Get Jl Electronic Data Interchange Edi Enrollment Edi Enrollment Form To Enroll For Electronic Billing

This guide provides a clear and structured approach to completing the JL Electronic Data Interchange EDI Enrollment Form for online enrollment in electronic billing. By following the instructions carefully, users will ensure that all necessary information is accurately submitted for processing.

Follow the steps to successfully complete the EDI Enrollment Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Complete the contract section by selecting all applicable options under the *Contract header, including 'Part B (Professional)' and any relevant state options.
3. In the *Provider Information section, fill in the required fields, which include the provider's name, street address, city, state, zip code, contact telephone number, fax number, and email address. Ensure the provider name matches the one reported on the CMS-855 Enrollment form.
4. Provide your billing/group PTAN, National Provider Identifier (NPI), and Tax Identification Number (TIN) or Employer Identification Number (EIN) in the relevant fields.
5. In the Electronic Billing Profile section, specify who will be preparing the electronic claims and who will submit them. Check only one option for each. If a billing service or clearinghouse is involved, include their name.
6. For *Request Type, select the reason for submission—either New Enrollment or Change Enrollment—and choose if needed to assign a new Novitasphere Portal submitter ID.
7. Designate how you want to handle ERA in the *ERA section. Provide details for either a new or existing Novitasphere Submitter ID.
8. Under *Novitasphere Portal Security, input the names and emails of your Provider Office Approver and their backup. Ensure these individuals are knowledgeable staff members.
9. If applicable, provide any additional optional information in the Additional Information section.
10. Review the PC-ACE software terms and ensure compliance.
11. Complete the attestation section by certifying that you are an authorized representative of the provider and understand the responsibilities involved in submitting claims electronically.
12. Finally, print the completed form, sign, date, and include your printed name and title in the designated areas before submitting it by mail or fax to Novitas Solutions.
13. Save your changes and if needed, download, print, or share the completed form for your records.

Begin your online enrollment process today by accurately completing the EDI Enrollment Form.