Pre-Enrollment Form New

Apex EDI Enrollment Survey
Thank you for choosing Apex EDI for your clearinghouse needs!

To fulfill enrollment requirements, please answer the following questions, whether for 1 payer or many. An assigned enrollment agent will contact you for additional information.

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.

Note: All fields are required, even if you have filled out this form before. Failure to provide accurate and complete information will cause your enrollment request to be rejected.
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
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.
Full Name (MUST BE A PERSON):*

First NameLast Name
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. However, 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 authorized to sign the enrollment forms. Typically, this person is a provider, e.g., the person credentialed with the payer, or owner of the practice.

If your office has more than one possible authorized signer, provide the name and title for one of them here and your assigned enrollment agent will work with you to ensure the forms are signed by the right person.
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:
Group IDs or PTAN IDs: Please X the payers that you will need enrolled and add the PTAN and/or Provider ID next to it.

MedicaidBCBSMedicareRR MedicareDME
Medicaid Provider ID*
This is the unique ID code your provider was given by the payer when credentialing was complete
Specific Medicaid payer ID*
This is the payer ID you bill to, found on the back of the member's card
BCBS Specific payer IDs*
add all payer IDs that apply for BCBS
Medicare PTAN*
This is the unique ID the payer assigned the provider upon becoming in-network
Specific Medicare payer ID*
This is the payer ID you bill to, found on the back of the member's card
RR Medicare PTAN*
This is the unique ID the payer assigned the provider upon becoming in-network
DME PTAN*
This is the unique ID the payer assigned the provider upon becoming in-network
You may use Apex's payer list to find payer IDs

Apex EDI Payer List
EDI Enrollment - Please provide a list of payer names and their 5-digit payer IDs that you are interested in submitting electronically:

(example: Medicare KS - 05202)0/800
ERA Enrollment - Please provide a list of payer names and their 5-digit payer IDs that you are credentialed with that you will need ERAs for:

(example: Medicare KS - 05202)0/800
Payer name and payer ID
Hold Ctrl to select more than one
Do you need Eligibility enrollment?

YesNo
Eligibility Marker

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

YesNo
Business Hours ID
Should be Empty:

Apex EDI Enrollment Survey

Enrollment Contact Information

Billing Information

Payer Information