REQUEST FOR SIGN-ON AND CLIENT ID



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Instructions for Completing Blue Cross Blue Shield of Alabama Professional Enrollment Form

1. Print entire document.

2. Electronic Data Interchange (EDI) Enrollment Form – complete B:Signature section only

- Provider Name – Name of facility

- UPIN and Provider Number – List the provider number and UPIN of at least one provider. If there are multiple providers, they will be listed on the last page of the form.

- Title – Title of individual completing enrolment form

- Address, City/ST/Zip – Physical street address, city, state and zip of facility

- By – Individual signing

- Signature – Signature of authorized individual from facility

- Title – Title of individual signing (if a different person than who completed the form)

- Date – Date of signature

3. EDI Enrollment Request for New Submitter ID Form - Complete Section I and IV and signature

- Section I – complete all information

- Section IV – Fill in Provider Name (facility name), Provider Number, Common Pay Number and Tax ID number

- Sign and date

4. Complete second page of EDI Enrollment Request for New Submitter ID Form only if multiple providers need to be listed.

5. Please fax all forms back to Passport Health at (866) 921-8415 attn: Enrollment Administrator

6. Do not fax enrollment forms to BCBS of Alabama.

7. For any questions, contact Stacey Smith at (615) 261-1272 or stacey.smith@

8. Billing Agencies: Your clients must complete and sign this paperwork, you cannot complete for them. Please have your client follow steps one through six and return the forms to you to return to Passport.

Thank you for your interest in Passport!

ELECTRONIC DATA INTERCHANGE (EDI) ENROLLMENT FORM

PLEASE CHECK APPLICABLE LINE OF BUSINESS

INSTITUTIONAL

PROFESSIONAL

The provider agrees to the following provisions for submitting physician, supplier or facility transactions electronically to Blue Cross and Blue Shield of Alabama further referred to as Blue Cross.

A. The Provider Agrees:

1. That it will be responsible for all electronic transactions submitted to Blue Cross by itself, its employees, or its agents.

2. That it will not disclose any information concerning a Blue Cross beneficiary to any other person or organization, except Blue Cross,

without the express written permission of the 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 Blue Cross,

or as required by State or Federal Law.

3. That it will submit claims only on behalf of those Blue Cross 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 is will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect at least 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 Blue Cross has the right o 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 Blue Cross guidelines.

6. That I will ensure that all claims for Blue Cross primary payment have been developed for other insurance involvement and that Blue Cross is the primary payer.

7. That is 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 Blue Cross claim for period of at least 6 years, 3 months after the bill is paid.

9. That it will affix the Blue Cross-assigned unique identifier number of the provider on each claim electronically transmitted to Blue Cross.

10. That the Blue Cross-assigned unique identifier number constitutes the provider’s legal electronic signature and constitutes and assurance by the provider that services were performed as billed.

11. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access.

12. That the submission of such claims is a claim for payment under the Blue Cross program, and that anyone who misrepresents or falsifies or caused to be misrepresented or falsified any record o 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 Blue Cross beneficiaries, or any information obtained from Blue Cross, shall not be used by agents, officers, or employees of the billing service except as provided by Blue Cross.

14. That it will research and correct claim discrepancies.

15. That it will notify Blue Cross if any transmitted data are received in an unintelligible or garbled form.

ELECTRONIC DATA INTERCHANGE (EDI) ENROLLMENT FORM

PLEASE CHECK APPLICABLE LINE OF BUSINESS

INSTITUTIONAL

PROFESSIONAL

B. Blue Cross Agrees To:

1. Make available to the provider an acknowledgement of claim receipt.

2. Affix the Blue Cross payer ID as its electronic signature, on each remittance advice sent to the provider.

3. Ensure that payments to providers are timely in accordance with contract policies.

4. Ensure that Blue Cross may not require the provider to purchase any or all electronic services from Blue Cross or from any subsidiary of Blue Cross of from any company for which Blue Cross has an interest. Blue Cross will make alternative means available to any electronic biller to obtain such services.

5. Ensure that all Blue Cross electronic billers have equal access to any services that Blue Cross requires of electronic submitters 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 Blue Cross sells directly, indirectly or by arrangement.

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

A. NOTICE:

Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by Blue Cross under this document.

This document shall become effective when signed by the p provider. The responsibilities and obligations contained in this document will remain in effect as long as Blue Cross electronic claims are submitted to Blue Cross. Either party may terminate this arrangement by giving the other party (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.

B. SIGNATURE:

I am authorized to sign this document on behalf of the indicated party and I have ready and agree to the foregoing provisions and acknowledge same by signing below.

Provider’s Name: UPIN and Provider Number

____________________________________________________ _______________________________

Title: __________________________________________________________________________________________

Address: _________________________________________________________________________________________

City/ST/Zip:_______________________________________________________________________________________

By: ____________________________________ X__________________________________________________

(PRINT NAME) (SIGNATURE)

Title: __________________________________________________________________________________________

Date: ______________________________________________

FAX THIS FORM WITH SIGNATURES TO: PASSPORT HEALTH COMMUNICATIONS AT (615)261-5618

EDI ENROLLMENT REQUEST

FOR NEW SUBMITTER ID

BCBSEDI-SNR-0706-AL

SECTION I. To be completed by facility

PRACTICE/FACILITY NAME:____________________________________________________________________

ADDRESS:__________________________________________________________________________________

CITY:_________________________________________ STATE:______________ ZIP:_____________________

TELEPHONE: (______)__________________________ CONTACT NAME:_______________________________

FAX NUMBER: (______)_________________________ E-MAIL:_______________________________________

SECTION II.

VENDOR/CLEARINGHOUSE NAME: Passport Health Communications, Inc______

TELEPHONE: (615) _261-1272__________________ CONTACT NAME: Stacey Smith___________ _______

FAX NUMBER: (866)_921-8415___ ____________ E-MAIL: enrollment@_ _______

SECTION III.

Indicate the method of Indicate the requested transactions

connection

(Choose One) (Choose One)

Dial Up 837 Dental Transaction Not required until new version adopted

Frame Relay 837 Institutional Transaction Indicate the ANSI format:

Internet 837 {repfessopma; Tramsactopm 837______________________

835 Remittance Transaction 835______________________

278 Referral/Precert Transaction 278______________________

270/276 Eligibility/Claim Status Transaction 270/276___________________

Assign 270/276 password by : Submitter ID

Provider ID

Submitter ID*: * if submitter ID is assigned by vendor/clearinghouse, please indicate submitter id

SECTION IV. Please list facility name, provider number, common pay number and tax id number

|NAME OF PROVIDER(S) YOU ARE ADDING TO CURRENT SUBMITTER |PROVIDER NUMBER |COMMON PAY NUMBER |TAX ID |

|NUMBER | | | |

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The undersigned hereby:

• Authorizes Blue Cross and Blue Shield of Alabama to disclose protected health information to the business associate identified in Section II;

• Authorized Blue Cross and Blue Shield of Alabama to return provider passwords to the business associate identified in Section II; and,

• Agrees to notify Blue Cross and Blue Shield of Alabama if the business associate identified in Section II changes.

_______________________________________________ _________________________________________

Authorized Signature Date

EDI ENROLLMENT REQUEST

ADDITIONAL PROVIDERS

(Must be accompanied by a New Submitter ID Form)

BCBSEDI-SNR-0706-AL

|NAME OF PROVIDER(S) |PROVIDER NUMBER |COMMON PAY NUMBER |TAX ID |

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Please fax to Passport Health Communications

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