Lifewise Health Plan of Oregon EDI Form for ERAs

93093
LIFEWISE HP OF OREGON
PAYER ENROLLMENT INSTRUCTIONS
✔ Professional
✔ Institutional
Claims
✔ ERAs
Important - HeW provides the EDI paperwork pre-populated with our submitter information as a courtesy to our clients.
Please note that even though we make all attempts to have the most current form available, we are not always notified
by the carriers when their EDI forms are updated.
SPECIAL NOTES
The paperwork is designed for you to type into while opened in Adobe Reader. Please use your Tab key on your
keyboard to move to the next field.
* This form requires an authorized signature.
* If you are discontinuing ERA with a previous billing agency or clearinghouse, please contact the Premera EDI Team
at 1-800-435-2715, or at edi@premera.com.
*Faxes and mailed copies will result in a paperwork rejection.
PAPERWORK SUBMISSION
RCM Clients: Please submit paperwork directly to the payer by mail to the address below. Then click here to send
HeW your list of payers.
HeW Clients: Please submit paperwork directly to the payer by mail to:
Premera Blue Cross
PO Box 327 MS481
Seattle, WA 98111-0327.
Please allow up to 14 business days for processing. For paperwork inquiries, contact the Premera EDI Team and
verify our submitter number is receiving ERAs on behalf of you / your provider. Contact the EDI Team at
1-800-435-2715, or at edi@premera.com
Updated: 08/29/2016
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LifeWise Health Plan of Oregon
835 Claims Payment and Remittance Advice
EDI Authorization Form
This Authorization Form is required for the set-up of the 835 Claims Payment and Remittance Advice. An original signature is
required. Please return the completed form to the address below:
Premera
PO Box 327 MS481
Seattle, WA 98111-0327
Provider or Group/Facility Information:
Name:
Contact Phone #:
Email Address:
__________________________________
Mailing Address:
City:
State:
Zip:
Tax ID:
Provider NPI:
Yes
No
Do you share this Tax ID with other groups, facilities or individual providers?
The 835 transaction will include payments for all providers who share this Tax ID and will be sent to the
Submitter ID specified below. The Paper vouchers with checks are not affected.
If Yes:
AC062
PBC, EDI Submitter ID of the office that will receive the 835 transaction:
Clearinghouse/Billing Service Information:
Name:
Health-e-Web
Current PBC Submitter ID
Address:
P.O. Box 1540
City:
Helena
Phone:
Contact Name:
877-565-5457
State:
Fax:
406-449-0190
MT
Zip:
AC062
59624
Email Address: HeWenrollment@availity.com
Heather Weis
I authorize the above named Clearinghouse/Billing Service to receive the 835 Health Care Claim Payment
Advice on my behalf.
Provider Signature:
(Print and Sign Here)
Date:
08/29/2016
Please note, should the exchange relationship between this provider and billing agent change,
immediately contact the EDI Team at 1-800-435-2715 or at edi@lifewise.com