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ACS EDI Gateway ʼ s Claims Payer List

ACS EDI Gateway ʼ s Claims Payer List ACS EDI Gateway ʼ s Claims Payer List

ACS EDI Gateway ʼs Claims Payer List

Last updated 12/2009

ACS EDI Gateway ʼ s Claims Payer List

Allstate Insurance Company – Payer ID 77066 !

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Allstate Workplace Division - Payer ID 77083 !

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Banner MediSun – Payer ID 77078 !

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BrickStreet Mutual Insurance Company - Payer ID 77025 !

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Deerbrook Insurance Company – Payer ID 77069!

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Encompass Insurance – Payer ID 77068!

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Liberty Mutual Insurance Company – Payer ID 77138 !

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MDwise (HIP) – Payer ID 77150!

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Peach State Health Plan – Payer ID 77084 !

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Staywell/HealthEase/Wellcare – Payer ID 77004!

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Child Health Plus (NY)"

 

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Family Health Plus (NY)"

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Harmony Health Plan (IL, IN, MO)"

16

HealthEase (FL)"

 

16

HealthEase Healthy Kids (FL)"

16

Healthy Choice (NY)"

 

16

Ohana Health Plan (HI) "

16

PreferredOne

HUSKY

A (CT) "

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PreferredOne HUSKY B (CT) "

16

Staywell (FL)"

16

Staywell Healthy Kids (FL) "

 

16

WellCare (GA, OH)"

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XL Health/Care Improvement Plus – Payer ID 77082!

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ACS EDI Gateway ʼ s Claims Payer List

Allstate Insurance Company – Payer ID 77066

Payer List Allstate Insurance Company – Payer ID 77066 http://www.allstate.com/ ACS EDI Direct is currently

ACS EDI Direct is currently accepting electronic medical bills for Allstate Insurance Company. Providers may submit X12 837 Professional and Institutional transactions and retrieve electronic EOBs for:

Allstate Insurance Company

Allstate Property & Casualty Insurance Company

Allstate Indemnity Company, and Allstate Fire and Casualty Insurance Company

ACS EDI Direct supports the following submission methods for Allstate Insurance Company:

ACS EDI Claims Data Entry website (data-keying claims on our internet site)

ediDIRECT File Exchange web portal (batch submission)

SFTP connection (secure file transfer protocol)

A software vendor, billing agent, or clearinghouse (through your current vendor)

Enrollment for Batch Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

Provider Authorization for X12 835 Vendors requesting to retrieve the 835 transaction (electronic EOB) must have authorization from their provider customer. The following form must be completed by EACH provider in order to retrieve an 835. Provider 835 Authorization Form

Enrollment for ediDIRECT Online Claims Entry and Submission If you are a provider and you would like to data-enter and submit claims directly to ACS using ediDIRECT, please complete the following form. ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

ACS EDI Gateway ʼ s Claims Payer List

Special Requirement for Allstate, Deerbrook, and Encompass Submitters If you are enrolling to submit electronic medical bills for Allstate Insurance company, Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also fax or mail a signed Trading Partner Agreement.

Attachments

Attachments required to be submitted with an Allstate Insurance medical bill (X12N 837 transaction) can be mailed. Please be sure to include the Claim Number in the upper right-hand corner and send to:

Allstate Insurance P.O. Box 440519 Kennesaw, Georgia, 30160

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ACS EDI Gateway ʼ s Claims Payer List

Allstate Workplace Division - Payer ID 77083

(Also known as American Heritage Life Insurance)

ID 77083 (Also known as American Heritage Life Insurance) http://www.ahlcorp.com/ ACS EDI accepts X12 837

ACS EDI accepts X12 837 Professional, Institutional, and Dental electronic transactions for Allstate Workplace Division a.k.a American Heritage Life Insurance.

Allstate Workplace Division (AWD) is the marketing name for American Heritage Life Insurance Company, a wholly-owned subsidiary of The Allstate Corporation. All products are underwritten by American Heritage Life Insurance Company, Jacksonville, Florida.

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

Special Requirement for Allstate, Deerbrook, and Encompass Submitters If you are enrolling to submit electronic medical bills for Allstate Insurance company, Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also fax or mail a signed Trading Partner Agreement. Trading Partner Agreement Form

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ACS EDI Gateway ʼ s Claims Payer List

Banner MediSun – Payer ID 77078

ʼ s Claims Payer List Banner MediSun – Payer ID 77078 http://www.medisun.com/ ACS EDI Direct accepts

ACS EDI Direct accepts X12 837 Professional and Institutional transactions for Banner MediSun.

If you are a provider, software vendor, clearinghouse, or a billing agent who will be submitting electronic medical transactions directly to ACS EDI in the ANSI X12N format, please complete the following:

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. In addition, you must also fax or mail a signed Trading Partner Agreement.

