Clearing House Engrollment
09/19/08 Electronic Enrollments
*Clients changing from DIALUP to sftp; Cost is 3-4 hours @ 160.00 per hour for ALL Electronic Billing.
*SFTP Requirements: Unix Operating System Version 5.7 or Greater than. – OnSTAFF Version *7/21/08 or greater than. PLEASE CHECK WITH YOUR SOFTWARE VENDOR ON THE VERSION OF THE OS BEFORE SIGNING UP FOR ANY CLEARING HOUSE.
Electronic Statements through DataBill:
Office : 888-638-1002
Fax : 602-415-1255
www.databill.com - Available on UNIX and Windows Platforms
Supported - Electronic Clearinghouse Choices:
The following clearinghouse options are listed in alphabetical order.
ENS http://www.enshealth.com - Available on UNIX and Windows Platforms-sftp
Products and services:
http://www.enshealth.com/enspublic/provider/providermain.htm
- Payer list: http://www.enshealth.com/enspublic/Download/downloadmain.htm
- Enrollment and pricing information included in this document.
Contact :Adrien Garrett
Regional Sales Director
ENS, an Ingenix Company
2525 Lake Park Blvd Salt Lake City, UT 84120
Direct number: : 801-982-3009
Fax: 888-787-8414
Email: adrien.garrett@ingenix.com
ENS ENROLLMENT & PRICING
Owner Information
A. Company Name: __________________________________________
B. Company Address: __________________________________________
City, State, Zip: __________________________________________
C. Area Code & Phone: __________________________________________
D. Area Code & Fax: __________________________________________
E. Contact Person/Title: __________________________________________
F. Email Address: __________________________________________
G. TIN/SSN: __________________________________________
H. Billing Program/Op Sys: __________________________________________
I. # of Prov or Tier Level: __________________________________________
J. Plan Type: __ Per Provider __ Volume Tier __ Per Claim
I. Service Level: __ Standard __ Silver __ Gold
K. ERA/EOBs: __ Flat Rate __ Per ERA/EOBs
L. Optional Service: __ Paper Claims
I. Services For Information
A. Same as Above: __________________________________________
B. Company Name: __________________________________________
C. Company Address: __________________________________________
City, State, Zip: __________________________________________
D. Area Code & Phone: __________________________________________
E. Area Code & Fax: __________________________________________
F. Contact Person/Title: __________________________________________
G. Email Address: __________________________________________
H. TIN/SSN: __________________________________________
I. GROUP BC Number: ________________IND BC:___________________
J. GROUP BS Number: _______________ IND BS:___________________
K. GROUP Medicare: _______________ IND Medicare:______________
L. GROUP Medicaid: _______________ IND Medicaid:______________
O. IND Medicare PIN: __________________________________________
P. Medicare UPIN: __________________________________________
R. Provider SSN (TriCare): __________________________________________
S. GROUP NPI: ______________ IND NPI:_____________________
II. Payment Information - Type
1. Credit Card __Visa __Mastercard __American Express
Card Number: __________________________________________
Expiration Date: __________________________________________
Security Code: __________________________________________
2. Check: Name of Bank:______________________________
Routing Number: __________________________________________
Account Number: __________________________________________
**Other Clearing House Options** – Available ONLY if client is currently transmitting to these clearinghouse**
Availity http://www.availity.com - Available on Windows Platform ONLY
• Products and services: http://www.availity.com/services_home.htm
• Payer list: http://www.availity.com/services_healthplan.htm
• Enroll online: http://www.availity.com/register_home.htm
• Contact number: 1-800-AVAILITY
Gateway EDI http://www.gatewayedi.com (TriZetto)- Available on UNIX Windows Platform
• *Clients changing from DIALUP to sftp; Cost is 3-4 hours @ 160.00 per hour for ALL Electronic Billing.
• *SFTP Requirements: Unix Operating System Version 5.7 or Greater than. – OnSTAFF Version *7/21/08 or greater than. PLEASE CHECK WITH YOUR SOFTWARE VENDOR ON THE VERSION OF THE OS BEFORE SIGNING UP FOR ANY CLEARING HOUSE.
• Products and services: http://www.gatewayedi.com/Products/tools.aspx
• Payer list: http://www.gatewayedi.com/Partners/payers.aspx
• Enrollment and pricing information contact: Beth Langwith, 1-800-969-3666 ext. 1446
.
California Electronic Claims and ERA Direct to Choices:
Blue Shield of California Direct - Available on UNIX and Windows Platforms
• Claims, ERA, and EFT enrollment forms follow.
California Medicare Palmetto GBA - Available on UNIX and Windows Platforms
• Contact Palmetto – 1-866-931-3901 Electronic Billing & ERN/ERA/EOB
California Medi-Cal – Available on UNIX and Windows Platforms
• Contact Medi-Cal CMC Help Desk: 800-541-5555
• ERA is available online, with manual upload into OnSTAFF & Intellect.
• *Any changes to the EB format are billable. See note above*