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HomeMy WebLinkAboutC05-163 State of Colorado c! os-. /~ J -.l- L.. . Colorado Medical Assistance Program PROVIDER ENROLLMENT FORM Please print or type. Complete all areas, unless otherwise indicated. Section 1. Classification Please indicate your classification. D Individual Provider r21 Group Provider Section 2. Submission method The default for all providers/submitters is the State's Provider Web Portal. If you have more then one submission method, please indicate how you plan to submit your electronic transactions. Please check all that apply. D Vendor Software 0 Billing Agent 0 Clearinghouse/Switch Vendor ~ State's Provider Web Portal 0 Asynchronous (Batch) Section 3. Provider Information Legal Business Name (If applicable): Eagle County Health & Human Services Name: Forinash Kathleen L Last First MI Suffix Telephone: 970-328-8840 Fax: 970-328-8829 Provider # (if applicable): 04445094 Group # (If applicable): EIN (Tax 10): 84-600762 Email address: kathleen.forinash@eaglecounty.us Location Street Address: Old Courthouse Building, 551 Broadway City: Eagle State: CO Zip: 81631 Billing Address: P.O. Box 660 City: Eagle State: CO Zip: 81631 Mai/- To Address: P.O. Box 660 1":'" ii:*'P "......:,<\i} x:i\.. ~</,7' . ell< ~. .ti", f...ti> '.f'" , ,.-",' "F.~ ',-.,. ~..' 81631 ,.., F,.<le1p State: CO Zip: -"J' ;, 11/2004 Page 5 of 5 A. C S' , Colorado Medical Assistance Program PROVIDER ENROLLMENT FORM Section 6. Contact Information Sub-Sect/on 6a. Primary Contact Information Contact Individual Name: Kathleen Forinash Contact Title: Director Business Street Address: 551 Broadway City: Eagle State: CO Zip: 81631 Telephone: 970-328-8858 Fax: 970-328-8829 Email address: kathleen.forinash@eaglecounty.us Sub-Section 6b. Additional Contact Infonnation Contact Individual Name: Jill Hunsaker Contact Title: Public Health Manag r Business Street Address: 551 Broadway City: Eagle State: CO Zip: 81631 Telephone: 970-328-8819 Fax: 970-328-8829 Email address: iill.hunsaker@eaglecounty.us ~';' ,-,~ . ;il{'~i-",~~l-_ J ~?1-:-. ~.- +4"$: -;~~, .':iio. , ~<<~--:,; '- (.<~. i.i<' ,'I'" ~~':" ;, 11/2004 Page 7 of 7 A. C S' F . Colorado Medical Assistance Program PROVIDER ENROLLMENT FORM Section 7. Transmission Transactions 0 X12N 270 (Eligibility Inquiry) [!J X12N 837P (Professional Claim) 0 X12N 276 (Claim Status Inquiry) D X12N 8370 (Dental Claim) W X12N 278 (Prior Authorization) D X12N 8371 (Institutional Claim) Section 8. Report Transactions Colorado Medical Assistance Program providers can receive X12N electronic reports. Please select the reports that you want to receive through the State's Provider Web Portal. Enter only one Trading Partner (TP) 10 per report. You may enter a different TP 10 for each selected report. Providers can no longer receive/retrieve reports through BBS/M EVS NET. Receiving TP Receiving TP 10 10 o X12N 271 (Eligibility Response) D X12N 835 (Claim payment/Claim report) o X12N 277 (Claim Status Response) D X12N 997 (Acknowledgement of a sent transaction) This report is automatically sent to providers. o X12N 820 (Client Capitation) o X12N 834 (PCP Roster) o X12N 824 (Error Report) , IZJ Provider Claim Report (Previously called the Remittance Advice Report) ~ Accept/Reject Report o PCP Roster Section 9. Delimiter Information For X12N transactions submitted directly to ACS EDI Gateway, please provide an alternate delimiter, if required. If left blank, the default delimiter will be used. Element Delimiter 0 Sub-element Delimiter 0 Segment Delimiter 0 to be used: to be used: to be used: Default Delimiter (asterisk) * Default Delimiter (colon) : Default Delimiter (tilde) - 4- "hIi ' ,'~ ,'~'\l>, ;\.. 11/2004 Page 8 of 8 A. C S' , Colorado Medical Assistance Program PROVIDER ENROLLMENT FORM SectIon 10. Additional Provider Ust If you are st.IbnittJng transactions on behIIIf d mJItipIe bIIIng providers. pJease supply the provider name and number d eech addftlonaI provtder. Eachd these bRIng provIdera nut authorize you to submit Ira IS8CtIona on their behalf. by flIIJng out the ProvIder Author1zaton Fann. If any d these biIIng provIdera wish to submit any cJaJrna elemncaDy on their own. or wish to r..... reports or eIIgJbiIIty verJftcatJon electronically. they roost also complete and nUn an entire Provider ErfdImentPackel Even If. biIIng provider listed here 'NIl not be lIUbmitIJng cJaima eJec:tronJcally. or retrtevIng reports or eIIgJbiIty yerlftcatlon eJectronJcaly. they MUST STILL EXECUTE AND RETURN the ProvIder Partk:IpaUal Agreement . Bllllna Provider Name Provtder ID LINDA MAGGIORE 12836354 REBECCA T. McCAULLEY 07813736 KRISTIN DIEDRICH 04445094 <:AVAlf SI:H 1"1"t<:K 07384597 , f .t. .' .w' ,- ~ "" j.'~t~ . ""';\i/ _ . <~/ ~>>,,'" i _ _. < _ _ _ ._ _ _ _ _ _ __ _ _ ._ _ _ _ u_ _ _ __ <._ _ - - -.. - .4.ttach additional sheets If necessary- - -- ~, 11/2004 Page 9 01'9 A. c S. , Colorado Medical Assistance Program PROVIDER SIGNATURE PAGE NO PROVIDER APPLICATION, ENROLLMENT FORM, PROVIDER AUTHORIZATION FORM (if applicable), OR PROVIDER PARTICIPATION AGREEMENT WILL BE PROCESSED WITHOUT COMPLETION OF THIS PAGE I certify by my signature below that I am fully authorized to sign and execute this Agreement on behalf of Provider; and that I have read, understand, certify, and agree to all the statements made above in all parts of this Provider Participation Agreement. I further understand that any false claims, statements, documents, or concealment of material fact may be grounds for termination as a Colorado Medical Assistance Program Provider, and/or may be prosecuted under applicable federal and state laws. Provider . By: Signature Name: /JRII/ 11. '1l1 R 1II1t/) ,u...: Title: ~.{ rr j t? ,.,.",,,. 1'\/ Provider # : Date: 6'1'7- ()~ i"'i,~. .""" - ......:i"~ ~; .,...,'.."t, .""..~ - - ~ .-- ;, 11/2004 Page 18 of 18 A c S'