Geisinger Health Plan® - Electronic Data Interchange (EDI) Application for Providers

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Electronic Data Interchange

Electronic Data Interchange (EDI) Enrollment Application

* indicates a required field.

Section I: Trading Partner Information

*Practice/Facility Tax ID # : 
* Practice / Facility Name :
 
* Primary Physical Address :
Address Line 1
Address Line 2
City
State
Zip
County
 
Remittance Address :
Address Line 1
Address Line 2
City
State
Zip
 
* Contact Person :
* Practice/Facility Telephone :
* Organization's NPI # (Type 2) :
* Type of Practice :


Section II: Requesting Application for the Following ASC X12 HIPAA Transactions

* (check each applicable box)
837 I (Claim: Institutional)
837 P (Claim: Professional)
270/271 (Eligibility/Benefit Inquiry and Response)
(Batch Process Only)
278 (Services Review-Request for Review and Response)
(Batch Process Only)
276/277 (Claim Status Request and Response)
(Batch Process Only)


Section III: EDI Clearinghouse / Billing Company / Financial Institution authorized to receive or transmit electronic transactions on behalf of provider

Name of EDI Clearinghouse that will be submitting claims to GHP :
Name of Intermediate EDI Clearinghouse
(if applicable) :
Name of Financial Institution :

If you have a billing company, please fill out this section:

Name of Billing Company :
Contact Person at Billing Company :
E-mail of Billing Company :
Telephone number of Billing Company :


Section IV: Provider / Facility Enrollment

Within your organization or practice, please list the entities or providers permitted to submit claims under the Tax ID# as listed in Section I. If more than 5 entries are made, please use the copy and paste feature below.

Provider / Facility submitting 837 I (UB92) transactions: Providers submitting 837P (CMS 1500) transactions:
Name:
Credentials:
NPI Type 1:
Name:
Credentials:
NPI Type 1:
Name:
Credentials:
NPI Type 1:
Name:
Credentials:
NPI Type 1:
Name:
Credentials:
NPI Type 1:
Copy and paste multiple providers here :
Copy and paste multiple providers here :

Geisinger Health Plan/Geisinger Indemnity Insurance Company/Geisinger Quality Options

Attestation: Geisinger Health Plan (EDI) Provider Enrollment Application
I hereby apply to Geisinger Health Plan for the purpose of electronic exchange of data including, but not limited to, the minimum necessary protected health information (as defined under the Health Insurance Portability Accountability Act of 1996) between Geisinger Health Plan and myself, or my authorized agent related to electronic data exchange transactions.

Upon acceptance [approval] by Geisinger Health Plan, the information on this application shall be [activated] and the parties hereunder my begin the electronic exchange of such data. I, or my authorized agent, agree to notify Geisinger Health Plan within five (5) business days of learning of any change to the information contained within this application. Either Geisinger Health Plan or I may terminate the electronic exchange of data at any time [upon prior notification to the non-terminating party].

The information contained within this application is true, correct and complete in all respects to the best of my knowledge and belief. I understand that the misrepresentation of any material fact by me on this application could constitute grounds for termination of the transmission, receipt or otherwise access of electronic exchange of data between the parties.



* Provider EDI Contact Person :
* Provider EDI Contact Telephone number :
* Provider EDI Contact e-mail address :