1. No category

Payer ID: HCP01, HCP02
HealthCare Partners
837 and 835
EDI Enrollment Instructions:
• Please save this document to your computer. Open the file in the Adobe Reader
program and type directly onto the form.
• Complete the form using the group/billing information as credentialed with
HealthCare Partners.
• EDI enrollment processing timeframe is approximately 5 to 7 business days.
837 Claim Transactions:
Enrollment applies to ERA only and is not necessary prior to sending claims.
835 Electronic Remittance Advice:
Authorization letter
Complete an authorization letter on company letterhead only if you are changing
the routing of existing ERA.
HealthCare Partners Medical Group ERA/835 Enrollment Request
Complete Section One as appropriate.
Complete Sections Three if applicable.
Submit Completed Documents:
For new requests:
Fax the 835 Enrollment Request form to
1. HealthCare Partners
310-965-1201
2. ClaimRemedi
707-573-1066
For changes:
Fax the 835 Enrollment Request form and the authorization letter to
1. HealthCare Partners
310-965-1201
2. Office Ally
360-896-2151
3. ClaimRemedi
707-573-1066
2015-05-21
Date
To: HealthCare Partners
Fax: 310-965-1201
and
Office Ally
Fax: 360-896-2151
RE: ERA
Billing Provider Name
NPI
Tax ID
To Whom It May Concern:
We are currently receiving ERA from HealthCare Partners via another entity, and
hereby request the ERA to be provided to Office Ally instead. We also authorize Office
Ally to provide our ERA to ClaimRemedi.
Sincerely,
Print Authorization Letterhead
835 Enrollment Request
Type of Request:
New (Check if not currently receiving an Electronic Remit. Complete section 1 & 2)
Change (Check if the delivery path of the 835 is being changed from a different receiver
Complete sections 1,2, and 3)
Delete (Check if terminating receipt of the 835. Complete sections 1 and 4.)
Please fax completed form to HCP ATTN: Technical Services – EDI (310) 965-1201
1.
Healthcare Professional / Institution Information
Contact Name
Contact Number
Contact Email
HealthCare
Prof/Inst Name
Address
TIN
City
State
2.
Phone
Receiver Information
Receiver Name
Office Ally, Inc.
Contact
Customer Service
Telephone
360-975-7000 Option 1
3.
Zip
HCP Submitter ID
Change Enrollment (Current/Old receiver)
Receiver Name
Change Enrollment for:
Target date for completion (Date will be no more than 15 days from enrollment date at HCP:
4.
Delete Enrollment
Receiver Name
Delete Enrollment for (HCP use Only):
5.
HCP / MCA – System Update
MCA Analyst Name:
Date Completed:
Paper EOB process will cease after 45 days
Print ERA Form