Enrollment Instructions
Thank you for your interest in Electronic Data Interchange (EDI).
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 Novitas Solutions office prior to initiation of electronic claims submission or inquiry.
You may need to copy and paste the links below into your web browser’s address bar in order for them to work properly.
1.
Novitas Solutions EDI Enrollment Form (8292)
2.
Novitas Solutions Vendor Agreement Form (8291) (For Billing Services Only)
If the links above do not work properly, please click on the following link:
Novitas Solutions Home Page
If you have any questions regarding any of the documents in this package, please call the Novitas Solutions EDI Technology Support Center at 1-877-235-8073.
Required Information
We recommend that you have the following information ready before filling out your forms:
| Your Submitter Information | Software Vendor Information |
| Name | Vendor Name - AXIOM Systems, Inc. |
| Address | Contact - EDI Team |
| Phone and Fax Numbers | Vendor Code - N/A |
| E-mail Address | Phone - 602-439-2525 |
| Contact Name | Fax - 602-439-0808 |
| Provider NPI Numbers for this payer | Address - 241 East 4th Street, Suite 200
Frederick, MD 21701 |
| Organization or Group NPI's for this payer | Software Name - SolAce EMC |
| E-mail - Support@SolAce-emc.com |
New EDI Submitters
Follow these instructions when filling out forms for a new Submitter ID.
Electronic Data Interchange (EDI) Enrollment Form
Section A: Select your Line of Business and State
Section B: Enter the name of the Group, Provider, Or Supplier who is applying for a Submitter ID
Section C: Enter your Practice’s demographic information
Section D: Enter the Provider’s NPI and PTAN
Section E: Do not check the box for PC-Ace Pro 32
For name of Software Vendor , enter Axiom Systems, Inc. Formerly Ivertex
- If Provider is sending and receiving using SolAce, place check mark next to Provider
- If a Billing Service is sending/receiving on behalf of the provider check, Billing Service
Check the last box in this section about your 855 form if applicable
Section F: Place a check next to Assign this provider a new electronic billing submitter ID
- Select either One Submitter ID or Separate Submitter ID’s per contract, whichever you prefer.
Section G: Skip this section if you do not have an existing submitter ID
Section H: Select the box that says “The new submitter ID being requested in block F of this form”
Section I: Skip this section
Signature Section: Type your Name and Title, then Sign and Date
Novitas Solutions, Inc. Vendor Agreement (Billing Services Only)
Header: Check Billing Service
Section I. Enter your Company’s Name, Demographic info, and Contact information
- For Name of Software enter SolAce-EMC
- Skip the first Box
- Check the second box if you wish to not receive paper mail responses.
Section II. Check the box to Assign a new submitter ID.
- Select the box that says “I am a Billing Service or Clearinghouse that will be submitting claims directly to Medicare”
- Name of Vendor: AXIOM Systems, Inc. formerly Ivertex
- Choose either one submitter ID for all Part B contracts or Separate ID’s per contract
- You would probably want Separate ID’s per contract.
- Check the box to assign a new ERA Receiver ID if you will be receiving your Provider’s ERAs.
Section III. Check these boxes:
- Create ANSI ASC X12N 837 claim files in the following version: Check box for 5010
- Retrieve ANSI ASC X12N 835 remittance files in the following version: Check box for 5010
- Provide the following type of connection to Novitas Solutions: Check box for FTP and Dial Up
- You may also select DDE and PPTN. Ask us about our ClaimShuttle Network Service today so we can get you access to the DDE or PPTN screens that you need to access!
- Provide services to the following contracts: Check applicable boxes for Part A, and/or Part B
Section IV. Skip this section
Signature Section: Print your Name and Title, then Sign and Date this application
Submitting your Forms
It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:
Novitas Solutions, Inc.
EDI Department
P.O. Box 890011
Camp Hill, PA 17089-0011
Or Fax to: 1 (877) 439-5479
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.)
After processing, a confirmation will be mailed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the Novitas Solutions EDI Technology Support Center at 1-877-235-8073
Testing
Once you have received your Submitter ID and Password from Novitas Solutions, please call the SolAce Support Team and set an appointment for a Mailbox setup and Test Transmission to Novitas Solutions.
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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