Dear Provider, Thank you for your interest in
Contents
1. Multiple Surgeries Solo Practice gt gt gt gt gt gt o o TrailBlazer Health Enterprises LLC Page 11 August 2003 Medicare Part B EDI Enrollment Packet Group Practice with Performing Provider ID s Purchased Test with Indicator Amount Provider ID Twelve Detail lines Anesthesia CRNA with modifiers minutes Independent Labs Independent Radiology Reference Labs o gt gt gt gt o Ambulance with GAO record Must include mileage supplies round trip transfers and special billings e g waiting time if these services are routinely rendered Podiatry Chiropractic with GCO record Physical Therapy EPO with initial EPO visits gt Testing validates the ability of a file to pass the GPNET edits Format testing checks for the following Layout of file Password to Submitter ID Version Numbers Record Sequencing Balancing Batch Type Batch Type to Files Batch ID Duplicate Batches Numeric Fields Date Fields Relationship Edits Field Values ef fF gt gt gt gt o HoH H oo He 2 The submitter of the test file must monitor the response file after each test submission to determine format and or data elements to be corrected and re tested Test results for telecommunicated submissions will be returned at the time of transmission Test results for rejected magnetic tape submissions are returned with the tape by mail You will2. MB only Signature Be To order Pro32 complete this form and mail or fax to TrailBlazer Health Enterprises LLC Electronic Data Interchange PO Box 4898 Timonium MD 21094 4898 Fax 410 683 2937 TrailBlazer Health Enterprises LLC Page 10 August 2003 Medicare Part B EDI Enrollment Packet Enrollment Process for Billing Services Clearinghouses EDI System Vendors Billing Services Clearinghouses and EDI System Vendors must enroll before they will be approved To enroll complete the following steps Step 1 Complete the EDI System Vendor Submitter Enrollment Form and mail to TrailBlazer Health Enterprises LLC EDI PO Box 4898 Timonium MD 21094 4898 Step 2 You will receive fax notification of your submitter vendor number and status New EDI system vendors are required to test the electronic claim process New submitters who use a system that has not been approved for production by TrailBlazer Health Enterprises LLC will also need to test Refer to Testing Requirements below for more information Step 3 New vendors submitters who have completed a successful test must submit an EDI Production Request Form by fax EDI analysts will review the test for completeness including the proper submission of Medigap information and will respond to the vendor submitter with notification of production status or the need for additional testing Step 4 Submitters who are approved for production status may beg
3. MEDICARE ELECTRONIC DATA INTERCHANGE EDI ENROLLMENT AGREEMENT The physician administrator or equivalent legal representative must sign this agreement if you will be submitting Medicare claims A copy of this agreement can be found following the EDI Provider Information Form SUBMITTING COMPLETED DOCUMENTS Please make sure you follow these steps Step 1 Complete the Electronic Data Interchange EDI Provider Information Form page 3 Step 2 Complete and sign the Medicare Electronic Data Interchange EDI Enrollment Agreement page 4 Step 3 Make copies of the completed forms for your records Step 4 Return all original documents to one of the following addresses Mailing Address Delivery Address TrailBlazer Health Enterprises LLC TrailBlazer Health Enterprises LLC Electronic Data Interchange Electronic Data Interchange P O Box 4898 Timonium II 6th Floor Timonium MD 21094 4898 1954 Greenspring Drive Timonium MD 21093 It is very important that you complete and return the entire enrollment packet as described above Incomplete packets will not be processed and will be returned to the submitter Once the complete provider enrollment packet has been received the documents will be processed Processing will take approximately two weeks from the date of receipt Remember that mailing time can take as much as five days After processing a confirmation will be faxed to the submitter as notification to begin filing claims elect
4. UPIN directory Address Changes ERN EFT Enrollment ini motn die esc ee ee SE ee 866 528 1609 Provider Education ii AA Sa 866 828 6264 Seminar Workshop INFOLINE Medicare Part B Metropolitan DC Area Delaware Provider ARS til A osssatativshabbecssnceteas 800 862 8780 Provider Appeal See s cs cesrstutets Ata id dins 866 237 4467 Coverage ISSUES OEE EEE EE E E EEE O es oa puedes nnguse dada ESEE 877 391 2610 Overpayments scen e e e ia ESEE AAE RE E ri oats 903 463 3948 Program Compliance un a a ia ee 469 372 7478 Provider Services ii a is ds said 866 528 1602 Provider Numbers UPIN directory Address Changes ERV P Tico A 866 528 1606 Provider Educa heheh ines Baines abe ued 866 828 6264 TrailBlazer Health Enterprises LLC Page 15 August 2003
