Availity® Health Information Network

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Last Update Payer ID Payer Name Availity's Electronic Data Interchange (EDI) Health Plan Partners Government Payer* Claim Enroll Required Remit (835) NPI Option Professional Claim (837) Institutional Claim (837) Eligibility & Benefits (270) Claim Status (276) Auth & Referral (278) Additional Information 76870 LIFEPATH HOSPICE 2 x x LIFE1 LIFEPRINT 2 x x 93093 LIFEWISE OF OREGON, A PREMERA HEALTH PLAN 2 x LIPA1 LIPA/AGATE RESOURCES x 4 x Click this link and complete the required EDI registration for Lipa/Agate: https://www.trilliumchp.com/providers.php . 35107 LOCAL 135 HEALTH BENEFITS FUND (INDIANAPOLIS, IN) 2 x x 37267 LOMA LINDA UNIVERSITY ADVENTIST 2 x x 45289 LONE STAR TPA 2 x x 60054 LOS ALAMOS TOTAL CARE (PRU) 2 x x 68069 LOUISIANA HEALTHCARE CONNECTIONS x 3 x x SX159 LOVELACE SALUD 2 x x 90328 LOVELACE SANDIA HEALTH PLANS (COMMERCIAL) 2 x x 52148 M.D. INDIVIDUAL PRACTICE ASSOC. (M.D. IPA) 2 x 36334 MACNEAL HEALTH PROVIDERS - CHS 2 x x 01260 MAGELLAN HEALTH SERVICES x 4 x x 11303 MAGNACARE 2 x x 68069 MAGNOLIA HEALTH PLAN x 3 x x payer ID 68062 may also be used 87726 MAILHANDLERS MENTAL HEALTH CLAIMS x 2 x x 22195 MAKSIN MANAGEMENT CORPORATION 2 x x 35162 MANAGED CARE SERVICES 2 x x 68069 MANAGED HEALTH CARE SERVICES - IN x 3 x x payer ID 39186 may also be used 22771 MANAGED HEALTH NETWORKS (MHN) 2 x x 68069 MANAGED HEALTH SERVICES - WI x 3 x x payer ID 39187 may also be used 60054 MARRIOTT 2 x x 37121 MASHANTUCKET PEQUOT TRIBAL NATION 2 x x MMPHB MASTERS, MATES AND PILOTS PLAN 3 x x 41154 MAYO MANAGEMENT SERVICES, INC. x 2 x x 87065 MBA BENEFIT ADMINISTRATORS 2 x 87065 MBA OF WYOMING 2 x x 59331 MCCREARY CORPORATION 2 x x 02331 MCC BEHAVIORAL CARE 2 x 38338 MCLAREN HEALTH PLAN 4 x x 06118 MD HEALTH PLAN 2 x 35199 MDWISE - ST. CATHERINE HEALTH NETWORK 4 x x 35199 MDWISE - ST. MARGARET-MERCY HEALTH NETWORK 4 x x 35199 MDWISE - ST. VINCENT HEALTH NETWORK 4 x x 35199 MDWISE - SELECT HEALTH NETWORK 4 x x M3CA0001 MED3000 CALIFORNIA 4 x M3CA1 MED3000 CALIFORNIA AFFILIATED PHYSICIAN GROUP 4 x M3FL0010 MED3000 CMS EARLY STEPS 4 x x M3FL0011 MED3000 CMS SAFETY NET 4 x x M3FL0013 MED3000 CMS TITLE 19 NONREFORM 4 x x M3FL0012 MED3000 CMS TITLE 19 REFORM 4 x x M3FL0014 MED3000 CMS TITLE 21 4 x x M3IL0001 MED3000 HEALTHSELECT IPA BCBS 4 x x M3FL0009 MED3000 HEALTHSPRINGS 4 x M3FL0008 MED3000 PEDICARE TITLE 19 4 x x M3FL0006 MED3000 PEDICARE TITLE 21 4 x x M3IL0002 MED3000 SOUTHWEST IPA BCBS 4 x 60054 MEDCONNECTION (MARRIOTT) 2 x x 56205 MEDCOST BENEFIT SERVICES (MBS) 2 x x 56162 MEDCOST, INC 2 x x 95321 MEDFOCUS 2 x 94265 MEDICA CHOICE (ALLINA) x 2 x x 78857 MEDICA HEALTH CARE PLAN 2 x 77027 MEDICAID FLORIDA x x x 3 x x Availity® Health Information Network Electronic Data Interchange (EDI) & Web Solutions Companion Guides To register for Florida Medicaid, first complete the Availity FL Medicaid Registration (http://www.availity.com/documents/Availity_FL_Medicaid_Registration_Instructions.pdf) . Once Florida Medicaid assigns your provider number, access the Availity portal, click Florida Medicaid Registration in the Value-Added Services section and follow the instructions. EDS will notify you within 30-45 days. Once you receive confirmation, you can receive files from the payer. AIDID MEDICAID IDAHO x x x 2 x Contact 1.866.686.4272 to enroll in EDI. IL621 MEDICAID ILLINOIS (HFS) x x 4 x x Contact 217.782.5565 to enroll in EDI. Contact 877.782.5565 for EDI issues. Providers must complete Kentucky's MAP380 form prior to submitting transactions. Visit AIDKY MEDICAID KENTUCKY x x x 4 x x http://chfs.ky.gov/NR/rdonlyres/F5C0E24B-5CEA-4B21-BADF- 9C79E428F029/0/MAP380Medicaid609.pdf to complete the required MAP380. Availity's submitter id = 9900004190. Visit this link and complete the required EDI Submitter Enrollment Form: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-4087-ENG Complete the ‘Submitter Information’ with the following: DPWMN MEDICAID MINNESOTA x x x 2 x x Submitter ID (UMPI) - A268453200 Submitter Name – Availity LLC Address – 740 E Campbell Rd, Ste 1000, Richardson, TX 75081 Phone – 800.282.4548 70029 MEDICAID MISSOURI x x 4 x x CNTNM MEDICAID NEW MEXICO x 4+ x x NPI required in all loops, EIN or SSN required in 2310A, 2310B, 2420A and 2420F 16 of 124 Visit our web site: www.availity.com
Last Update Payer ID Payer Name Availity's Electronic Data Interchange (EDI) Health Plan Partners Government Payer* Claim Enroll Required Remit (835) NPI Option Professional Claim (837) Institutional Claim (837) Eligibility & Benefits (270) Claim Status (276) Auth & Referral (278) Additional Information PRESA MEDICAID NEW MEXICO PRESBYTERIAN SALUD x 4 x x Please add provider number in 2010AA REF02 "or" 2310B REF02. Provider number is 11 digits or less. Contact 888.863.3638, #6 then #2 to obtain ID. MMISODJFS MEDICAID OHIO x x x 4 x x Please contact 1.800.686.1516 for EDI enrollment. 86916 MEDICAID TEXAS x 4# x x 86916 MEDICAID TEXAS HEALTH STEPS x 4# x x NPI - No REF 0B. Providers must enroll with Virginia Medicaid prior to submitting transactions. For enrollment questions please call 1.888.829.5373. For providers needing help interpreting Virginia Medicaid policy and AIDVA MEDICAID VIRGINIA x x x 4 x x procedures and in resolving problems with individual claims please contact the Virginia Department of Medical Assistance Services (DMAS) “HELPLINE” at 804.786.6273. To reach the Virginia Medicaid EDI Helpdesk please call 1.866.352.0766. Click this link and complete the required EDI enrollment for ProviderOne: AIDWA MEDICAID WASHINGTON PROVIDER 1 x x 4 x https://www.waproviderone.org/ . Availity’s ProviderOne Clearinghouse ID is 1054194. If you have questions, call 800.562.3022 ext. 16137 37298 MEDICAL BENEFITS ADMINISTRATORS OF MARYLAND, INC. 2 x x 74323 MEDICAL BENEFITS MUTUAL 2 x x 52181 MEDICAL DEVELOPMENT INTERNATIONAL 2 x x 29076 MEDICAL MUTUAL OF OHIO 2 x x BC004 MEDICAL MUTUAL OF OHIO 3 x CSMED MEDICAL NETWORK OF COLORADO SPRINGS 2 x 58203 MEDICAL RESOURCE NETWORK 2 x x 38224 MEDICAL VALUE PLAN - MVP - OHIO 2 x x 17003 18003 19003 MEDICARE DMERC REGION B (Covering: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin) MEDICARE DMERC REGION C (Covering: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia and West Virginia.) MEDICARE DMERC REGION D (Covering: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, N. Mariana Island,Oregon, South Dakota, Utah, Washington, and Wyoming.) x x x 4* x x x x 4* x x x x 4* x 17 of 124 Visit our web site: www.availity.com Availity® Health Information Network Electronic Data Interchange (EDI) & Web Solutions Companion Guides New Electronic Providers (Form 1 and 3 required) http://apps.ngsmedicare.com/applications/CEDIEnrollmentAgreement.aspx & http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Existing Electronic Enrolled Providers (Form 3 only) http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Form 1 – Complete the Submitter Information as follows: Submitter Status: Existing Submitter, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230, Submitter Name: Availity LLC, Submitter Type: Clearinghouse Form 3 – Complete the Submitter and/or Receiver Information as follows: Entity Name - Availity LLC, Operating as a – Clearinghouse, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230 Address - 740 E Campbell Rd, Ste 1000, Richardson, TX 75081, Contact Name - Availity Client Services, Contact Phone Number - 800.282.4548, Contact Email – support@availity.com. Ordering provider name and number are required on every service line. The information must go in Loop 2420E, NM109. New Electronic Providers (Form 1 and 3 required) http://apps.ngsmedicare.com/applications/CEDIEnrollmentAgreement.aspx & http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Existing Electronic Enrolled Providers (Form 3 only) http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Form 1 – Complete the Submitter Information as follows: Submitter Status: Existing Submitter, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230, Submitter Name: Availity LLC, Submitter Type: Clearinghouse Form 3 – Complete the Submitter and/or Receiver Information as follows: Entity Name - Availity LLC, Operating as a – Clearinghouse, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230 Address - 740 E Campbell Rd, Ste 1000, Richardson, TX 75081, Contact Name - Availity Client Services, Contact Phone Number - 800.282.4548, Contact Email – support@availity.com. Ordering provider name and number are required on every service line. The information must go in Loop 2420E, NM109. New Electronic Providers (Form 1 and 3 required) http://apps.ngsmedicare.com/applications/CEDIEnrollmentAgreement.aspx & http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Existing Electronic Enrolled Providers (Form 3 only) http://apps.ngsmedicare.com/applications/CEDISupplierAuthForm.aspx Form 1 – Complete the Submitter Information as follows: Submitter Status: Existing Submitter, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230, Submitter Name: Availity LLC, Submitter Type: Clearinghouse Form 3 – Complete the Submitter and/or Receiver Information as follows: Entity Name - Availity LLC, Operating as a – Clearinghouse, Region B Submitter ID C08495979, Region C Submitter ID C08495979, Region D Submitter ID D08607230 Address - 740 E Campbell Rd, Ste 1000, Richardson, TX 75081, Contact Name - Availity Client Services, Contact Phone Number - 800.282.4548, Contact Email – support@availity.com. Ordering provider name and number are required on every service line. The information must go in Loop 2420E, NM109.
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