Get Edi 837 Claims Enrollment Form (to Send ... - Intotal Health

Filling out the EDI 837 Claims Enrollment Form is an essential step for users looking to submit electronic claims efficiently. This guide provides a step-by-step approach to ensure you complete the form correctly and understand each component.

Follow the steps to accurately complete your form.

1. Press the ‘Get Form’ button to access the EDI 837 Claims Enrollment Form and open it for editing.
2. Begin by completing the submitter information section. Enter the clearinghouse details including contact name, address, city, state, zip, phone number, and email. Ensure the email address provided is correct, as enrollment confirmation will be sent there.
3. In the billing agent/service information section, enter the billing agent tax identification number. This information is necessary for billing purposes.
4. Next, provide the provider group information. This includes the group name, group tax ID, and group NPI number if applicable. Make sure to have the W-9 form ready as it is required.
5. Complete the provider remittance/billing address section with the provider's address, city, state, and zip code. Include the provider's name and title, specialty, NPI number, and taxonomy code. Indicate whether the provider is a participating or non-participating provider.
6. If instructed by the clearinghouse, either email the completed form as an attachment to ihp_edi@vapremier.com or fax it to 877-685-5729. Otherwise, follow your clearinghouse’s guidelines for submission.
7. Once completed, save your changes. You may also choose to download, print, or share the form, as needed.

Complete your EDI 837 Claims Enrollment Form online today to streamline your electronic claims process.