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Payer ID: MOBLU

Missouri Blue Cross Blue Shield Anthem Midwest 837 and 835
EDI Enrollment Instructions Please use the File/Save As command and save this document to your computer, then type directly on the forms. Complete the blue highlighted fields only, as applicable, using the payee provider information. For your convenience, the enrollment forms contain areas that are pre-filled.

837 Claim Transactions
EDI enrollment is not required prior to sending electronic claims.

835 Electronic Remittance Advice
1. Complete the EDI Trading Partner Registration Form – Payment Advice/Remit.

Submit Completed Document
1. Fax to Central Region EDI at • 502-889-4533. 2. Fax to ClaimRemedi at • 707-827-1270.

2011-08-25

ClaimRemedi Enrollment@ClaimRemedi.com

800-763-8484 x 3 Fax: 707-827-1270

EDI TRADING PARTNER REGISTRATION FORM – Payment Advice/Remit Please print legibly to avoid form being returned Type of Request Check one Sender ID = Gateway mailbox from where the inbound 837 claim is being submitted Receiver ID = Gateway mailbox to where the outbound 835 payment is being routed INITIAL 835 SETUP – Receiver ID to be same as 837 Sender ID ___________________ Important .com E-Mail Address State Zip Code Phone Fax CA State 95403 Zip Code 800-763-8484 x 3 Phone 707-827-1270 Fax Form Continued on page 2 . notify the EDI Help Desk by completing this form as a maintenance request.fill in sender ID MAINTENANCE – add/delete/change 835 profile for Receiver ID MO00006C _________________ Important . claim payments are made based on the Payee ID assigned to the individual provider and/or group. or need to activate or deactivate additional providers for receiving the 835.fill in receiver ID The following is required to receive an 835 Payment / Remittance Advice: Name of Provider or Organization Anthem assigned Payee ID Number Provider Tax ID Number associated with Provider ID Number National Provider Identifier (NPI) associated with Provider ID Number (*does not apply to exempt providers) NOTE: Depending on the payment arrangement between the provider(s) and Anthem. For further detail and latest news about the 835. In cases where multiple providers are paid under the same Payee ID or group pay-to number. activation of the number will generate 835s for all providers linked under this hierarchy.anthem. If you have any changes in provider status. Since the payee ID/Tax ID can only be associated with one Anthem Sender/Receiver ID. Inc.fill in sender ID INITIAL 835 SETUP – Receiver ID to be different from 837 Sender ID ___________________ Important . refer to the EDI website: http://www. changes to your provider ID number or tax ID number may affect the distribution of your 835s. Vendor Name 422 Larkfield Center #282 Address Santa Rosa City Enrollment Dept Contact Name Enrollment@claimRemedi.com/edi Contact Information Provider Information Provider Name Address City Contact Name E-Mail Address Technical Information ClaimRemedi.

KY 40223 Phone: 800-470-9630 Fax: 502-889-4533 page 2 .Type of Request Initial Set Up State *PLEASE PRINT LEGIBLY Missouri Ohio Wisconsin Indiana Kentucky Deletion Addition Name of Provider/Organization Tax ID NPI Provider/Payee ID COMPLETED REGISTRATION FORM MUST BE RETURNED VIA MAIL OR FAX TO: Central Region EDI 13550 Triton Park Blvd. Louisville.