5. healthcare claims It can be used in conjunction with your existing claims management system or as a stand alone product Features of Pro 32 include User friendly system with extensive help screens and a manual providing step by step instructions Provided at no charge Distributed on a CD TrailBlazer Health Enterprises LLC Page 8 August 2003 Medicare Part B EDI Enrollment Packet Claims are transmitted via telephone line with modem speeds ranging from 9600 bps to 28 8 bps Claims are put into batches that can contain any number of claims an entire batch is transmitted during the same on line session multiple batches per day can be transmitted Our transmission lines are available 24 hours a day seven days a week Has the ability to print all claims in a batch or selected individual claims Supports the retrieval of Electronic Remittance Notices ERAs and Electronic EOB Combined Medicare Part A and CMS 1500 system Electronic submission of claims in NSF or ANSI 837 formats Automatic code validation Context sensitive pop up selection lists speed claim entry and promote accuracy Maintains claim payment history Integrated backup restore and file maintenance functions Familiar Microsoft Windows look and feel Ongoing maintenance updates and enhancements ef gt gt gt gt gt o FH FT FH 2 Technical support is available through the To operate successfully the program requires IBM or IBM compat
6. auses to be misrepresented or falsified any record or other information relating to that claim that is required pursuant to this Agreement may upon conviction be subject to a fine and or imprisonment under applicable Federal law 13 That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries or any information obtained from CMS orits contractor shall not be used by agents officers or employees of the billing service except as provided by the contractor in accordance with T1106 a of the Act 14 That it will research and correct claim discrepancies 15 That it will notify the contractor or CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form B The Health Care Financing Administration will L Transmit to the provider an acknowledgement of claim receipt 2 Affix the intermediary carrier number as its electronic signature on each remittance advice sent to the provider 3 Ensure that payments to providers are timely in accordance with CMS s policies 4 Ensure that no contractor may require the provider to purchase any or all electronic services from the contractor or from any subsidiary of the contractor or from any company for which the contractor has an interest The contractor will make alternative means available to any electronic biller to obtain such services 5 Ensure that all Medicare electronic billers have equal ac
7. cess to any services that CMS requires Medicare contractors to make available to providers or their billing services regardless of the electronic billing technique or service they choose Equal access will be granted to any services the contractor sells directly indirectly or by arrangement 6 Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form TrailBlazer Health Enterprises LLC Page 6 August 2003 Medicare Part B EDI Enrollment Packet Notice Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by the CMS under this document This document shall become effective when signed by the provider The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to CMS or the contractor Either party may terminate this arrangement by giving the other party 30 days written notice of its intent to terminate In the event that the notice is mailed the written notice of termination shall be deemed to have been given upon the date of mailing as established by the postmark or other appropriate evidence of transmittal C Signature I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and acknowledge same by signing below Provider s Name Auth
