Approved Software Vendor List

Production Ready Form

Please fill out the form below.

Providers who submit via a Billing Agent or Clearinghouse should not complete this form. Please contact your Billing Agent or Clearinghouse to verify their HIPAA readiness.
Submitter Name: (required field)
Submitter Tax ID:
(One registration form is required per Tax ID. This Tax ID will be set up as the Trading Partner and should be submitted in the appropriate data elements of the ISA, GS and NM1 segments.)		 (required field)
Contact Name: (required field)
Contact Phone #: (required field)
Contact Fax #
Contact E-mail Address: (required field)
ANSI X12 File Name: (example: ptxxx, ubxxx, or ecxxx) (required field)
Last Certification Report Rundate: (required field)
Total Number of Accepted Claims:
Percent Accepted:
Transaction(s)/Version Tested: (required field)
examples of transactions / versions tested:
(please type them in the box above):
837 4010 A1 Institutional Claims
837 4010 A1 Professional Claims
835 4010 A1 Remittance Advice
270 4010 A1 Eligibility Inquiry
276 4010 A1 Claim Status Inquiry
278 4010 A1 Authorization/Referral
820 4010 A1 Premium Payment
834 4010 A1 Enrollment
 Please Add to the Approved Vendor List.
(In order to be added to the Approved Vendor List, please complete the following):
Address: (required field)
City: (required field)
State: (required field)
Zip: (required field)
Contact (if different from above):
Contact Phone #: (required field)
Contact Fax #:
Contact E-mail Address: (required field)
Web Site Address:
 
Listing Options (choose all that apply):
 Software Vendor  Clearinghouse  Billing Agency
 

Page last modified:November 9, 2006