Read Microsoft Word - Enrollment GHI Professional.doc text version

200 South Tryon Street Suite 1700 Charlotte, NC 28202

800-466-9676

GHI

Group Health Incorporated Electronic Medical Claims Payer Enrollment

Payer ID Number: Enrollment Requirements:

13551 / 25531

Phone request or Secure EDI Payer Enrollment Request form No special limitations Mail to: Secure EDI 200 South Tyron St. Suite 1700 Charlotte NC, 28202 Attention Enrollment (917) 591-8247 800-466-9676 Call Center for enrollment request

Payer EDI Restrictions: Registration Forms:

Or Fax to:

Or Call:

For Further Information or Assistance, please call Secure EDI customer call center with your enrollment questions at (800) 466-9676 or e-mail [email protected] Please allow proper processing time for your enrollment request to complete system configurations, until approved continue to bill your claims by paper.

200 South Tryon Street Suite 1700 Charlotte, NC 28202

800-466-9676

Provider Payer Enrollment Request Medical Claims

Payer Name: Group Health Incorporated "GHI"

Provider/Organization Name: ______________________________________________ Address: _______________________________________________________________ City, State & Zip Code: ___________________________________________________ Office Phone Number: _______________________ Fax # ________________________ Tax ID or Social Security Number of the submitting provider or organization: ____________________________________

GHI 7 digit Provider Number/ Group # (if applicable): If a Group, please list the following: Provider Name(s):

_____________________________________ _____________________________________ _____________________________________ _____________________________________

_________________________

_________________________________________ _________________________________________ _________________________________________ _________________________________________

Contact Name: __________________________ Position: _________________________ Date of Request: _________________________

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