ID
National Provider Identifier (NPI)
Beacon Health Options Network Specific Assigned ID (Massachusetts, Illinois, Georgia Only)
Provider, Practice or Facility Tax IDs to be associated to this online account. If more than one, please list all.
Address
Cit
y
State Zip Code
( )
( )
Telephone Number
Fax Number
Please indicate if this request is for MBHP, Commercial or both. _______________
If you intend to submit batch transactions for one of the states below please mark the appropriate box:
1. Illinois, batch registration for Illinois Mental Health Collaborative or ICG clients? Yes No
2. Georgia, batch registration, authorization, discharge or claims for Georgia Collaborative ASO?
Yes No
Default functions included with your account access: Eligibility Inquiry, Claim Status, Authorization Inquiry and Provider
Summary Voucher access.
If
you intend to submit Direct Data Entry claims via ProviderConnect please mark here: Yes No
Conta
ct Name (ProviderConnect Account User)
Contact’s e-mail address
E-mail
address where you would like to receive your batch submission file feedback
Page 2 of 3
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
Agreement Terms:
A. The
undersigned submitter authorizes Beacon Health Options, Inc. to receive and process batch registration,
authorization and/or discharge submissions via Beacon Health Options Online Provider Services Program on
his/her/its behalf in accordance with the applicable regulations.
B. Al
l 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 Health Options 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 Health Options.
This is to certify that the following is true:
I am a provider
OR
I am office staff of a Provider, and am authorized to sign on their behalf.
Signatures:
Lega
l name of Organization Title of individual signing for organization
Name of Indivi
dual Signing for Organization Authorizing Signature Date
For Super User Accounts Only; managed user Information:
Fi
rst and Last Name of Initial Managed User Managed User’s Phone
(Must differ from Super User on page 1)
Managed User’s e-mail address (Please print)
(Must differ from Super User on page 1)
click to sign
signature
click to edit
Page 3 of 3
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
Instructions for Account Request
Form
The Account Request Form is only for activating online access on Beacon Health Options ProviderConnect website. If
you need to update your address, tax ID or NPI information, you will need to contact our Provider Relations area at
800.397.1630. Please do not make additional notations on the Account Request Form unless advised to do so by
these instructions or by the EDI Helpdesk.
For guides on Direct Claim Submission and Authorization Submission, visit the Compliance page at:
http://www.valueoptions.com/providers/ProCompliance.htm
.
Additional User Account:
If a ProviderConnect account already exists for the provider or facility, and an office staff member needs their own unique
ID/password, you can check this box. If this secondary account needs to be disabled or deleted for any reason, it will be the
provider’s responsibility to contact the EDI Helpdesk immediately.
Super User Account:
Only check this box if you are registering to access ProviderConnect as an administrator to manage other users of your
account.
Provider ID number:
You can retrieve your Beacon Health Options assigned provider number by reviewing any Provider Summary
Vouchers/EOBs you have previously received; the Provider # will be present at the beginning of each claim. Or,
depending on what state and type of claims you will be submitting, the following service centers will be able to best
assist you:
For all commercial accounts or states not listed below: 800.397.1630
Illinois Mental Health Collaborative or ICG: 800.397.1630
Massachusetts MBHP: 800.495.0086 (If submitting for both Commercial and MBHP clients, please provide
both provider numbers)
Georgia Collaborative: 800.397
.1630
Direct Claim Submission:
Direct Claim Submission: If you are a smaller practice, or happen to have a low volume of Professional claims (normally
submitted on a HCFA-1500 or CMS-1500), Single Claim Submission may be best and easiest. With this option, you can
submit each claim directly on the website, the member and provider information are verified, and you receive a claim
number right away.
Claim Adjustment: The ProviderConnect Online Adjustment Module allows users to electronically submit changes
(adjustments) to previously processed claims. This feature allows users to correct claims where the original result of the
claim’s processing is not the correct outcome for the services rendered or where information was submitted incorrectly on
the original claim.
Commercial and Medicaid Claims:
We may need to create more than one online account for you if you need to submit both commercial and Medicaid claims.
If you only select commercial or Medicaid for now, and you need to add the other in the future, please contact the EDI
Helpdesk and we can make the appropriate updates for you. If no option is checked, the default will be Commercial
Only.
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ProviderConnect Online Services Account Request Form Provider, Practice

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Completed 25 May 2022

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