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Provider Online Services Registration

*Required fields are denoted by an asterisk ( ) adjacent to the label. 

Provider Name
,
Provider ID
National Provider Identifier (NPI)
Tax ID
Provider Group, Facility or Clinic Name
 
Please check which Online Provider Services options to which you would like to have access:
Electronic Batch Claims Submission (837 HIPAA format)
Military OneSource Case Activity Form
Direct Claims Submission
Automatically included:
Eligibility Inquiry Claim Status Inquiry
Authorization Inquiry & Submission
Provider Summary Vouchers/EOBs
 
Provider has retained a 3rd party Billing Agent or Clearinghouse to submit claims on their behalf. 
(Other than office staff)(If yes, please complete the Billing Intermediary Authorization Form)
Yes   No
 

Claim Operation Center

 
Depending on the state in which you are practicing, you may need multiple accounts created to ensure the claims are processed accurately (e.g., Medicaid vs. Commercial).Therefore, to help us in setting up your account(s) correctly, if you are located in...
Colorado, will you be submitting CO Medicaid clients?     Yes   No, Commercial Only   Both
Kansas, will you be submitting either KS Medicaid Claims or AAPS Block Grant clients? Yes   No, Commercial Only   Both
Maryland, will you be submitting MD BHA clients? Yes   No, Commercial Only   Both
Massachusetts, will you be submitting MBHP clients? Yes   No, Commercial Only   Both
Pennsylvania, will you be submitting SWPA Medicaid clients? Yes   No, Commercial Only   Both
Pennsylvania, will you be submitting for the Non-HealthChoices Mental Health Program? Yes   No, Commercial Only   Both
Texas, will you be submitting TX NorthStar clients? Yes   No, Commercial Only   Both
 
E-mail address where you would like to receive your batch submission file feedback
Provider's Contact Name

For assistance with any technical problems (such as connecting to or accessing the site) please call our e-Support Help Line at 888-247-9311 during business hours Monday through Friday 8AM - 6PM ET or you can email an Applications Support Specialist at e-supportservices@carelon.com

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