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E-Business Profile Smart Form
Submitter Type:
Type:
Clearinghouse/Vendor/TPA
Healthcare Provider
Employer
Submitter Name:
Physical Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
W.DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
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MS
MT
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OR
PA
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RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip:
Mailing Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
W.DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip:
Phone Number:
(602-123-1234)
Fax Number:
(602-123-1234)
Contact Information:
Office Contact:
Phone:
(602-123-1234)
Fax:
(602-123-1234)
Email:
(name@whichever.com)
Alternate Contact:
Phone:
(602-123-1234)
Fax:
(602-123-1234)
Email:
(name@whichever.com)
Healthcare Provider
Information
How many Physicians will be utilizing the HIPAA testing?
1
2
3
4
5
6
7
8
9
10
Check here if you need to enter more than 10 healthcare providers, and a BCBSAZ representative will email you an Excel spreadsheet where you may enter additional healthcare provider information.
Healthcare Provider #1
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #2
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #3
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #4
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #5
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #6
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #7
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #8
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #9
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Healthcare Provider #10
Healthcare Provider Name:
Tax ID:
Provider ID Number:
Computer Information
Name of Management System:
Version:
Electronic Claim Software
(if different from above):
Software Vendor:
Contact Name:
Phone:
Fax:
Email:
HIPAA Transaction Setup
Connectivity Method
FTP
Batch Only
Tumbleweed
Batch Only
Socket to Socket
Real-Time Only
MQ Series
Batch
Real-Time
Both
Clearinghouse/Vendor/TPA HIPAA Customer Profile
HIPAA TRANSACTION SETUP
Contact your software vendor for the following required information.
Please check the box next to those transactions you will be sending.
It is VERY important that all requested information be filled in completely.
270 Eligibility Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
276 Claim Status Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
278 Request For Referral Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
837 Claims (Professional, Institutional, Dental) Transaction
Version:
4010-A-1
Other:
Claim Type:
Professional
Institutional
Dental
Medicare
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
I/we will be interested in receiving an 835 Electronic Remittance Advice Transaction.
Healthcare Provider HIPAA Customer Profile
HIPAA TRANSACTION SETUP
Contact your software vendor for the following required information.
Please check the box next to those transactions you will be sending.
It is VERY important that all requested information be filled in completely.
270 Eligibility Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
276 Claim Status Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
278 Request For Referral Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
837 Claims (Professional, Institutional, Dental) Transaction
Version:
4010-A-1
Other:
Claim Type:
Professional
Institutional
Dental
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
I/we will be interested in receiving an 835 Electronic Remittance Advice Transaction.
Employer Customer Profile
HIPAA TRANSACTION SETUP
Contact your software vendor for the following required information.
Please check the box next to those transactions you will be sending.
It is VERY important that all requested information be filled in completely.
820 Eligibility Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
834 Claim Status Inquiry Transaction
Version:
4010-A-1
Other:
What Segment Terminator delimiter will you be using?
What Element Separator delimiter will you be using?
What Component Separator delimiter will you be using?
Will you be placing a carriage return after each Segment Terminator?
Yes
No
Additional Information
Is this a New or Existing Group?
New
Existing
Are you able to send Adds(new employees), Terms(cancellation of entire contracts and cancellation of dependents) and Changes(adding and deleting, correcting members on a file) in one file?
Yes
No