Rev Date 2016.12.19 Compulink | 1100 Business Center Circle | Thousand Oaks, CA 91320 | 800.888.8075 | www.compulinkadvantage.com Page 1 of 5

Edienrollment@compulinkadvantage.com Fax #: 805-435-1637

Provider Setup Form CBS ACCT # Location ID#

In order to ensure accurate electronic submission setup and timely filing, please complete the information below with accurate information. A Billing NPI and Tax ID are required to complete enrollment. You must complete a separate PSF packet for each Group NPI. Please review the payer contracts that your office holds with each payer to confirm that the information provided on this and any additional enrollment forms is accurate. Failure to complete all fields correctly may result in enrollment form rejections and delays in revenue.

Full name and office position of the individual whom reviewed and confirmed that the information provided on this Provider Setup Packet is accurate:

Last Name: First Name: Office Position: Main Point of Contact: Individual in charge of enrollment

Last Name: First Name: Phone #:

Email: Position: Section 1: Billing Information

Practice/Facility Name:

Street Address:

City: State: Zip Code (9 digit):

Phone Number: Fax Number:

Tax ID: Group NPI:

SSN: Group Medicare PTAN:

Group DME NPI: Group Railroad Medicare PTAN:

Group DME PTAN: Group Medicaid ID:

Section 2: Key Questions Does each location have its own NPI? Does Each location have its own Tax ID?

Number of Providers in the Practice?

What type of practice do you have?

Is the practice already billing and getting paid?

Is the practice contracted with ALL payers necessary?

What is the Billing NPI used?

Rev Date 2016.12.19 Compulink | 1100 Business Center Circle | Thousand Oaks, CA 91320 | 800.888.8075 | www.compulinkadvantage.com Page 2 of 5

Section 3: Providers: Add more providers by attaching an additional page with all the information requested below.If your providers are all billing under a group NPI for all payers, DO NOT complete this section!

Last Name First Name Individual NPI

SSN (if using in

place of Tax ID)

Individual Medicare

PTAN

Individual RR Medicare

PTAN Individual DME PTAN

Individual Medicaid

ID

Section 5: Emdeon Payers: The following section captures information regarding your practice’s billing requirements for Electronic Claims, ERAs, and Eligibility Verification. Please list Medical payers only. Please also indicate which are the top payers for your practice so we can make them a priority.

IMPORTANT: All payer contracts must be approved prior to enrollment.

Payer Name & ID State/Region

Cla

ims?

Rem

it?

Elig

ibili

ty?

Top Payer?

Do you receive

EFTs for this

payer?

contracted with this payer?

Billing NPI used?

Billing form used?

Medicare

RR Medicare (SRRGA)

Medicaid

BCBS

Section 4: Billing Exceptions: Complete this section if you answered BOTH to “What is the Billing NPIUsed?” under Section 2 of page 1. Please specify the payer(s) and payer ID(s) this applies to below.

Provider Last Name Provider First Name MI Contracted to use SSN

and not Tax ID

Contracted to use Provider (Individual)

NPI only, not group NPI

Payers & Payer IDs Example: Aetna 60054

Rev Date 2016.12.19 Compulink | 1100 Business Center Circle | Thousand Oaks, CA 91320 | 800.888.8075 | www.compulinkadvantage.com Page 3 of 5

Section 5: Emdeon Payers (Continued) Please add any other payers you bill to ensure proper setup

Payer Name & ID State/Region

Cla

ims?

Rem

it?

Elig

ibili

ty? Top

Payer?

Do you receive

EFTs for this

payer?

Are you contracted with this payer?

Billing NPI used?

Billing form used?

DME – Region?

Tricare for Life

Tricare – Region? United

HealthCare (87726)

Aetna (60054)

Cigna (62308)

Humana (61101)

Rev Date 2016.12.19 Compulink | 1100 Business Center Circle | Thousand Oaks, CA 91320 | 800.888.8075 | www.compulinkadvantage.com Page 5 of 5

Section 6: Additional Notes Please use this section to provide any exception(s) or special circumstance(s) not already provided above

Section 7: Certification By entering your name below and checking the box, you indicate that you have reviewed the document in its entirety, and certify that all information provided is current and accurate. Please note that failure to complete all fields correctly may result in enrollment form rejections and delays in your ability to bill and receive payment. This Provider Setup Form(PSF) will not be processed unless this section is completed. You are responsible for the accuracy of all information reported to us on this form. For any future changes to your Group or Provider information, please contact Compulink EDI immediately to initiate any EDI enrollment changes that may be required. Additionally, be aware that Compulink is not responsible for communicating any such changes to your payors or the NPPES registry. I have reviewed the Provider Setup Form in its entirety and certify that all the information provided is current and accurate. If something should change, I will notify Compulink's EDI Department immediately. Last Name: First Name: Date: Office Position: Email: Phone#: