Approved Software Vendor List

Testing Registration Form

The testing registration form is for providers and vendors only. If you are a member wanting to view claim status and eligibility, please login to BlueAccess and use Member Self-Service.
Please answer the selected questions 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.
Are you a current electronic submitter?  Yes  No
If you answered yes, please enter your BBS User ID or e-Commerce assigned File Name:
BBS User ID or File Name: ( as in: ptxxx, ubxxx,ecxxx)
Submitter Name: (required field)
Submitter Tax ID:
(submit only one form per Tax ID)		 (required field)
Contact Name: (required field)
Contact Phone #: (required field)
Contact Fax #:
Contact E-mail Address:
 Which of the following transactions will you be testing?
 (check all that apply)
 837 4010 A1 Institutional Claims
 837 4010 A1 Professional Claims
 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
 835 4010.A1 Remittance Advice
Page last modified:November 9, 2006