8. e contact the appropriate Provider Support person for your area to obtain additional information DC Delaware 008 Cynthia Huddleston cccecceesceescseeceeeceseceneceeceeecaeeeseeeneeeeeeereneeensees 469 372 7315 Maryland eens Cynthia Huddleston initiis ienie avid She dite ri 469 372 7315 MA ele Meee acs VACKIS 0 a O 469 372 8937 TES ET Angela T sDycurntniinn in ins incitar 469 372 2118 TrailBlazer Health Enterprises LLC Page 9 August 2003 Medicare Part B EDI Enrollment Packet Pro 32 Claim Submission Software Request Form I have read and understand the system requirements for the free Pro32 software and I have verified that my system meets the minimum equipment requirements to submit my claims electronically using the Pro32 software Medicare s Provider Group Name Submitter Name if not provider s office Address City Office Phone Contact Person Computer Type brand Processor check one L Pentium I L Pentium II L Pentium Pro L Pentium II Processor Speed check one L 133 L 200 L 233 L 266 L Other Windows Version check one _ 95 L 98 L 2000 L NT 4 0 L Other Available Conventional Memory Available Extended Memory XMS Available Disk Space Modem Type Brand Baud Rate Communication Software SVGA monitor resolution On a Network check one L Yes L No Pro32 Software is available on diskettes 1 44
9. ible for all Medicare claims submitted to CMS by itself its employees or its agents 2 That it will not disclose any information concerning a Medicare beneficiary to any other person or organization except CMS and or its contractors without the express written permission of the Medicare beneficiary or his her parent or legal guardian or where required for the care and treatment of a beneficiary who is unable to provide written consent or to bill insurance primary or supplementary to Medicare or as required by State or Federal law 3 That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so and to certify that required beneficiary signatures or legally authorized signatures on behalf of beneficiaries are on file 4 That it will ensure that every electronic entry can be readily associated and identified with an original source document Each source document must reflect the following information e Beneficiary s name e Beneficiary s health insurance claim number e Date s of service e Diagnosis nature of illness e Procedure service performed 5 That the Secretary of Health and Human Services or his her designee and or the contractor has the right to audit and confirm information submitted by the provider and shall have access to all original source documents and medical records related to the provider s submissions including the beneficiary s authorizatio
10. ible personal computer with a hard disk not on a network Pentium 133 MHz processor Pentium II 350 for larger claim volume 32 MB system memory 64 MB recommended SVGA mointor resolution 800x600 Windows 95 98 2000 or NT 4 0 operating system Adobe Acrobat Reader Version 4 0 This free software can be downloaded from www adobe com 5 gt gt gt o Asynchronous modem at 9600 bps or higher Notice Pro 32 was not developed for network use Technical support will not be provided for users who install Pro32 on a network You must obtain all assistance from your Network Administrator MEDICARE ELECTRONIC REMITTANCE ADVICE ERA For Medicare Part B Texas Maryland Virginia Delaware and DC Metropolitan Area the following ERA formats and versions are available National Standard Format Electronic Remittance version 1 04 2 00 and 2 01 American National Standards Institute ANSI X12 835 Electronic Remittance versions 3030 2B 3051 3B and 3051 4B To obtain additional information please contact the appropriate Provider Support person for your area DC Delawate Jonathan SCOSSIMS iii 469 372 7477 Maryland o on Cynthia Huddleston escri ipod 469 372 7315 TEXAS nta MVACKIO YORK irte 469 372 8937 tan Angela Tasby votes sc eoa woewt bopeeeay er 409 372 21 18 MEDICARE ELECTRONIC FUNDS TRANSFER EFT For Medicare Part B Texas Maryland Virginia and DC Metropolitan Area Delawar
11. in submitting claims for providers who have a Medicare Electronic Data Interchange EDI Enrollment Agreement on file Testing Requirements NEW EDI SYSTEM VENDORS AND SUBMITTERS New EDI System vendors and submitters including providers who have programmed their own systems will be required to complete a testing phase to ensure accurate format and claims data quality before production status can be granted Once the vendor or submitter is granted approved status they can enroll new providers without additional testing Test files should consist of a variety of at least 25 claims that represent the type of claims the vendor submitter will be submitting once production status is achieved Test claims will not be processed for payment but will be validated against production files therefore they must contain valid patient procedure diagnosis and provider information Because test claims will not be processed for payment claims previously submitted for payment or claims that have not yet been submitted may be used In addition to the fields required for specific specialties we request that test files include where applicable Multiple Place of Service 11 12 21 22 32 Referring UPINs x ray lab consults PT Medigap for Participating Providers Secondary Insurance BCBS Med Assistance Commercial MSP claims paid and allowed amounts insurance type code Narratives Modifiers Assistant Surgery Mod 80 with Facility ID
