1. No category

Payer ID: PRBLS
Puerto Rico Blue Cross Blue Shield
Triple-S Salud
837 and 835
EDI Enrollment Information:
• 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 provider’s billing/group information as credentialed
with this payer.
• Complete all fields of form in BLOCK/CAPITAL letters.
• Once completed, save for your records, print, obtain appropriate signature and
submit the documents based on the guidelines stated below.
• Please Note: The document must be signed in BLUE ink.
837 Claim Transactions and 835 Electronic Remittance Advice:
Complete the Electronic Transactions Transmition and ERA Participating
Provider Registry as appropriate.
Submit Completed Document:
1. Fax to ClaimRemedi
707-573-1066
2. Mail the original signed in BLUE ink Electronic Transactions Transmition and
ERA Participating Provider Registry form to:
Triple-S Salud Inc.
Health Information System
PO BOX 363628
San Juan, PR 00936-3628
2015-04-01
ELECTRONIC TRANSACTIONS TRANSMITION
AND ERA PARTICIPATING PROVIDER REGISTRY
NPI:
Provider Name:
Provider Address:
Telephone (specific OFI/FAX/Other):
Billing Contact:
Will a third party billing company handle your Electronic Claims?
Yes
Company Name:
No
Billing Software (select 1 per office or write):
AirisPro/Medi2000
Best2000
DentalMax
DentOne
IMClaim
Infomedika
InstantMed
LabSoft
LAMARS
MCPC
MedCenter
Medical Biller
Phone Number:
Medical Clinics/Practice
MedicMax
Meditrack
Med One
Med One Express
OffiMed
SAIL
SimpelSoft
TekPro
TRA
TurboMed
VisualMass
Specify transmit Method:
Clearinghouse Name:
CLAIMREMEDI
Other
Will this be the only medium to transmit to Triple-S?:
Yes
If NO, please indicate the office which this form applies to:
No
Where will you like to receive your electronic explanation of payment from Triple-S?:
Clearinghouse Name:
CLAIMREMEDI
Other
Reason for submission:
New Enrollment
Date
Change Enrollment
Cancel Enrollment
Participating Provider’s Signature
Print Form
Please complete all the information in block letters, sign the document using blue ink and send the
original form to: Triple-S Salud Inc., Health Information System, PO Box 363628, San Juan, PR 00936-3628. For any
question, please write us an email at: [email protected].