Signature CLAIMS files

 
 
The following files are for use by Signature Claims customers only. For information regarding these files and forms, please contact Signature Claims
 

 

PLEASE NOTE how the forms are handled. Some forms MUST be MAILED back to Signature Claims and others can be sent or faxed directly to the insurance company

 

Latest Payers list You can right-click on this and save

Signature Claims Business Partner Agreement

This is the agreement to get you started with Signature Claims!!

 

National

Tri-Care NORTH Enrollment forms for Tri-Care NORTH.  This form they want MAILED directly to Tri-Care North.
Tri-Care SOUTH Enrollment forms for Tri-Care SOUTH.  This form they want MAILED directly to Tri-Care South.
Tri-Care West Enrollment forms for Tri-care West. These forms can be faxed directed to the Tri-Care administration (WPS).
Tri-Care ERA Send to WPS to receive ERAs

RailRoad Medicare Enrollment Form

Enrollment forms for Railroad Medicare. You MUST be a Railroad Medicare provider.
EMDEON Enrollment form Use this form when using EMDEON for any insurance agencies that issue their own provider numbers.
EMDEON ERA Form Fill this out and fax or email to Emdeon to receive remittance advice from the commercial payers
Value Options Form Special Emdon form for Value Options

 

Dmerc Jurisdiction States Chart 


For all the below, use the Signature Claims submitter number of V08900526 and use your browser and go to http://apps.ngsmedicare.com/applications/CEDIEnrollmentAgreement.aspx
Jurisdiction A Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Jurisdiction B Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
Jurisdiction C Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia
Jurisdiction D Alaska, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, Mariana Islands, American Samoa

Arizona

Arizona Medicare Follow Instructions to fill out an on-line form

Arkansas

Arkansas Blue Cross/Blue Shield This form can be faxed directly to Availity.

Alabama

Alabama Medicare This form can be mailed or faxed directly to Cahaba

California

Medi-Cal California This form is for Medi-Cal California. You MUST send this back to Signature Claims AND MUST BE SIGNED IN BLUE INK.
Medicare-Southern California Enrollment forms for Medicare-Southern California. This requires a signature from the provider.
Medicare-Northern California Enrollment forms for Medicare-Northern California. This requires a signature from the provider.

 

Colorado

Colorado Medicare Enrollment forms for Novitas

Delaware

Medicare-Delaware Enrollment forms for TrailBlazer (Delaware)

Florida

Medicare Florida These can be mailed directly to Florida Medicare
   
Blue Cross/Blue Shield-Florida Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Georgia

   
Georgia Medicaid This form must be MAILED to ACS, PO Box 4000, McRae, GA 31055
Georgia Medicare This form can be mailed or faxed directly to Cahaba

Idaho

Idaho Blue Cross Fax or mail this form
Idaho Blue Shield This form can be faxed directly to Availity.
Idaho Medicare Enrollment Form You need to fill out BOTH of these and send them to Medicare of North Carolina.
Idaho EDI Profile  

Illinois

Illinois Medicare Need to fill out two forms from NGS.
http://apps.ngsmedicare.com/applications/EDIProviderAuthForm.aspx
http://apps.ngsmedicare.com/applications/EDIEnrollmentAgreement.aspx?CatID=2
Include the Signature Claims submitter number of 11753
Blue Cross/Blue Shield-Illinois Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Indiana

Indiana Medicare Fill out the noted on-line form AND the Emdeon form above

Iowa

Iowa Medicare This can be faxed back to WPS

Kansas

Kansas Blue Cross/Blue Shield This can be faxed back to ASK-EDI
Kansas Medicare This can be faxed back to WPS

Kentucky

Kentucky Medicare Fill out the attached forms and FAX to CGS

Louisiana

Medicare Louisiana  Enrollment forms for Novitas

Maine

Maine Medicare Billing Agreement This form needs to be signed and mailed back to NHIC.
   

Massachusetts

Massachusetts  Medicare Billing Agreement This form needs to be signed and mailed back to NHIC.
   
Blue Cross/Blue Shield of MA EMDEON form that can be faxed back
MASS. BC/BS ERA form Mass Electronic Remittance form. This must be MAILED in.

Maryland

Medicare-Maryland Enrollment forms for TrailBlazer (Maryland Medicare)

Michigan

Michigan Blue Cross/Blue Shield Providers must complete a Provider Trading Partner Agreement online (http://www.bcbsm.com/ ) and enter their provider codes (and NPI) in Provider Authorization Table with c0iib as the submitter and receiver.  The provider must call 800.542.0945, option 1 to get their login id and password.
Michigan Medicare These can be faxed back to WPS

Minnesota

Minnesota Medicaid This can be faxed or mailed to Minnesota DHS
Minnesota Medicare These can be faxed back to WPS

Mississippi

Mississippi Medicare Enrollment forms for Novitas

Missouri

Missouri Medicaid Email provider information to Signature Claims and Signature Claims will notify Missouri Medicaid
Missouri Medicare These can be faxed back to WPS

Nebraska

Nebraska Medicare This can be faxed back to WPS

 

New Hampshire

New Hampshire Medicare Billing Agreement This form needs to be signed and mailed back to NHIC.
   

New Jersey

Medicare-New Jersey This can be mailed or faxed to (717) 302-4252
Blue Cross/Blue Shield-New Jersey EMDEON form that can be faxed back to Signature Claims

New Mexico

Blue Cross/Blue Shield-New Mexico Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

New York

New York Medicare Fill out the noted on-line form AND the Emdeon form above (included)
Blue Cross/Blue Shield New York This can be faxed directly to ASK-EDI

North Carolina

Blue Cross/Blue Shield-North Carolina Fill this out and fax back to BC/BS of North Carolina
North Carolina Medicare Enrollment Form You need to fill out BOTH of these and send them to Medicare of North Carolina.
North Carolina EDI Profile  

Oklahoma

Blue Cross/Blue Shield-Oklahoma Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Oregon

Oregon Medicare Follow Instructions to fill out an on-line form

 

Ohio

Ohio Medicare Fill out the attached forms and FAX to CGS

 

Pennsylvania

Pennsylvania Medicare These need to be mailed to Highmark
Blue Cross/Blue Shield of Central Pennsylvania Mail this form directly to Capital Blue Cross

South Carolina

South Carolina Medicaid Mail this form directly to South Carolina Medicaid AND email your Medicaid information to Signature Claims because of a separate form that must come from the clearinghouse.

Tennessee

Tennessee Medicare Enrollment Form You need to fill out the following form, sign and fax to CAHABA. You will also need the Signature Claims submitter number of TN201674
http://www.cahabagba.com/documents/2012/02/part-b-partbediapplication.pdf.
 

Texas

Blue Cross/Blue Shield-Texas Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.
Medicare-Texas Enrollment forms for Novitas (Texas Medicare)

 

Vermont

NHIC/VERMONT Medicare This form needs to be signed and mailed back to NHIC.
   
Vermont Medicaid Enrollment form for Vermont Medicaid that must be MAILED into them.

Virginia

MediCaid-Virginia These can be faxed in
Medicare-Virginia Enrollment forms for TrailBlazer (Virginia)

Washington DC

Medicare-Wash D.C. Enrollment forms for TrailBlazer (Washington DC-Medicare)

Wisconsin

Wisconsin Medicare These can be faxed back to WPS

                   

 

 

                 

                                                 

 

 

 

 

 


 
     

Copyright 2014 William C. Greenland