Pre-Enrollment Form New

Ensora Clearinghouse Enrollment Survey
Thank you for choosing Ensora Clearinghouse for your clearinghouse needs!

To fulfill enrollment requirements, please answer the following questions. An assigned enrollment agent will contact you for next steps.

If you bill using more than one tax ID, please fill out this form for each unique tax ID.

If you are not ready to start the enrollment process, then please do not fill out this form. Please make sure all credentialing has been completed before EDI/ERA enrollment is requested.
Have you completed this survey before?*

YesNo
Has any information changed since the last time you completed this survey?*

YesNo
Who is your software vendor?*
Apex EDI Client ID*
This is the 3 character code your account is known by in the Apex system.
Vendor Code:*
What type of claims do you send?*

MedicalDental
Dental

Dental
Who do you currently process electronic claims through?*

Enrollment Contact Information
Full Name (MUST BE A PERSON):*

First NameLast Name
Please fill out these fields with the person's information that should be contacted to help facilitate the enrollment process on your side, i.e., the person who will be contacted by the assigned enrollment agent. This person is often the office manager or person who oversees the billing in your office.
Contact Title (ie. Office Manager, Owner, etc.):*
Phone Number:*

Area CodePhone Number
Email:*
example@example.com
GetAMB*

GetAMB

Billing Information
Please provide the information you use when billing your claims. If you bill using more than one tax ID, please fill out this form for each tax ID.
If you bill using more than one NPI, but the same tax ID, then you only need to fill out this form one time and your assigned enrollment agent will work with you to ensure that the correct NPI is used with each payer that requires enrollment.

Note: The address must be the physical address you have on file with the payers. PO Boxes are not allowed.
Billing Group Name:*
Primary/Corporate Site Name - Credentialed Name (Provider/DBA or Group Name):
Billing NPI:*
This is a type 2 NPI
Billing Tax ID:*
Credentialed Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Taxonomy number*
The authorized signer is the person in your office who is typically the administator with each of your payers and is allowed to make contractual changes at the payer level.
Authorized Signer Name:*

First NameLast Name
Authorized Signer Title:*
Vendor Submission:
Vendor Email
example@example.com
Apex Enrollment Email
example@example.com
EHR Support Email
example@example.com
Correlation ID
Do you have multiple locations with multiple NPIs?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary NPI:*
Do you have multiple NPIs to enroll under this one Tax ID?*

YesNo
Additional NPI/Provider Name:

Payer Information
Let us know the payers you will need enrollment for:
You may use Ensora Clearinghouse's payer list to find payer IDs

Ensora Clearinghouse's Payer List
Please provide us with the Payer Name and 5 Digit Payer ID that you would like to enroll for EDI and ERA. If you are requesting Medicare, please provide your PTAN. If you are requesting Medicaid, please provide your Medicaid Provider ID.
Payer Name 1*
Payer ID 1*
Insurance Type*
Payer Name 2
Payer ID 2*
Insurance Type*
Payer Name 3
Payer ID 3*
Insurance Type*
Payer Name 4
Payer ID 4*
Insurance Type*
Payer Name 5
Payer ID 5*
Insurance Type*
Payer Name 6
Payer ID 6*
Insurance Type*
Payer Name 7
Payer ID 7*
Insurance Type*
Payer Name 8
Payer ID 8*
Insurance Type*
Payer Name 9
Payer ID 9*
Insurance Type*
Payer Name 10
Payer ID 10*
Insurance Type*
PTAN*
Medicaid Provider ID*
Do you need Eligibility enrollment?

YesNo
Eligibility Marker

Eligibility
I have more than 10 payers I need to enroll for EDI/ERA.*

YesNo
I have entered all of the payers I require enrollment for.*

YesNo
Business Hours ID
Should be Empty:

Ensora Clearinghouse Enrollment Survey