12. le on screen instructions eliminate the need for a training or user s manual Network access is available through free software for dial up access Benefit and claims information is in an easy to read format Access to Online Services is made available using a dial up connection through AT amp T Global Network Services For Medicare inquiries there is a 3 per month fee plus a connection time charge For metropolitan areas where network access is a local call the connection charge is about 9 cents per minute For areas requiring the use of a toll free 1 800 number the charge is about 18 cents per minute Most major cities have local dial up access Access is available Monday through Friday from 8 00 a m to 6 30 p m EST and some Saturdays The bulletin board regularly posts exact times of availability Equipment needed to use Online Services An IBM compatible microcomputer Windows Operating System 3 1 95 98 or NT A hard disk drive or high density floppy drive with at least one megabyte of storage available An asynchronous modem gt gt A single analog telephone line the system will not function if connected to multi line or digital PBX For more information or to order Online Services contact the Technology Support Center toll free at 1 866 749 4302 PRO 32 CLAIM SUBMISSION SOFTWARE Medicare provides free electronic claims submission software Pro 32 Pro32 is a comprehensive management system for electronic
13. lef TrailBlazer HEALTH ENTERPRISES LLC A CMS Contracted Intermediary and Carrier Dear Provider Thank you for your interest in Electronic Data Interchange EDI Section 1 contains the required enrollment documents that must be completed signed and returned to our office prior to initiation of electronic claims submission or inquiry Section 2 contains information regarding various options available to our electronic trading partners These are not mandatory they are intended to ensure you are aware of all of the electronic opportunities available to you If you choose to take advantage of any of these options simply complete the associated request form and return it along with the enrollment documents Your request will be processed as quickly as possible Please allow 2 weeks for processing software requests If you have any questions regarding any of the documents in this package please phone the TrailBlazer EDI Technology Support Center toll free at 1 866 749 4302 Medicare Part B EDI Enrollment Packet TrailBlazer Health Enterprises LLC New EDI Provider Enrollment Packet Section 1 The following documents are required for electronic data interchange including electronic claims submission and inquiry Electronic Data Interchange Provider Information Form page 3 e Medicare Electronic Data Interchange Enrollment Agreement page 4 All new providers must complete and return these enrollment documents in order t
14. n and signature All incorrect payments that are discovered as a result of such an audit shall be adjusted according to the applicable provisions of the Social Security Act Federal regulations and CMS guidelines 6 That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that Medicare is the primary payer 7 That it will submit claims that are accurate complete and truthful 8 That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years 3 months after the bill is paid TrailBlazer Health Enterprises LLC Page 5 August 2003 Medicare Part B EDI Enrollment Packet 9 Thatit will affix the CMS assigned unique identifier number of the provider on each claim electronically transmitted to the contractor 10 That the CMS assigned unique identifier number constitutes the provider s legal electronic signature and constitutes an assurance by the provider that services were performed as billed 11 That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and protect all beneficiary specific data from improper access 12 That it will acknowledge that all claims will be paid from Federal funds that the submission of such claims is a claim for payment under the Medicare program and that anyone who misrepresents or falsifies or c
