Emdeon Claims Provider Setup Form

1

/

Provider Organization

Practice/ Facility Name
/ Provider Name / NPI
Provider Specialty Code
/ Tax ID/ SSN / Site ID
Address
/ City/State / Zip Code
Contact First Name
/ Contact Last Name / Title / CEOCFODDODDSDMDDOMDPHDDCOffice ManagerNone
E-mail Address
/ Telephone / Fax
2 /

Vendor (Emdeon certified vendor used to submit files to Emdeon)

Vendor Name
/ MD On-Line /
Submitter ID
/ 223389595
Contact First Name
/ Miranda / Contact Last Name / Beadle / Title / CEOCFODDODDSDMDDOMDPHDDCOffice ManagerNone
E-mail Address
/ / Telephone / 888-397-3434 / Fax / 707-839-5961

3

/

Product Type

TSO ID / F3RK / Communication Protocol /Output / Select from ListA = Async (Kermit 5)E = BISYNC (M)F = File Transfer (NDM)K = PK Zipped/CommServer, FTP, ITS, VPNM = KermitR = BISYNC (H)S = CommlinkOTHER
Report Type
/ P / POSI Direct Cust # /User ID
Report Format
/ B / Paper Claims Mailed? / Yes No

4

/ Payer
M = Medical / H = Hospital / Commercial
Please list additional payers below
Check the Emdeon Payer List to see if additional enrollment is required http://www.emdeon.com/PayerLists/payerlists.php
Payer ID / Group ID / Individual Provider ID / Payer ID / Group ID / Individual Provider ID
MH / MH
MH / MH
MH / MH
MH / MH
MH / MH

5

/

Confirmations

Send Emdeon Claim Setup Confirmations To:
/ Select from ListNoneBoth - Sections 1 and 2Provider Org - Section 1Vendor - Secton 2
Send Additional Claim Setup Confirmations To:
/

Emdeon Internal Use Only Division ID: 15347 Account ID:______Master Account ID: ______

Claim Provider Setup Form Revised 03/07