Envoy Provider Acd (Add, Change, Delete) Form

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:

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

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