Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the Medicaid office prior to initiation of electronic claims submission or inquiry. 1. IHP Trading Partner Profile (must be completed online) 2. IHP Trading Partner Agreement (must be printed and mailed in) If the above links do not work properly, please download the forms here:

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the MassHealth office prior to initiation of electronic claims submission or inquiry. 1. Trading Partner Agreement If you have difficulty accessing the link above, please go here to download the form: http://www.mass.gov/eohhs/gov/laws-regs/privacy-security/masshealth/edi/masshealth-trading-partner-agreement.html

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the LA BCBS office prior to initiation of electronic claims submission or inquiry. 1. Electronic Trading Partner Agreement (you will need to complete 2 copies of this form in ink) If the above link does not work properly, please go here to download the form: http://www.bcbsla.com

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the EDS office prior to initiation of electronic claims submission or inquiry. 1. Kansas MMIS Electronic Data Interchange Application If the above link does not work properly, please download the form from: https://www.kmap-state-ks.us/
  • Choose EDI at the top then select EDI Application

Enrollment Instructions

Required Documents for those applying for new Submitter ID's

The following documents are required enrollment documents that must be completed, signed and returned to the ASK office prior to initiation of electronic claims submission or inquiry. 1. Enrollment Form (Claims) 2. Enrollment (Electronic Remittance) If you are an existing Submitter, but need to change your information please complete the following: 1. Change Form http://www.ask-edi.com/pdf-docs/EDI_Change_Form.pdf

Required Information

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the Idaho Blue Cross office prior to initiation of electronic claims submission or inquiry. 1. EDI Registration Form If the link listed above does not work properly, please go here: https://www.bcidaho.com/edi_clearinghouse/index.asp Then scroll down to Provider Information and click on “”EDI Registration Form”

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the HP office prior to initiation of electronic claims submission or inquiry. 1. Trading Partner Agreement (Provider) 2. SFTP Access Request Form

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the Delaware Medicaid office prior to initiation of electronic claims submission or inquiry.
  1. ECS Agreement
If the above link does not work properly, you may download the form from here: http://www.dmap.state.de.us/downloads/software.html

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter ID’s

The following documents are required enrollment documents that must be completed, signed and returned to the ACS office prior to initiation of electronic claims submission or inquiry.

Providers

Download and complete the following:

Billing Services/Clearinghouses

Download and complete the following:

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter ID's

The following documents are required enrollment documents that must be completed, signed and returned to the Medi-Cal office prior to initiation of electronic claims submission or inquiry. 1. Medi-Cal Telecommunications Provider and Biller Application/Agreement If the link above does not work properly, please go here: http://files.medi-cal.ca.gov/pubsdoco/forms.asp (You will find this under the Billing, Computer Media Claims (CMC) Section, form number DHCS 6153)

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