15. not receive any other form of notification for initial test results Once a successful test file has been accepted with no errors fax a completed EMC Production Request Form see page 13 to request production status An EDI analyst will verify the test submissions for accuracy and fax back to the submitter a confirmation form within three 3 business days Do not attempt to submit production claims until you receive this form EXISTING EDI SYSTEM VENDORS AND SUBMITTERS Although we do not require approved systems vendors and submitters to test new providers we encourage all vendors and submitters to test new versions formats and or enhancements to their software programs to ensure their electronic claims software continues to meet format and quality standards Vendors can use their 6 digit vendor code as the submitter ID to transmit a file for test purposes You will need to contact the Technology Support Center for a password TrailBlazer Health Enterprises LLC Page 12 August 2003 Medicare Part B EDI Enrollment Packet lef TrailBlazer HEALTH ENTERPRISES LLC EDI Systems Vendor Submitter Enrollment Form Fax Completed Form To 410 683 2937 C Add LI Update Business Name Check One L Vendor O Billing Service L Submitter O Clearinghouse L_ Provider s More than one provider billing independent from same office List all providers at bottom Address City State Zip Vendor Submitter Password P
16. o enroll in Electronic Data Interchange EDI The Medicare Electronic Data Interchange Enrollment Agreement must be signed by the physician administrator or equivalent legal representative and the original returned prior to sending electronic production claims The enrollment documents must be completed and returned to us by mail for processing Faxes are not acceptable You should keep a copy of the Medicare EDI Enrollment Agreement for your records If you have any questions please contact the Technology Support Center toll free at 1 866 749 4302 ELECTRONIC DATA INTERCHANGE EDD PROVIDER INFORMATION FORM Part A Provider Data This portion of the form is to be completed by the Physician Supplier or Group Practice It must include the Physician Supplier or Group Practice name and the complete street address city state zip code primary contact s name phone number fax number and provider number s If you are requesting approval for multiple physician supplier or group identification numbers a separate EDI Provider Enrollment Packet must be completed for each individual billing number If you are enrolling a group practice only one Enrollment Packet should be completed with the group billing identification number Provider is Submitter Place a check before this choice if you will be submitting Electronically Direct to us from your office Using the software indicated in Part B of the form This must be checked if a
17. orized Signature Title Address City State Zip By Title Date TrailBlazer Health Enterprises LLC Page 7 August 2003 Medicare Part B EDI Enrollment Packet TrailBlazer Health Enterprises LLC Provider Enrollment Packet Section 2 GPNET ONLINE SERVICES SOFTWARE Online Services is an online computer inquiry system that provides easy and immediate access to claims processing and beneficiary eligibility information for Medicare providers The information can be obtained through dial up capabilities using software that is provided at no cost The software is designed for IBM or IBM compatible microcomputers Inquiry software is available in Windows Online Services can save you time and money Instead of calling one of the Medicare Customer Service Units Online Services provides immediate access to the following Physician Summary Information Month to Date and Year to Date Individual Claim Display by Claim Control Number List of Pending Claims Electronic Assigned and Non Assigned Claims List of Paid Claims Electronic Assigned and Non Assigned Claims Electronic Claims Submitter Provider File Inquiry Physician Bulletin Board for claims processing information e gt Beneficiary Eligibility Inquiry Medicare Participating Providers only Online Services is easy to use After logging on the system takes you step by step through your inquiry Extensive but simp
18. pplicable Provider is with Billing Service or Clearinghouse Place a check before this choice if your claims will be submitted Electronically Through a billing service or clearinghouse as indicated in Part C of the form This must be checked if applicable Provider is with other Providers Place a check before this choice if There is more than one physician supplier or group in your office You will be submitting electronically directly from your office Be sure to include the Provider Identification Numbers in the space provided With this choice the group of providers will be assigned one special submitter number to be used by all providers Note Only individual practice or group numbers are needed Physician s individual numbers that are within a group billing practice are not needed Part B EDI Software Vendor Data If you received this packet from your software vendor this section may have already been completed for you If it is not completed you must provide the company name of your software vendor TrailBlazer Health Enterprises LLC Page 2 August 2003 Medicare Part B EDI Enrollment Packet Part C EDI Billing Service or Clearinghouse Data If you received this packet from your billing service or clearinghouse this section may have already been completed for you If it is not completed you must provide the company name of the billing service or clearinghouse that will be submitting your claims
