New EDI Enrollment Form

All fields are required except where marked (optional).

Trading Partner Information

Organization Name – Name of trading partner organization.

Organization Name (legal name)

Trading Partner Address

Trading Partner Address – Mailing address of the trading partner organization, including Street, City, State and ZIP Code.

Street City State/Province ZIP Code/Postal Code

Select Payer You Will Be Submitting Claims To

Blue Cross and Blue Shield of Kansas (BCBSKS)
Blue Cross and Blue Shield of Kansas City (BCBSKC)
Highmark Blue Cross Blue Shield of Western New York
Highmark Blue Shield of Northeastern New York
Preferred Health Professionals (PHP)

Select the Line of Business You Will Be Submitting

Institutional
Professional
Dental

Provider Identifiers Information

Provider Identifiers – Tax ID (EIN or SSN) and corresponding NPI (10 digits) of the billing provider. (Remittance Advice will be returned based on Billing NPI.)

Note: The Billing NPI can only be loaded under one Trading Partner ID for the ERA.

Provider Federal Tax Identification Number (TIN) or
Employer Identification Number (EIN) National Provider Identifier (NPI)

Other Identifiers

Other Identifier(s) – Assigning Authority – Administrative Services of Kansas (ASK)

Assigning Authority

Provider Contact Information

Provider Contact Name

Provider Contact Name – Provider office contact name.

Contact Telephone Number – Phone number of the contact name, including extension if available.

Email Address – Provider contact email address used to confirm ERA Enrollment to the provider.

Fax Number – Fax number of the contact name.

Contact Name Telephone Number Telephone Number Extension (optional) Email Address Fax Number (optional) Additional Contact Name (optional) Additional Contact Email Address (optional)

Vendor Information

Vendor Name – Name of the software company that supports your practice management software.

Vendor Contact Name – Name of contact at the software company.

Telephone Number – Telephone number for the contact at the software company.

Email Address – Email address for the contact at the software company.

Vendor Name Vendor Contact Name Telephone Number Email Address Additional Vendor Contact Name (optional) Additional Vendor Email Address (optional)

Submission Information

Authorized Signature

Authorized Signature – The name and title of the individual within the provider office authorized by the provider to initiate, modify or terminate an enrollment.

Print Name of Person Submitting Enrollment Print Title of Person Submitting Enrollment

For questions about this form, please call the EDI Help Desk at 1-800-472-6481, option 1.

Setup will be completed within 3-5 business days.
To enroll for the 835s complete the Electronic Remittance (ERA) form
NPI must be reported to all payers before completing this form.

Please provide in writing to ASK any future changes to the information contained in this EDI Setup form with in 5 business days of the change.

ASK will make every attempt to give 60 days' notice of any material changes to the EDI System that may effect trading partners' data transmissions. Updates to any system changes will be made through email notification on the ASK website. Trading partners are strongly encouraged to sign up for email notification.

Kansas law applies to this business relationship.

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