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10/2013 v2. 11 EDI Services Part A Enrollment Application General Information State Alabama Georgia Rural Health Clinic Tennessee Reason for Submission Provider Information Provider Name Provider Address physical address for the facility or practice City Zip Code Email Address Provider Contact Name name of contact in provider s office for EDI or ERA related issues Fax Number Phone Number Provider Identifiers Tax ID EIN Numbers Medicare Facility n...

How to fill out cahaba edi enrollment form

Point by point instructions on how to fill out the Cahaba EDI enrollment form:

1. Obtain the Cahaba EDI enrollment form from the Cahaba website or contact their customer service for assistance.
2. Carefully read through the instructions and requirements provided with the form to ensure you understand the process.
3. Begin by providing your personal or organization's information, including name, address, phone number, and email address.
4. If you are representing an organization, include its name, contact person, and any necessary identification numbers.
5. Indicate the type of enrollment you are seeking, such as new enrollment or an update to existing enrollment.
6. Fill out the sections related to the specific services you are enrolling in, such as electronic submission of claims or electronic remittance advice (ERA).
7. Provide any additional information or documentation that may be required, such as a copy of your National Provider Identifier (NPI) certificate or Tax Identification Number (TIN).
8. Review the completed form for accuracy and completeness, ensuring that all mandatory fields are filled out.
9. Sign and date the form as required, either electronically or by hand, depending on the submission method.
10. Submit the completed enrollment form to Cahaba through the designated method specified in the instructions.

Who needs Cahaba EDI enrollment form?

1. Healthcare providers who plan to submit claims electronically to Cahaba for reimbursement.
2. Organizations or individuals who wish to receive electronic remittance advice (ERA) from Cahaba.
3. Any entity seeking to enroll or update their enrollment status with Cahaba for electronic transactions.

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What is cahaba edi enrollment form?

The Cahaba EDI Enrollment Form is a standardized form used by healthcare providers to enroll in the Electronic Data Interchange (EDI) system managed by Cahaba GBA. EDI allows providers to submit claims and receive electronic remittance advice (ERA) for Medicare services.

Who is required to file cahaba edi enrollment form?

Healthcare providers who wish to submit claims and receive electronic remittance advice (ERA) for Medicare services through the Cahaba GBA EDI system are required to file the Cahaba EDI Enrollment Form.

How to fill out cahaba edi enrollment form?

To fill out the Cahaba EDI Enrollment Form, providers need to provide their personal and practice information, such as name, address, contact details, Tax ID, National Provider Identifier (NPI), Medicare number, and other relevant information. The completed form can be submitted electronically or via mail to Cahaba GBA.

What is the purpose of cahaba edi enrollment form?

The purpose of the Cahaba EDI Enrollment Form is to gather information from healthcare providers who wish to participate in the Medicare program and utilize the EDI system managed by Cahaba GBA. The form ensures that providers meet the necessary requirements and can receive electronic claims and remittance advice.

What information must be reported on cahaba edi enrollment form?

The Cahaba EDI Enrollment Form requires healthcare providers to report their personal and practice information, including name, address, contact details, Tax ID, National Provider Identifier (NPI), Medicare number, and other relevant information as required by Cahaba GBA.