SolAce Electronic Medical Claims - Medicaid

Magellan Complete Care of Virginia

cneely — Fri, 28 Jul 2017 22:15:19 +0000

The following document is a required enrollment form that must be completed, signed and returned to the MCC of VA office prior to initiation of electronic claims submission or inquiry.

1.https://mccofva.com/media/1531/ebusiness-submitter-profile-form-fill_mccva.pdf

If the link above does not work properly, please download it from here:

https://mccofva.com/ccc-plus/for-providers/provider-tools/forms/claims-forms/

If you have trouble finding the form above, please call the Magellan eBusiness Service Center at 1-800-424-4524.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - N/A

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Magellan Complete Care of Virginia

Section 1

Please enter your Business Name and Tax ID

Section 2

Please complete this section with your Demographic and Contact information

Section 3

Please select 837P if you submit Professional Claims (CMS 1500 if done by paper)
Please select 837I if you submit Insitutional Claims (UB 04 if done by paper)

Section 4

Please skip this section it is simply advising you of your responsibility to obtain and review all electronic reports to ensure receipt of claims.

Section 5

The option for SFTP should be checked. If a check box is not available on the form, please place a checkmark next to that section after printing.
Please list the individuals who will be accessing Magellan Complete Care of Virginia systems. Since you will be sending via SFTP, you only need to list one individual.

Section 6

Please Print Name, Position and Date, then sign this document

Submitting your Forms

It is recommended that you keep a copy of the form you will be submitting for your records. Email the form reflecting original signature to:

EDI_Tech_Support@mccofva.com

It is very important that you complete and return the entire enrollment document. Incomplete forms will not be processed and will be returned to the submitter.

Waiting for a Response

Once the enrollment document has been recieved, they will begin processing. Processing will take approximately one to two weeks from the date of receipt.

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a returned form is received after two weeks, please please call the Magellan eBusiness Service Center at 1-800-424-4524.

Testing

Once you have received your Submitter ID and Password from Magellan, please call the SolAce Support Team and set an appointment for a Mailbox setup and Test Transmission.

Please have at least 5 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.

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Medicaid

West Virginia Medicaid

cneely — Mon, 07 Apr 2014 21:37:43 +0000

Please follow the enrollment instructions below to become an electronic submitter to West Virginia Medicaid.

Please Note: Our connection to WV Medicaid cannot be scripted due to their EDI system’s website structure therefore, once your EDI file has been generated, you will need to upload and download your files manually. We will be glad to walk you through this process.

Users who wish to submit direct to WV Medicaid must sign up for the WV Portal by following the instructions in this document:

https://www.wvmmis.com/User%20Guides/WV%20TPA-Trading_Partner_Account_Account_Registration_User_Guide%20V%202.0.pdf

If you are having difficulty accessing the link above, please go to the main page found here:

https://www.wvmmis.com/SitePages/User-Guides.aspx

Click on the User Guide titled: WV TPA - Trading_Partner_Account_Account_Registration_User_Guide_V2.20

Questions regarding the enrollment process can be sent to edihelpdesk@molinahealthcare.com

You can also call the EDI Help Dest at 888-483-0793 ext 6

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - 64103

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Waiting for a Response

Once the complete provider enrollment registration has been completed, the information will be processed. Processing can take approximately two weeks for the date of submission.

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If no confirmation is received after two weeks, please call the Medicaid EDI Technology Support Center at the number listed above.

Testing

Once you have received your Submitter ID and Password from Medicaid, please call the SolAce Support Team and set an appointment for a Mailbox setup and Test Transmission to Medicaid.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment, but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.

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Medicaid

South Dakota Medicaid

cneely — Fri, 31 May 2013 23:01:08 +0000

Please follow the Enrollment Instructions below to become an electronic submitter to South Dakota Medicaid.

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 SD Medicaid office prior to initiation of electronic claims submission or inquiry.

