835 Healthcare Claim Payment/Advice Request Form General Completion Instructions. SECTION A TYPE OF REQUEST (Please choose only one)

“835 Healthcare Claim Payment/Advice Request Form”

General Completion Instructions

Purpose: The 835 Healthcare Claim Payment/Advice Request Form is designed for entities wanting to

sign up to receive an 835 version 4010A1 Healthcare Claim Payment/Advice electronic transaction. This form may also be used by entities to change (Add/Remove a provider) or modify existing demographic information.

SECTION A – TYPE OF REQUEST (Please choose only one)

· Initial Request - Check this box to sign up to receive an 835 Healthcare Claim Payment/Advice.

· Change - Check this box to:

o Modify existing sender/receiver information

o

Add or delete a provider

SECTION B – ORGANIZATION/SENDER INFORMATION

Complete the Organization/Sender information appropriately. All fields are required with the exception of the “Sender Number” field. The “Sender Number” field should be the entity that will be retrieving the remittance from Availity and should only be completed if applicable.

SECTION C – VENDOR INFORMATION

(Example: Company that supports ERA Software, Billing Service, and Clearinghouse) Complete the Vendor information appropriately. This section is for the vendor that supports your electronic remittance advice software.

The following fields are required:

· Vendor Name

· Contact Name

· Telephone Number

The remaining fields should only be completed if applicable.

SECTION D: WHERE DO YOU WANT YOUR ELECTRONIC REMITS SENT?

Select A if you would like your electronic remits sent to your Availity Mailbox directly (where you retrieve your other files on Availity)

Select B if you would like your electronic remits to be sent to your vendor, billing service, or clearinghouse and not directly to you.

SECTION E – PROVIDER/SUPPLIER/PA GROUP/ FACILITY NUMBER(S)

List all individual providers (physician or facility), their Federal Tax ID, and their Blue Cross Blue Shield of Florida assigned provider number for which you would like to receive Remittance Notification.

SECTION F – AVAILITY INFORMATION

All 835 version 4010A1 Healthcare Remittance Payment/Advice receivers must be registered with Availity prior to submitting this request form to Blue Cross Blue Shield of Florida. Check “yes” if registered with Availity.

To Register with Availity, please call 1-800-Availity or visit their website at www.availity.com.

Completed Forms – Return completed forms to the address indicated on page 6 of the 835 Healthcare

Claim Payment/Advice request form or fax them to 904-359-8259 Attention: Sender Setup.

835 HEALTHCARE CLAIM PAYMENT/ADVICE

REQUEST FORM

SECTION A: TYPE OF REQUEST

Initial Request

Change (Add/Remove Provider)

SECTION B: ORGANIZATION/SENDER INFORMATION

Organization/Sender Name:

Organization Address:

Contact Name:

Telephone Number:

Fax Number:

Sender Number (if applicable)

SECTION C: VENDOR INFORMATION

(Example: Company that supports ERA Software, Billing Service, and Clearinghouse)

Vendor Name:

Address:

Contact Name:

Telephone Number:

Fax Number:

Vendor Number (if applicable)

SECTION D: WHERE DO YOU WANT YOUR ELECTRONIC REMITS SENT?

A -Your Availity Mailbox

B - Vendor, Billing Service, Clearinghouse Availity Mailbox

Electronic Network Systems, Inc

7899 Lexington Drive, Suite 203

Colorado Springs CO 80920

719 - 277-7545 x1303 719-277-0254 Kim Escher

SECTION E: PROVIDER/SUPPLIER/PA GROUP/ FACILITY NUMBER(S)

List all individual providers (physician or facility), their Federal Tax ID, and their Blue

Cross Blue Shield of Florida assigned provider number for which you would like to

receive Remittance Notifications on their behalf.

Professional

If you receive reimbursement for multiple tax ids, please list them here. If there is a

preference to receiving the 835 for one tax id, please list the tax id in 1

st

row.

Provider Name /

PA Group Name

BCBSFL

Provider

No.

Federal Tax ID

For

Inter

Use

Only

Institutional

If you receive reimbursement for multiple tax ids, please list them here. If there is

a preference to receiving the 835 for one tax id, please list the tax id in 1

st

row.

Facility Name

BCBSFL

Facility No.

Federal Tax ID

For

Inter

Use

Only

SECTION F: AVAILITY INFORMATION

All Electronic Remittance Advice (ERA) receivers must be registered with Availity.

In order to receive an 835, you must be registered with Availity prior to submitting this

request to Blue Cross Blue Shield of Florida. Please contact 1-800-Availity or visit their

website at

www.availity.com

.

RETURN COMPLETED FORMS TO:

BCBSF

4800 Deerwood Campus Parkway

Jacksonville, FL 32246

Attn: DCC2-5 - Sender Setup

OR FAX TO: 904-357-8259 Attention: Sender Setup

FOR INTERNAL USE ONLY

Provider File Update: By:

TPD SCODE: GENKEY:

Availity Business Associate Provider Access Delegation Form

To:

Availity,

L.L.C.

From [Provider]:

Tax ID #:

Subject:

Availity Business Associate Provider Access Delegation Form

Date:

I am a Physician, Hospital-Based Physician, or Physician Group currently under

contract with

[Business Associate]

having

offices

at

for medical billing and/or other claims related services.

I do hereby authorize [Business Associate] access to claims and other related

information for my patients through their use of the Availity

®

Gateway

.

I do hereby

affirm that all of the necessary consents have been obtained from such patients to grant

access to their claims and other related information to [Business Associate].

Upon the termination of services provided by [Business Associate] to my practice, I

understand it is my responsibility to notify Availity through the execution of the

Availity

Business Associate Provider Access Termination Form

, which can be provided by the

Business Associate currently performing transactions on my behalf or accessed online

at

www.availity.com

.

Physician, Hospital-Based Physician, or Physician Group Name

Title

Signature