Get Maryland Medical Care Program Submitter Identification Form - Dhmh - Dhmh Maryland

Filling out the Maryland Medical Care Program Submitter Identification Form is essential for efficient communication with Maryland Medicaid regarding electronic data interchange. This guide provides clear, step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the Maryland Medical Care Program Submitter Identification Form and start filling it out.
2. Identify the type of submission by selecting one of the options under 'This is a' section. Choose from 'New Application', 'Electronic Transfer & Paper Voucher', 'Change of Submitter Agent', 'Paper Voucher Only', or 'Submitter Identification Form Update'.
3. Complete the 'Provider Information' section by filling in the provider's name, address, provider number (which must be 9 digits), and National Provider Identifier (NPI).
4. In the 'Electronic Submitter Information' section, provide the submitter's name, address, and Submitter ID, which includes ISA Qualifier and ISA ID.
5. In the 'EDI Information' section, check the transactions you wish to exchange with Maryland Medicaid. Ensure you are familiar with each transaction type, such as 270/271 for eligibility inquiries or 837 for health care claims.
6. If applicable, complete the 'Receiver EDI Information' including receiver name, address, and ISA Qualifier and ISA ID, especially if it differs from the listed Submitter ID or for specific providers.
7. Authorize the submission by having the provider and submitter agent sign the form. Ensure that both signatures are provided, along with printed names and telephone numbers.
8. Review the form to ensure all required fields are completed accurately. Note that original signatures are necessary for processing.
9. You can now save your changes, download the completed form, or print it for submission. Make sure to mail the form to the address provided for Systems Liaison Services.

Begin the process of filling out your Maryland Medical Care Program Submitter Identification Form online now.