Application for BlueExchange Medicare Crossover 835s
All fields are required except where marked (optional).
For questions about this form, please call the EDI Help Desk at 1-800-472-6481, option 1.
To report a missing or late 835 transaction (ERA), please contact the EDI Help Desk at 1-800-472-6481, option 1.
The following items are needed to track a missing electronic remit(s):
Kansas law applies to this business relationship.
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