MT DPHHS EDI Provider Enrollment Form free printable template

MONTANA DP HHS EDI PROVIDER ENROLLMENT FORM Please return to: ACS, A Xerox Company Attn: MT EDI PO Box 4936 Helena, MT 59604 Or fax to 406-442-4402 EDI SUBMITTER ENROLLMENT FORM. Please print or type.

How to fill out MT DPHHS EDI Provider Enrollment Form

How to fill out MT DPHHS EDI Provider Enrollment Form

1. Begin by downloading the MT DPHHS EDI Provider Enrollment Form from the official website.
2. Fill in your legal business name as it appears on your business documentation.
3. Provide your business address including street, city, state, and zip code.
4. Enter your National Provider Identifier (NPI) number.
5. Indicate the type of provider you are (e.g., individual, group practice, facility).
6. Complete the contact information section, including phone number and email address.
7. Review the section for required attachments, such as proof of NPI or licenses.
8. Sign and date the bottom of the form to certify the information is accurate.
9. Submit the completed form via mail or email as specified in the guidelines.

Who needs MT DPHHS EDI Provider Enrollment Form?

1. Healthcare providers and organizations seeking to enroll in the Montana DPHHS Electronic Data Interchange (EDI) system.
2. Providers looking to bill Medicaid or other services through electronic means.
3. Any new provider wanting to establish credentialing for EDI transactions with Montana's Department of Public Health and Human Services.

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What is MT DPHHS EDI Provider Enrollment Form?

The MT DPHHS EDI Provider Enrollment Form is a document used in Montana for health care providers to enroll and participate in the Electronic Data Interchange (EDI) system. It facilitates the processing of electronic claims and other related transactions.

Who is required to file MT DPHHS EDI Provider Enrollment Form?

Health care providers and organizations that wish to participate in the state's Medicaid program and submit claims electronically must file the MT DPHHS EDI Provider Enrollment Form.

How to fill out MT DPHHS EDI Provider Enrollment Form?

To fill out the MT DPHHS EDI Provider Enrollment Form, providers should provide their business and contact information, including their National Provider Identifier (NPI), and ensure that all sections of the form are completed accurately according to the instructions provided.

What is the purpose of MT DPHHS EDI Provider Enrollment Form?

The purpose of the MT DPHHS EDI Provider Enrollment Form is to establish a provider's ability to send and receive electronic health care transactions, such as claims, ensuring they are compliant with state and federal regulations.

What information must be reported on MT DPHHS EDI Provider Enrollment Form?

The form requires providers to report information such as their legal business name, NPI, contact details, tax identification number, and information related to their practice or services offered.