Indiana Childrens Health Insurance Plans by zqx15399


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									                                         ZIRMED.COM Provider Enrollment Information
Please complete this form as soon as possible so we may ensure your enrollment in our Zirmed account and with third party payers is completed
accurately and expediently. Fax this form to HelpHorizons: 617-338-3881 Attn: Ian Gottfried.

Upon receipt of this document you will be mailed (or faxed) the appropriate enrollment forms for governmental and commercial payers, to whom you
anticipate submitting claims, who require the completion of their own enrollment process and/or who assign their own provider identification number.

You will NOT be able to submit claims to these payers electronically until that payer has granted approval. If you have any questions, please call Customer Support at 1-877-494-7633.

Provider Name [first] _______________ [last] _______________                              Provider Tax ID _______________

Phone # ______________________                   Fax # _________________________

Billing Address                                          Address where Service is Rendered

__________________________________                       ________________________________

__________________________________                       ________________________________

__________________________________                       ________________________________

BlueCrossBlueShield Provider ID _______________

Medicare Provider ID _______________

Medicaid Provider ID _______________

Commercial Payer Provider ID [see the list of Commercial Payers that assign & require Provider ID’s ]

        Payer Name _________________________ Provider ID _______________ Authorization completed? Y/N
        Payer Name _________________________ Provider ID _______________ Authorization completed? Y/N
        Payer Name _________________________ Provider ID _______________ Authorization completed? Y/N
        Payer Name _________________________ Provider ID _______________ Authorization completed? Y/N

Last Updated: 11/22/10
                                      ZIRMED.COM Provider Enrollment Information

                                                           Commercial Payers

This is probably not a complete listing of Commercial Payers that require authorization for electronic processing of insurance and/or that
assign unique Provider ID’s. Please list other payers that are not on this list who have similar requirements.

       Arizona Physicians IPA - AZ                                                Keystone Health Plan Central – HMO
       Basic Health                                                               Keystone Health Plan East – HMO
       Blue Care Network HMO - MI                                                 Keystone Mercy Health
       Claims Management Services                                                 Magellan Specialty Health – Found of FL
       Colorado HMO                                                               MatureWell
       Columbia/ST Mary’s/Physician Network Inc                                   Mercy care Plan of AZ
       Community Health Plan of WA ( CHPWA)                                       MVP Health Plans of NY
       Connecticut Physician Health Services                                      New York Group Health Inc (GHI)– Commercial
       Educator’s Mutual InsurANCE association                                    Oregon SelectCare
       Epic Life Insurance Company                                                PacifiCare Health Systems
       Farmington Hills (PPOM)                                                    PacifiCare of AZ
       FirstCare                                                                  PaciCare/Secure Horizons SR Plan – CO
       Foundation for Medical Care – AZ                                           Passport Health Plan
       Foundation Health – Professional Claims – CA                               PCA Health Plan of FL
       Harvard Pilgrim Health Care                                                Phoenix Health Plans
       Health Insurance Exchange                                                  Priority Health of Michigan
       Health Partners North – AZ                                                 Priority Health Services of CA
       Health Partners South – AZ                                                 Providence Health Plan
       Health Care Benefits, Inc – (HBI)                                          Secure Horizons (Tufts)
       Healthlink _                                                               Southeastern Indiana Health Organization
       Health Partners                                                            Southfield (PPOM)
       Healthy Options                                                            Texas Childrens Health Plan
       Independent HLTH Assoc (IHA) – Hudson VA                                   Tufts Associated Health Plan
       Independent HLTH Assoc (IHA – Western                                      Wellmark Administrators Inc (WAI)
       Insurance Service of Lubbock                                               WPS Regular Business
       Intermountain Health Care (IHC)

Last Updated: 11/22/10
                         ZIRMED.COM Provider Enrollment Information

Last Updated: 11/22/10

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