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Availity's Electronic Remittance Advice (ERA) Health Plan Partners Payer Name Payer ID Additional Information Availity Required Forms (links) Payer Specific Forms (links) MEDICARE PART A FLORIDA 09101 MEDICARE PART A ILLINOIS (ADMINISTAR) NONE MEDICARE PART B ALASKA 00831 MEDICARE PART B ARIZONA 03102 Complete the EDI enrollment form. Select Florida, then Part A, then Customize. Click “EDI enrollment form.” Section A - Click the boxes for Part A and/or Part B, and Florida. Section B - Enter P8467 in the “Existing Submitter Number field”. Sections C and D - Enter your information in the fields marked with a red asterisk (*). Do not complete Section E. Section F - Click “Add to existing submitter ID” and enter P8467 in the blank. Select the “Electronic Remittance (835) change (section H)”. NOTE: To receive ERA files thru Availity, you must complete the Multi-Payer Electronic Remittance Advice Enrollment Form prior to submitting the EDI Enrollment form to Medicare. Section G - Complete this section if it applies to your business model. Section H - Complete this section. Check “An existing submitter/receiver ID” and enter submitter id P8467 in the blank. Do not complete Section I. Complete the EDI enrollment form, print, sign, date Availity Multi-payer Form EDI enrollment form Click this link and complete the required ERA enrollment: http://apps.ngsmedicare.com/applications/edisubmitt eractionrequest.aspx?CatID=2 Complete each field marked with an asterisk. The items below must contain Availity's information: Entity Name - Availity LLC, Street – P.O Box 550857, Contact Name - Availity Client Services City/State/Zip – Jacksonville, FL 32255, Phone Number - 800.282.4548, Email – support@availity.com, Fax Number – 904-470-4773, Submitter ID - ZAHW, Contractor Code – Part A IL 00131, Are you a Clearinghouse or Third Party Service – Yes, Are you a Vendor – No, Network Service Vendor – IVANS 36 of 124 Visit our web site: www.availity.com Availity® Health Information Network Electronic Data Interchange (EDI) & Web Solutions Companion Guides Contact the NGS EDI Help Desk at 877-273-4334 for any questions concerning the form. Availity Multi-payer Form See Additional Information for instructions Please complete Availity’s Multi-payer enrollment form prior to visiting the payer’s site and completing ERA enrollment with the payer Please complete Availity’s Multi-payer enrollment form prior to visiting the payer’s site and completing Availity Multi-payer Form EDISS Total OnBoarding ERA enrollment with payer Availity Multi-payer Form EDISS Total OnBoarding
Availity's Electronic Remittance Advice (ERA) Health Plan Partners Payer Name Payer ID Additional Information Availity Required Forms (links) Payer Specific Forms (links) MEDICARE PART B FLORIDA 09102 MEDICARE PART B IDAHO 02202 MEDICARE PART B ILLINOIS 00952 MEDICARE PART B MINNESOTA 00954 Complete the EDI enrollment form. Select Florida, then Part B, then Customize. Click “EDI enrollment form.” Section A - Click the boxes for Part A and/or Part B, and Florida. Section B - Enter P8467 in the “Existing Submitter Number field”. Sections C and D - Enter your information in the fields marked with a red asterisk (*). Do not complete Section E. Section F - Click “Add to existing submitter ID” and enter P8467 in the blank. Select the “Electronic Remittance (835) change (section H)”. NOTE: To receive ERA files thru Availity, you must complete the Multi-Payer Electronic Remittance Advice Enrollment Form prior to submitting the EDI Enrollment form to Medicare. Section G - Complete this section if it applies to your business model. Section H - Complete this section. Check “An existing submitter/receiver ID” and enter submitter id P8467 in the blank. Do not complete Section I. Complete the EDI enrollment form, print, sign, date and return all pages to: FCSO Medicare EDI, P.O. Box 44071 - 3C, Jacksonville, FL 32031-4071 or Fax: (904) 361-0470. You will receive an acknowledgement from FCSO once they process your request form. For questions concerning the forms, contact the Medicare EDI help desk 888.670.0940. Please complete Availity’s Multi-payer enrollment form prior to visiting the payer’s site and completing Availity Multi-payer Form EDI enrollment form ERA enrollment with the payer Availity Multi-payer Form EDISS Total OnBoarding Please complete Availity’s Multi-payer enrollment form prior to visiting the payer’s site and completing ERA enrollment with the payer Availity Multi-payer Form Please complete Availity’s Multi-payer enrollment form prior to visiting the payer’s site and completing ERA enrollment with the payer Availity Multi-payer Form 37 of 124 Visit our web site: www.availity.com Availity® Health Information Network Electronic Data Interchange (EDI) & Web Solutions Companion Guides WPS Authorization Form for Electronic Remittance Advice Processing (ERA) WPS Authorization Form for Electronic Remittance Advice Processing (ERA)
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