1. Online Enrollment form for ALL submitters:

The Online Enrollment form can only be accessed after logging in to SD Medicaid Provider Enrollment Portal

(Please remember you are applying for a submitter ID as a Self Biller and to become a Direct Submitter)

2. Trading Partner Agreement: Trading_Partner_Agreement.pdf

If you have any questions regarding any of the documents in this package, please call the South Dakota Medicaid Provider Enrollment hotline at 605-773-3495 or email your questions to DSS-Medicaid@dss.state.sd.us

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - SV00016

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Trading Partner Agreement

Please Enter the name of your organization in the first line
Please Print your name and title, enter your contact information

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the Trading Partner Agreement form reflecting original signatures to:

DEPARTMENT OF SOCIAL SERVICES
DIVISION OF MEDICAL SERVICES
700 GOVERNORS DRIVE
PIERRE, SD 57501-2291

It is very important that you complete and return the entire form as described above. Incomplete forms will not be processed and will be returned to the submitter.

Waiting for a Response

After approval by South Dakota Medicaid, we will contact you via email to determine your interest in submitting electronic transmissions. You will be required to test with SDMA. We will send you testing instructions for the Launchpad application, along with your Submitter ID and temporary password. All test transactions will need to be submitted through Launchpad, even if you choose to submit productions transactions through secure FTP. When submitting an 837 Institutional and/or Professional test file in Launchpad, please idicate so with a "T" in the data element ISA15.

Request to submit and receive file svia sFTP once in Production

If you have any questions please call the Claimshuttle Support Team at 602-439-2525, You can also contact SD Medicaid directly at 605-773-3495 or email DSS-Medicaid@dss.state.sd.us

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Medicaid

New Jersey Medicaid

solace_admin — Wed, 07 Nov 2012 20:16:19 +0000

Please follow the Enrollment Instructions below to become an electronic submitter for New Jersey Medicaid.

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 NJ Medicaid office prior to initiation of electronic claims submission or inquiry.

1. EDI 101 New Submitter Agreement
2. EDI 201 Submitter Provider Agreement
3. EDI 801 Electronic Remittance Agreement

If the links listed above do not work properly, you can download the forms from here:
https://www.njmmis.com/documentDownload.aspx?fileType=93661110-6DC5-406B...

The first drop down, Select “Provider”
The second drop down Select “HIPAA”
Press “Submit”

If you have any questions regarding the documents and process listed please call the NJ Medicaid EDI Support Center at: 609-588-6051

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - 9802070

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Please Note: If you are using a Billing Service, your Billing Service is the “Submitter” and you will only put your information in the Provider Sections. Since your Billing Service is the one submitting and receiving on your behalf, please have them fill in the Sections for Submitter with their information.

EDI 101 New Submitter Agreement

Header:

Check the box for “Medicaid”

Section 1:

Enter the name of the Submitter, whether it be provider, clearinghouse, or billing service
Enter the demographic and contact information of the submitter
Enter the contact information for the main contact
The Submitter Representative’s signature should be the person who has liability authority of the business
Print name and Date the application

Section 2:

Check the box in the 5010 section for 837 Claim Professional
For Certification Vendor Name enter: AXIOM Systems, Inc. formerly Ivertex
Check the box for “No”

Section 3:

Software Vendor Name: AXIOM Systems Inc. formerly Ivertex
Enter the address and contact information listed in the box above
Product Name SolAce EMC
Version is 4.0.11
Release date: Sep 18th 2012

EDI 201 Submitter Provider Agreement

Header: Check Medicaid

Section 1:

Enter the name of the Submitter, whether it be the provider, clearinghouse or billing service
- If you are a provider applying for a New Submitter ID, leave the Submitter ID blank
- If you are a Billing Service who already has an ID, enter your Submitter ID
Enter the Name, Address, and Contact information for the Submitter’s Authorized Representative
As Billing Services: you must fill out this form for each provider you will be submitting on behalf of

Section 2:

Check the Box to “Add New Provider”
Enter the Provider’s Name, Medicaid Number, and NPI
Enter the Provider’s Address and Contact information
The Provider, or authorized representative, must print their name, sign and date the application

Section 3:

Please enter the Software Vendor information listed above for your convenience
Version is 4.0.11
Release date: Sep 18th 2012

ERA EDI Agreement

Please fill out this form after receiving your Submitter ID.