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ACS EDI Gateway ʼ s Claims Payer List

BrickStreet Mutual Insurance Company - Payer ID

77025

(Formerly WVWC)

Mutual Insurance Company - Payer ID 77025 (Formerly WVWC) http://www.brickstreet.com/ ACS EDI Direct accepts X12 837

ACS EDI Direct accepts X12 837 Professional and Institutional transaction for BrickStreet Mutual Insurance.

Providers have the capability to submit (HCFA-1500 and UB92) Workers' Compensation claims electronically to ACS. Providers may choose from the following options:

The free ACS WINASAP2003 software

A system vendor, billing agent, or clearinghouse using the ANSI X12N FORMAT

Enrollment for Electronic Claim Submission If you are a provider, software vendor, clearinghouse, or a billing agent who will be submitting electronic medical transactions directly to ACS EDI for BrickStreet Mutual Insurance, please use the following form:

Upon receipt of your completed form, ACS will acknowledge your enrollment in Electronic Data Interchange (EDI) by returning a Logon Information Sheet. The Logon Information Sheet will contain the information necessary for you to begin electronic filing.

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ACS EDI Gateway ʼ s Claims Payer List

Deerbrook Insurance Company – Payer ID 77069

Payer List Deerbrook Insurance Company – Payer ID 77069 http://www.deerbrook.com/ ACS EDI Direct accepts electronic

ACS EDI Direct accepts electronic medical bills for Deerbrook Insurance Company. Providers may submit X12 837 Professional or the X12 837 Institutional transactions and retrieve electronic EOBs for Deerbrook Insurance Company using the following options:

ACS EDI Claims Data Entry website (data-keying claims on our internet site)

ediDIRECT File Exchange web portal (batch submission)

SFTP connection (secure file transfer protocol)

A software vendor, billing agent, or clearinghouse (through your current vendor)

Enrollment for Batch Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

Provider Authorization for X12 835 Vendors requesting to retrieve the 835 transaction (electronic EOB) must have authorization from their provider customer. The following form must be completed by EACH provider in order to retrieve an 835. Provider 835 Authorization Form

Enrollment for ediDIRECT Online Claims Entry and Submission If you are a provider and you would like to data-enter and submit claims directly to ACS using ediDIRECT, please complete the following form. ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

Special Requirement for Allstate, Deerbrook, and Encompass Submitters If you are enrolling to submit electronic medical bills for Allstate Insurance company, Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also fax or mail a signed Trading Partner Agreement.

ACS EDI Gateway ʼ s Claims Payer List

Attachments Attachments required to be submitted with a Deerbrook Insurance medical bill (X12N 837 transaction) can be mailed. Please be sure to include the Claim Number in the upper right-hand corner and send to:

Deerbrook Insurance P.O. Box 440456 Kennesaw, Georgia, 30160

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ACS EDI Gateway ʼ s Claims Payer List

Encompass Insurance – Payer ID 77068

s Claims Payer List Encompass Insurance – Payer ID 77068 http://www.encompassinsurance.com/ ACS EDI Direct accepts

ACS EDI Direct accepts electronic medical bills for Encompass Insurance Company. Providers may submit X12 837 Professional or the X12 837 Institutional transactions and retrieve electronic EOBs for Encompass Insurance Company using the following options:

ACS EDI Claims Data Entry website (data-keying claims on our internet site)

ediDIRECT File Exchange web portal (batch submission)

SFTP connection (secure file transfer protocol)

A software vendor, billing agent, or clearinghouse (through your current vendor)

Enrollment for Batch Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

Provider Authorization for X12 835 Vendors requesting to retrieve the 835 transaction (electronic EOB) must have authorization from their provider customer. The following form must be completed by EACH provider in order to retrieve an 835. Provider 835 Authorization Form

Enrollment for ediDIRECT Online Claims Entry and Submission If you are a provider and you would like to data-enter and submit claims directly to ACS using ediDIRECT, please complete the following form. ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

Special Requirement for Allstate, Deerbrook, and Encompass Submitters If you are enrolling to submit electronic medical bills for Allstate Insurance company, Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also fax or mail a signed Trading Partner Agreement. Trading Partner Agreement Form

Attachments

ACS EDI Gateway ʼ s Claims Payer List

Attachments required to be submitted with an Encompass Insurance medical bill (X12N 837 transaction) can be mailed. Please be sure to include the Claim Number in the upper right-hand corner and send to:

Encompass Insurance P.O. Box 440457 Kennesaw, Georgia, 30160

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ACS EDI Gateway ʼ s Claims Payer List

Liberty Mutual Insurance Company – Payer ID 77138

List Liberty Mutual Insurance Company – Payer ID 77138 http://www.libertymutual.com/ ACS EDI Direct is your

ACS EDI Direct is your entry-point for submitting electronic medical bills to the following Liberty Mutual Group companies for Personal Lines insurance including No Fault and Medical Payments Coverage.

