835 Health Care Claim Page 2
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3Exhibit A
(To be completed by EDI Support Services)
Trading Partner #: ______________________________
835 Registration 4010A1
Submitter #: ______________________________
835 HEALTH CARE CLAIM
PAYMENT/ADVICE REGISTRATION
VERSION 4010A1
Noridian Administrative Services, LLC (NAS)
Phone number: (800) 967-7902
EDI Support Services
Contact us via e-mail at:
PO Box 9319
Visit our website at:
Fargo, ND 58106-9319
The information you provide on this EDI registration is used to set your facility up for electronic health care claim
payment/advice transaction. Print legibly and complete every section as accurately as possible. If a section is not
applicable, write “N/A”. If you have any questions concerning the correct completion of the form, please contact EDI
Support Services (EDISS) for assistance. Once you are approved for EDI production status, notify EDISS by using the
Electronic Claims Termination/Change Form whenever this information changes.
PROVIDER INFORMATION
1. For Medicare providers, testing is not required for your electronic 835 Health Care Claim Payment/Advice
transaction but it is available upon request. Blue Cross Blue Shield of North Dakota (BCBSND), Dental Service
Corporation of North Dakota (DSC) and North Dakota Vision Services, Inc. (VSI) providers are required to test the
835.
Would you like to test this transaction?
Yes What date would you like to begin the testing process?
Date: _____ /_______ / ________
No
What date would you like to begin receiving 4010A1 remits?
Date: _____ /_______ / ________
_____________________
2. Federal Tax ID/SSN:
3.
CH00047
______________________
Current Trading Partner ID:
Current Submitter ID:
FACILITY INFORMATION
4. Fill in the facility information for the provider/clinic that the health care payment/advice will represent.
Name: _______________________________________________________________________
Mailing Address: ______________________________________________________________
City: _________________________________ State: ______ Zip: _______________________
Physical Address: _____________________________________________________________
City: _________________________________ State: ______ Zip: _______________________
Contact: _____________________________________________________________________
( )__________________
( ) ___________________________________
Telephone:
Fax:
E-Mail: ______________________________________________________________________
5. PC-ACE Pro32 software has the ability to read remits. If you do not have this software, would you like to obtain it
for your facility?
Yes
No
If yes, a signed Software License Agreement will be necessary. The agreement is available for download at
.
Page 2 of 3
Last update on 07/15/04
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