Section 1:

Check the box for “Medicaid”
Check the box for “Web”

Section 2:

Check the box to Add New Provider
Enter the Providers name
Enter the Submitters name (Either the name of the Provider, Billing Service, or Clearinghouse)
The date entered should be on a Monday, per their recommendation
Print Name, Sign and Date the application
Enter the Medicaid Provider ID, and Group NPI
- The ID listed should be the NPI of the Provider/Group that is registered with Molina Medicaid
Enter the Name of the Provider
Enter the Provider’s Demographic and Contact information

Section 3:

Enter the business name of the Provider/Submitter or Billing Agent/Submitter who will be receiving the ERAs
Enter the Submitter ID assigned to you by Molina Medicaid
Enter the demographic and contact information

Section 4:

Check the box for 5010

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail or Fax the enrollment forms reflecting original signatures to:

Via U.S. Mail
Provider Enrollment
Molina Medicaid Solutions
P.O. Box 4804 Trenton, New Jersey 08650 – 4804

Other Carriers
Provider Enrollment
Molina Medicaid Solutions
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately 2 weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after 2 weeks, please call the NJ Medicaid EDI Support Center at: 609-588-6051

Testing

Once you have received your Submitter ID and Password from NJ Medicaid please call the SolAce Support Team and set an appointment for a Mailbox setup.

Testing is not required at this time; we are an approved vendor for Professional Claims Submission and Inquiry with NJ Molina Medicaid. If you bill institutional claims (UB04) and wish to use SolAce to submit to NJ Medicaid, Please call the SolAce Support Team at 602-439-2525.

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Medicaid

Utah Medicaid

solace_admin — Tue, 30 Oct 2012 15:15:48 +0000

Utah Medicaid claims must be submitted directly to the Utah Health Information Network.

All interested electronic submitters are required to enroll directly with their service for a yearly membership fee, and fees are calculated based on business type, size, and claim volume.

SolAce currently does not support this connection.

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Medicaid

Minnesota Medicaid

solace_admin — Mon, 29 Oct 2012 21:29:01 +0000

Please follow the Enrollment Instructions below to become an electronic submitter to Minnesota Medicaid.

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

Billing Agents Only:

MHCP Clearinghouse or Billing Intermediary Enrollment Form
Update Form for Clearinghouses and Billing Intermediaries
Electronic Remittance Advice Request Form

To obtain the forms above, please download them from:

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&Redirected=true&dDocName=id_017533

Providers:

To enroll for a submitter ID and password for Medicaid-DHS’ electronic billing system, please call the DHSEDI Technology Support Center at 651-431-2700 or 1-800-366-5411, option 6 and ask to Register for their MN-ITS billing system. Once you receive your MN-ITS log in ID please call the SolAce Support Team at 602-439-2525.

If you have any questions regarding any of the documents in this package, please call the DHSEDI Technology Support Center at 651-431-2700 or 1-800-366-5411, option 5.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - N/A

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Provider Enrollment Application for Billing Intermediaries, Clearinghouses and EDI Trading Partners

Section 1

· Please select “Billing Intermediary

Section 2

· Enter your Business Name and Demographic information

Section 3

· The main billing contact for your office should complete this section

Provider Setup Form

Section 1

· Please complete the Billing Intermediary section with your information

Section 2

· Complete this section and state the necessary information for the providers you bill for.

o For “Begin Date” enter the date you started billing for the said provider

o Choose “Both”

o Have each provider you bill for fill sign the Pay to Provider Signature field.

Electronic Remittance Advice Request Form

If you would like to receive the Electronic EOBs for your provider please have each provider that you bill for sign one of this form.

Section 1

· Enter your provider’s information and the main contact for his or her office

Section 2

· Enter your business information and the main contact for your office

Section 3

· Please mark the ADD “835X12” option and enter today’s date

Section 4

· Have your provider complete this section

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail or Fax the enrollment forms reflecting original signatures to:

Minnesota Department of Human Services

Provider Enrollment

PO Box 64987

Saint Paul, MN 55164-0987

Fax 651-431-7462

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately 4-6 weeks from the date of receipt.

(Remember that mailing time can take as much as five days.)

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. When you receive this letter it will contain instructions for registration of the MN-ITS website, if you have any difficulty with the registration process please call: MHCP Provider Call Center at (651) 431-2700 or (800) 366-5411 (option 6)

If neither confirmation nor a returned packet is received after four to six weeks, contact the DHSEDI Technology Support Center at 651-431-2700 or 1-800-366-5411, option 5.

Testing

Once you have received your MN-ITS Submitter ID and password from DHS please call the SolAce Support Team and set an appointment for a Mailbox setup and Test Transmission to DHS.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.

Page Category:

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Medicaid

Rhode Island Medicaid

solace_admin — Mon, 29 Oct 2012 21:22:35 +0000

Please follow the Enrollment Instructions below to become an electronic submitter for Rhode Island Medicaid.

Required Documents for those applying for new Submitter IDs

The following online application must be completed and submitted to the Medicaid office prior to initiation of electronic claims submission or inquiry.

1. Electronic Data Interchange Trading Partner Agreement

To access the application, please click the following link:

Trading_Partner_Agreement.pdf (sd.gov)

Then, click "Trading Partner Enrollment Application" to begin.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - N/A

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Electronic Data Interchange Trading Partner Agreement

Please click "Continue" after reading their welcome page
Enter your Provider or Business name
Select an identifier from the drop-down (NPI if you have one, if not use your Medicaid ID) then enter that number as the "Identifier"
Taxonomy code is optional so no need to enter
CNOM providers please review the additional instructions
Press Continue
On the following screen enter your contact information
Select "Other" in the specify software section
Please select "Web" as your Method of Transmission
Enter your contact information in the EDI section
In the transactions section, please select the following:
- 837P if you send professional claims (CMS 1500)
- 837I if you send institutional claims (UB 04)
- 835 if you wish to receive your remittance advice electronically
On the following screen, please enter all your providers with their name, NPI, and taxonomy code
For each provider, check the same transactions you selected above
Once done adding all your providers, please click "Continue"
On the final screen check the box to accept their terms then enter your name to electronically sign along with your title, then press "Submit"
Review your information one last them then press "Confirm"

Submitting your Forms

It is recommended that you keep a record of the application tracking number so if necessary you can check the status of your application.

Waiting for a Response

Once the complete provider enrollment packet has been received, the application will be processed. Processing will take approximately 7-10 days from the date of submission.

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither notification, nor a returned enrollment packet is received after 2 weeks, please call their EDI Department at 1-800-964-6211.

Testing

Once you have received your Submitter ID and Password from Medicaid, please call the SolAce Support Team and set an appointment for a Mailbox setup and Test Transmission to Medicaid.

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Medicaid

Idaho Medicaid

solace_admin — Mon, 29 Oct 2012 21:22:35 +0000

Please follow the Enrollment Instructions below to become an electronic submitter for Idaho Medicaid.

Required Process for those applying for new Submitter ID’s

Online Trading Partner Registration
https://www.idmedicaid.com/

If you are interested in submitting claims electronically to ID Medicaid, they require you fill out a 5 step online registration form, which we provide the link for above.

After filling out the online form, ID Medicaid will email you a trading partner ID also known as a Submitter ID. Please have 3 batches of claims containing 15 claims in each batch, ready for testing. When you call the SolAce Support team just state that you have a new Submitter ID from Idaho Medicaid and we will assist you with adding your new mailbox to SolAce and submitting your test batches to Medicaid.

If you have any questions regarding any of the documents in this package, please call the Medicaid EDI Technology Support Center toll-free at 1-866-686-4272 and select the option for EDI Support.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - N/A

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

Please Note: Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.

Page Category:

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Medicaid

District of Columbia Medicaid

solace_admin — Mon, 29 Oct 2012 21:22:35 +0000

Please follow the Enrollment Instructions below to become an electronic submitter for Disctrict of Columbia Medicaid.

Required Documents

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.

To obtain the forms above if the links do not work, please download them from:

https://www.dc-medicaid.com/dcwebportal/providerSpecificInformation/providerInformation

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Vendor Name - AXIOM Systems, Inc.