The First Liberty Insurance Corp

Liberty County Mutual Ins Co

Liberty Insurance Corp

Liberty Mutual Mid Atlantic Ins Co

Liberty Mutual Fire Insurance

Liberty Mutual Insurance Co

Lm Insurance Corp

ACS EDI accepts the X12N 837 Professional and Institutional Healthcare claim transactions and enables the retrieval of electronic EOBs using the following options:

Submit Claims to Liberty Mutual for FREE using a Direct Data Entry web portal (data-key claims through MD On-line)

ediDIRECT File Exchange web portal (batch submission)

SFTP connection (secure file transfer protocol)

A software vendor, billing agent, or clearinghouse (through your current vendor)

PLEASE NOTE: Bills for the treatment of worker’s compensation claims will not be processed if submitted to ACS EDI Gateway, Inc. Please contact Liberty Mutual directly regarding worker’s compensation claims.

Enrollment for Batch Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

ACS EDI Gateway ʼ s Claims Payer List

Provider Authorization for X12 835 Vendors requesting to retrieve the 835 transaction (electronic EOB) must have authorization from their provider customer. The following form must be completed by EACH provider in order to retrieve an 835. Provider 835 Authorization Form

MD On-line FREE Web Portal You may submit claims to Liberty Mutual for FREE through MD On-line. MD On-line offers a Direct Data Entry (DDE) application that allows Providers to submit medical bills (CMS-1500s) through a web interface to Liberty Mutual Group companies. For further details on MD On-line’s exclusive offer for Liberty Mutual providers and to register to begin submitting claims electronically, visit MD On-Line.

Notice Regarding MD On-line: : If you intend to use or are currently using the MD On- line FREE web portal to submit your Liberty Mutual medical bills, you DO NOT need to enroll with ACS EDI Gateway using the Trading Partner Enrollment Form referenced above. You only need to register with MD On-line.

Attachments Attachments required to be submitted with a Liberty Mutual medical bill (X12N 837 transaction) can be mailed. Please be sure to include the Claim Number in the upper right-hand corner and send to:

Liberty Mutual P.O. Box 1052 Montgomeryville, PA 18936

PLEASE NOTE: Do NOT send the corresponding paper claim if submitted electronically.

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ACS EDI Gateway ʼ s Claims Payer List

MDwise (HIP) – Payer ID 77150

ʼ s Claims Payer List MDwise (HIP) – Payer ID 77150 http://www.mdwise.org/ ACS EDI Direct accepts

ACS EDI Direct accepts X12 837 Professional and Institutional transactions for the MDwise Healthy Indiana Plan (HIP).

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. In addition, you must also fax or mail a signed Trading Partner Agreement.

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ACS EDI Gateway ʼ s Claims Payer List

Peach State Health Plan – Payer ID 77084

Claims Payer List Peach State Health Plan – Payer ID 77084 http://www.pshpgeorgia.com/ ACS EDI Direct serves

ACS EDI Direct serves as the entry point for electronic medical claims for Peach State Health Plan. ACS EDI accepts X12N 837 Professional, Dental, and Institutional transactions for Peach State.

ACS EDI’s WINASAP2003 software is available to create and submit your electronic Peach State Health Plan claims.

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. ACS EDI Gateway Trading Partner Enrollment Form

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ACS EDI Gateway ʼ s Claims Payer List

Staywell/HealthEase/Wellcare – Payer ID 77004

Payer List Staywell/HealthEase/Wellcare – Payer ID 77004 http://www.wellcare.com/ ACS EDI Direct accepts electronic

ACS EDI Direct accepts electronic transactions for the following Staywell/HealthEase/ Wellcare plans:

Child Health Plus (NY) Family Health Plus (NY) Harmony Health Plan (IL, IN, MO) HealthEase (FL) HealthEase Healthy Kids (FL) Healthy Choice (NY) Ohana Health Plan (HI) PreferredOne HUSKY A (CT) PreferredOne HUSKY B (CT) Staywell (FL) Staywell Healthy Kids (FL) WellCare (GA, OH)

ACS EDI Direct accepts X12 837 Professional and Institutional transaction for Staywell/HealthEase/Wellcare plans.

ACS EDI’s WINASAP2003 software is available to create and submit your electronic Staywell/HealthEase/Wellcare claims.

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form.

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ACS EDI Gateway ʼ s Claims Payer List

XL Health/Care Improvement Plus – Payer ID 77082

List XL Health/Care Improvement Plus – Payer ID 77082 http://www.xlhealth.com/careimprovementplus/ ACS EDI Direct

ACS EDI Direct accepts X12 837 Professional and Institutional transactions for the XL Health/Care Improvement Plus.

All direct submitters (trading partners) must first enroll with ACS EDI. Please visit Enrollment within the Claims Gateway menu.

Enrollment for Electronic Claims Submission If you will be submitting electronic claims directly to ACS EDI Gateway, please complete the following form. If you are using a third party vendor to submit electronic claims on your behalf, please contact them and have them complete the enrollment form. In addition, you must also fax or mail a signed Trading Partner Agreement.

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