19. rimary Contact s Name Phone Number SOFTWARE Fax Number Vendor Name Address City State Zip Contact Phone Claim Submission Format ANSI X12 837 _ 4010 A1 Requested Response Format GPNET Claim Acceptance Response L File Format L Report Format L CMS flat file L ANSI X12 997 This response is sent in addition to the GPNET Claim Acceptance Response in report format Mode LCI ASYN C FTP CI NDM Data Compression To receive files compressed for faster transmission please indicate which data compression utility you support L PKZIP version 2 04g or compatible LI UNIX Compress Do you currently have users who wish to submit electronic claims If yes please list below Billing Provider Provider Name City TrailBlazer Health Enterprises LLC Page 13 August 2003 Medicare Part B EDI Enrollment Packet lef TrailBlazer HEALTH ENTERPRISES LLC EDI Production Request Form I have completed claims testing and received a response file with no rejected claims or warnings Fax completed form to 410 683 2937 Date Please complete the information requested below to update your status from test to production You will be notified within 3 business days by fax confirmation EDI Submitter Vendor ID s Contact Person Office Phone Fax Date s of Test Transmission s File ID s Please List the Provider Number s used for Tes
20. ronically If neither confirmation nor a returned packet is received after two weeks contact the Technology Support Center toll free at 1 866 749 4302 TrailBlazer Health Enterprises LLC Page 3 August 2003 Medicare Part B EDI Enrollment Packet lef TrailBlazer HEALTH ENTERPRISES LLC EDI Provider Information Form Part A Provider Data to be completed by Provider Name Address City State Zip Phone Number Fax Number Medicare Provider Number Check one of the following L Provider is Submitter Provider submits claims directly from their office L Provider is with Billing Service Clearinghouse L Provider is with other Providers list Provider ID s Check the format in which you will be submitting _ NSF L UB92 L ANSI Indicate the version number Part C EDI Billing Service Clearinghouse Data to be completed by Billing Service Clearinghouse Company Name Primary Contact Phone Fax Submitter ID Password Check the format in which you will be submitting _ NSF Indicate the version number TrailBlazer Health Enterprises LLC Page 4 August 2003 Medicare Part B EDI Enrollment Packet Medicare Electronic Data Interchange Enrollment Agreement Medicare Billing Provider Number The undersigned provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS s contractors A The Provider Agrees 1 That it will be respons
21. ting Name of EDI Analyst if known Technology Support Center toll free 1 866 749 4302 TrailBlazer Health Enterprises LLC Page 14 August 2003 Medicare Part B EDI Enrollment Packet Telephone Directory TRAILBLAZER EDI Technology Support Center sissies scini locaciones dolo doors tan sa 1 866 749 4302 Fel6COMMUMNICALIONS EE EEE RE 803 788 9860 Medicare Part B Texas Provider Automated Response System ARS ococooccccocononononononnonncanonnonononocononnononononnonnrnncn conan nena nancons 800 863 9755 Provider Appeal Svin aeei eenaa ii E e R ESTN EENE REE a AEE 866 237 4481 Coverage ISSUES viii a E EE TEE EO REEE ES 877 392 9865 OVErpay Men iia a ui 903 463 3948 Program Compliance sieeve ien bgi draenei nade endeared 469 372 7478 Provideri Service Snoen E E E E E EA E E EE lic 866 528 1602 Provider Numbers UPIN directory Address Changes ERN EFT Enrollment seenen a a E E e E E EE E E EE E E E A a 866 528 1605 A A A a 866 528 1607 Provider Educ ii aro 469 372 5494 Seminar Workshop INFOLINE Medicare Part B Maryland Provider ARS iman 800 862 8162 Provider AP EAS tail pidas E AEA Nr asno 410 683 2505 Coverage Issues c sivcsscsevesessssncssddadssssbevseesaedsanstes ARENE Tp EEn SEESE E ay sas EE Oa O EE OESE Sees Pe sE SERA ei ese 866 539 5591 Overpayments isidro 903 463 3948 Progr m Compliance sec tibia 469 372 7478 Provider Servic ss sic c ees ida 866 528 1602 Provider Numbers
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