EDI Help Desk Form

EDI Help Desk (Provider)

Please complete this form if you have a problem with the EDI Submission.

* indicates a required field.

* Provider Name:
Confirmation E-mail Address:
* Contact Name:
* GHP Provider/CDIP Number:
* Tax ID Number:
* NPI Type I (Individual Provider) Number:
* NPI Type II (Group) Number:
* Office/Site Number:
* Provider Phone Number:
* Date of EDI Submission:	/ / (mm/dd/yyyy)
* Member GHP ID Number:
* Vendor Name:
* Error Received:
*Patient Control Number on Rejected Claims:
Questions / Issues: