PROFESSIONAL BATCH CLAIMS PROVIDER ACD (ADD, CHANGE, DELETE) FORM
ADD CHANGEDELETE / Effective Date: / Form Completed By: / Title: / Phone:1) CURRENTREIMBURSEMENT INFORMATION / 1) CHANGE/ADDREIMBURSEMENT INFORMATION
Pay to Name (Provider/Group): / Pay to Name (Provider/Group):
Pay to Address: / Pay to Address:
City: / State: / Zip: / City: / State: / Zip:
Contact: / Phone: / Contact: / Phone:
Fax: / Site ID: / Fax: / Site ID:
ID # for Claims Submission: / TAX ID SSN / NEW ID # for Claims Submission: / TAX ID SSN
2) Product type: Check only one box / 2) Product type: Check only one box
WebMD Certified Vendor / Vendor/Submitter ID: / WebMD Certified Vendor / Vendor/Submitter ID:
Claim Type: / Medical Dental / TSO ID: / Claim Type: / Medical Dental / TSO ID:
NO PACKET / Report Format: / NO PACKET / Report Format:
Communication Protocol: / Communication Protocol:
Xpedite
/Customer Number:
/ Xpedite /Customer Number:
Other
/Product Name:
/ Other /Product Name:
Customer Number:
/Customer Number:
3) PROVIDER INFORMATION
/3) PROVIDER INFORMATION
Group Name: / Group Name:Provider Name: / Title: / Provider Name: / Title:
Address: / Mail Street / Address: / Mail Street
City: / State: / Zip: / City: / State: / Zip:
Site ID: / (if necessary) / SSN: / Site ID: / (if necessary) / SSN:
UPIN: / License : / State: / UPIN: / License: / State:
Provider Specialty Code(s) : / Type(s) of Practice: / Provider Specialty Code(s) : / Type(s) of Practice:
4) PROFESSIONAL (HCFA 1500/ADA) PAYER SELECTION LIST
/4) PROFESSIONAL (HCFA 1500/ADA) PAYER SELECTION LIST
Check the professional payer(s) to which you plan to submit claims. / Check the professional payer(s) to which you plan to submit claims.Commrcl:
/ Plan: / ID # / Plan: / ID # / Commrcl: / Plan: / ID# / Plan: / ID#Paper:
/ Check here if you want WebMD to print and mail paper claims for you. / Paper: / Check here if you want WebMD to print and mail paper claims for you..*Medicare:
/ Group # / Individual #: / State: / *Medicare: / Group # / Individual #: / State:*Medicare Participating? Yes No (Will default to YES if not marked) / *Medicare Participating? Yes No (Will default to YES if not marked)
Medicaid:
/ Group # / Individual #: / State: /Medicaid:
/ Group # / Individual #: / State:Champus:
/ Group # / Individual #: / State: /Champus:
/ Group # / Individual #: / State:Blue Cross:
/ Group # / Individual #: / State: /Blue Cross:
/ Group # / Individual #: / State:Blue Shield:
/ Group # / Individual #: / State: /Blue Shield:
/ Group # / Individual #: / State:Medicare __Railroad:
/ ID # / DMERC #: / Region: /Medicare ….Railroad:
/ ID #: / DMERC #: / Region:5)
/VENDOR/BILLING service INFORMATION
Vendor Name: / Vendor Phone:Vendor Contact:
/ Vendor E-mail:Billing Service Name:
/ Billing ServicePhone:Billing Service Contact:
/ Billing ServiceE-mail:E-MAIL: FAX: (615) 885-3713 PHONE: (800) 845-6592
Revised 10/9/00