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Organization Information
Name:
Tax Id:
Org Type:
-- Type --
Billing Agency
Clearing House
Clinic
Group Practice
Home Care Services
Hospital
Other
Pharmacy
Physician Office
Skilled Nursing Facility
Social Adult Day Care
Vendor
Address 1:
Address 2:
City:
State:
Zip:
Contact Information
First Name:
Last Name:
Job Title:
Phone Number:
Email:
Electronic Information
Authorization 278
Claim Status 276/277
Claims 837 Dental
Claims 837 Institutional
Claims 837 Professional
DDE Claims CMS-1500
DDE Claims UB-04
EFT
Eligibility 270/271
Enrollment 834
Premium 820
Proprietary Formats
Remittance 835
General Information
What clearinghouses do you currently interface?
ABILITY
Availity
Change Healthcare
ClaimMD
Gateway EDI (now Trizetto)
MDON-line (now ABILITY)
Navicure (now Waystar)
OfficeAlly
Optum/ENS
Other
Practice Insight
SSI
Xifin
Zirmed (now Waystar)
Other clearinghouses not listed above?
What is your Practice Management Software?
Please list top 5 payors you interface with?
Payor
Volume
Would you like to be contacted for an AdminisTEP demo?
Yes Please
No Thank You
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