Availity® Health Information Network
Availity® Health Information Network
Availity® Health Information Network
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Availity's Electronic Remittance Advice (ERA) <strong>Health</strong> Plan Partners<br />
Payer Name Payer ID Additional <strong>Information</strong> Availity Required Forms (links) Payer Specific Forms (links)<br />
MEDICAID OHIO MMISODJFS<br />
MEDICAID VIRGINIA AIDVA<br />
MEDICAL PLAN OF KANSAS CITY 61101<br />
MEDICARE DMERC REGION B 17003<br />
Please complete both enrollment forms and fax back<br />
to Availity. Availity will complete section III and<br />
forward the form to Ohio Department of Job and<br />
Family Services. Allow 10 business days for<br />
processing.<br />
34 of 124 Visit our web site: www.availity.com<br />
<strong>Availity®</strong> <strong>Health</strong> <strong>Information</strong> <strong>Network</strong><br />
Electronic Data Interchange (EDI) & Web Solutions Companion Guides<br />
Designation of an 835 or 834-820 Trading<br />
Partner Form<br />
Please complete Availity’s Multi-payer enrollment<br />
form prior to visiting the payer’s site and completing<br />
ERA enrollment with the payer. Availity's Service<br />
Center number is 1285. To reach the Virginia<br />
Medicaid EDI Helpdesk please call 1.866.352.0766. Availity Multi-payer Form<br />
New Electronic Providers (Form 1 and 3 required) -<br />
http://apps.ngsmedicare.com/applications/CEDIEnro<br />
llmentAgreement.aspx &<br />
http://apps.ngsmedicare.com/applications/CEDISup<br />
plierAuthForm.aspx<br />
Existing Electronic Enrolled Providers (Form 3 only)<br />
http://apps.ngsmedicare.com/applications/CEDISup<br />
plierAuthForm.aspx<br />
Form 1 – Complete the Submitter <strong>Information</strong> with<br />
the following:<br />
Submitter Status: Existing Submitter, Submitter ID:<br />
Region B Submitter ID C08495979, Region C<br />
Submitter ID C08495979, Region D Submitter ID<br />
D08607230, Submitter Name: Availity LLC,<br />
Submitter Type: Clearinghouse<br />
Form 3 – Complete the Submitter and/or Receiver<br />
<strong>Information</strong> with the following:<br />
Entity Name - Availity LLC, Operating as a -<br />
Clearinghouse, Submitter ID: Region B Submitter ID<br />
C08495979, Region C Submitter ID C08495979,<br />
Region D Submitter ID D08607230, Address - 740 E<br />
Campbell Road, Suite 1000, Richardson, TX 75081<br />
Contact Name - Availity Client Services, Contact<br />
Phone Number - 800.282.4548, Contact Email –<br />
support@availity.com. Ordering provider name and<br />
number are required on every service line. The<br />
Provider Service Center Authorization<br />
ERA/EFT Setup-Maintenance Request<br />
System<br />
information must go in Loop 2420E, NM109. Availity Multi-payer Form EDI Submitter Action Request Form
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