Contact - EDI Team

Vendor Code - N/A

Phone - 602-439-2525

Fax - 602-439-0808

Address - 241 East 4th Street, Suite 200
Frederick, MD 21701

Software Name - SolAce EMC

E-mail - Support@SolAce-emc.com

EDI Provider Enrollment Form

Section 1

Please select the appropriate classification for your business, either Individual or Group

Section 2

If submitting claims yourself using SolAce please select Vendor Software
If you plan to have a billing agency submit claims on your behalf please select Billing Agent Clearinghouse and then complete form titled EDI Authorization for Billing Agents, Clearinghouses, and Software Vendors

Section 3

Fill in your demographic and contact information
Please ensure you enter the correct Provider Number (Solo NPI) or Group Number (Group NPI)

Section 4

Leave this section blank since you are applying for a new submitter ID

Section 5

Please enter the demographic and contact information for two contacts in your office

Section 6

Select Software Vendor if using SolAce
Select Billing Agent if you will be using a billing agency
If you are using SolAce then enter in Axiom System’s demographic and contact information located in the box above
If you are using a Billing Agency enter that company’s demographic and contact information

Section 6b

If you are using SolAce to submit your claims please enter: SolAce EMC Version 4.0 Protocol SFTP

Section 6c

If you are using a Billing Agency you will need to get their ID
If you are using SolAce please leave this blank

Section 7a

Please Skip

Section 7b

If you going to be sending professional claims select X12N 837P
If you are going to be sending institutional claims select X12 837I

Section 8

Leave blank for default

Section 9

Select the following options:
X12 277CA
X12N 999
X12N 835

Section 10

Please add any additional providers on this last page

Authorization Form for Billing Agents and Clearinghouses

Only fill out this form if using a billing service

Section A

Please indicate your appropriate classification, either Individual Provider or Group Practice
Fill in your Contact and Demographic information
Please ensure you enter the correct Provider Number (Solo NPI) or Group Number (Group NPI)

Section B

Please type your name (the name of the provider) and then enter the name and submitter ID of the billing service you wish to authorize to submit claims on your behalf
If you would like the EOB’s and Reports to be sent to the Billing Service, please select: 277CA, 999, and 835
The Provider must print their name, sign and date

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Please mail or fax the forms listed above to:

Technical Support/Enrollment

PO Box 34734

Washington DC 20043-4761

Also Fax to: 202-906-8399

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

Testing

Once you have received your Submitter ID and Password from Medicaid, please call the SolAce Support Team at 602-439-2525 and set an appointment for a Mailbox setup. Testing is optional for this payer.

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Medicaid

Hawaii Medicaid

solace_admin — Mon, 29 Oct 2012 21:22:35 +0000

Please follow the Enrollment Instructions below to become an electronic submitter for Hawaii Medicaid Med-QUEST.

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 Hawaii Medicaid office prior to initiation of electronic claims submission or inquiry.

1. Electronic Data Interchange Request (DHS1188A)

To obtain the form listed above please send an email to: hi.ecstest@xerox.com

If you have any questions regarding the enrollment form please send an email to the address listed above.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Electronic Data Interchange Request

Section I.

This section should be prefilled for you. The boxes checked should be: Add User, Upload, and Download

Section II.

Please enter your Business/Practice or Provider Name, Address, and contact information
Leave the Submitter ID field blank
For SolAce's IP Address please call us at 602-439-2525 option 1
Note: Feel free to make up any four digit PIN for the "last four of SSN" field. Please remember to write it down in the event they need to confirm your identity for security measures
Enter a point of contact for all EDI requests
Enter a point of contact for all technical issues
If you are a Billing Service, the provider you will be submitting for goes in this section and your information will go in Section III.

Section III.

If you are a Business/Practice or Provider submitting for yourself please reenter your information
If you are a Billing Service submitting on behalf of a Business/Practice or Provider, please enter your information in this section

Section IV.

The box for 837 Claims Transactions will automatically be checked
Please check the box for 835 Remittance Advice if you wish to receive your Explanation of Benefits electronically

Section V.

The Affirmation Attached box will be checked for you

Section VI.

Please skip this section

External User Affirmation Statement

Please read through this statement and have the signing authority in your office print their name, enter their signature and todays date

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Fax or Email the forms to:

Email: hi.ecstest@xerox.com

Fax: 808-952-5595 ATTENTION: EDI Coordinator

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt.

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a response is received after two weeks, contact the HI Medicaid EDI Department at: hi.ecstest@xerox.com

Testing

Once you have received your Submitter ID and Password from HI Medicaid, please call the SolAce Support Team at 602-439-2525 option 1 to set an appointment for a Mailbox setup and Test Transmission.

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Medicaid