AVAILITY ENROLLMENT FORM PAYER ID: 06102, 06202, 06302 ...

AVAILITY ENROLLMENT FORM

PAYER ID: 06102, 06202, 06302 ,13202

PAYER NAME: NGS MEDICARE PART B (ILLINOIS, MINNESOTA, WISCONSIN, NY Downstate)

Enrollment Instructions:

In order to enroll in electronic transactions for, please complete the following enrollment online at . Please follow the below steps to complete the enrollment.

1. Complete EDI Enrollment If attestation screen comes up, click Accept Select I need to complete a Registration Form Choose Clearinghouse for Method of Electronic Submission Choose Availity LLC form Approved Entities List Clearinghouse Contact Information: o Contact First Name: Client o Contact Last Name: Services o Email: enrollments@

2. Complete EDI Guided Enrollment Enter your provider's billing information (this is the information submitted on the CMS-855 form when originally applying to Medicare) Enter the contact information for your billing provider Contractor Code: Part B IL 06102, Part B MN 06202, Part B WI 06302 (depending on the payer for which you are enrolling) Enter PTAN & NPI Enter billing Provider/Facility Name, billing address, phone number Select Next Choose Transaction Status ? 837 and/or 835 (depending on which transactions you wish to enroll in) Click Submit

3. Complete EDI ERA Enrollment Form Complete General Enrollment Information section. Once the General Enrollment Information section is complete and submitted, the necessary enrollment forms will appear for verification. Information previously entered will auto-populate on each individual EDI enrollment form. o Verify all fields display the correct information for your provider

? Availity, LLC, all rights reserved. | Confidential and proprietary. Page 1 of 2 | Updated 11/30/2017

o Enter provider's Tax ID o Enter CHBN75163 for Trading Partner ID/Submitter ID

If enrolling for ERAs, choose Clearinghouse for Method of Retrieval

Choose/ type in Availity LLC for Vendor Name Enter Client Services for Vendor Contact Enter enrollments@ for Vendor Email o Enter authorized signer's name and title in the Authorized Signature section o Check I Agree box for Terms and Conditions o Enter authorized official's name in the Authorized Official Name section o Select Electronically Sign

4. Complete EDI Registries Form Verify information is correct Check I Agree box for Terms and Conditions Enter authorized official's name in the Authorized Official Name section Select Electronically Sign Choose Link to Third Party Enter CHBN75163 for Trading Partner ID/Submitter ID Select Transaction Authorized for This Submitter and check I Agree box if you agree Enter authorized official's name in the Authorized Official Name section Select Electronically Sign

Note: Once online enrollment is complete, you will be provided with a Packet ID (PID) number at the top right corner of the completed packet if you print it out. *Please save this number for your records and send to a copy to your EDI Specialist for tracking purposes.*

If needed, see the NGS manuals on the NGS website for assistance on completing this enrollment: .

Provider Name: __________________________________________

TIN: ______________________ NPI:_________________________

Email: __________________________________________________

Packet ID Number: ________________________________________

Required: Submission of this form indicates the enrollment instructions have been completed.

Questions: Please contact NGS EDI Helpdesk at 877-273-4334 (J6) or 888-379-9132 (JK)

? Availity, LLC, all rights reserved. | Confidential and proprietary. Page 2 of 2 | Updated 11/30/2017

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