Remittance Enrollment Guide for MEDICARE NEW YORK UPSTATE PART B

Enrollment required. Go to the "Part B" column and select "EDI"; accept the attestation terms; and in the "Enrollment Information" section, select "Enrollment Forms and Information".Select the transactions the provider is authorizing Availity to exchange with NGS (837,276/277,835). You must already be enrolled for ERAs with Availity before selecting 835 for your ERAs to be delivered. If you are a new provider with NGS, please complete the "EDI Enrollment Agreement Form" and the "EDI Third-Party Authorization Form". If you are a current provider with NGS and you are only changing clearinghouses, then please complete only the "EDI Third-Party Authorization Form". The "EDI Submitter Action Request Form" is not required. The information needed to complete the "EDI enrollment Agreement Form": Submitter Status: Existing Submitter, Submitter ID: CHBN75163, Submitter Name: Availity, L.L.C., Submitter Type: Clearinghouse, Contractor Code: Part B IL 06102; Part B MN 06202; Part B WI 06302 (depending on the payer for which you are enrolling). The information needed to complete the "EDI Third-Party Provider Authorization Form": Name: Availity LLC, Operating as a: Clearinghouse, Submitter ID: CHBU75187, Address: 10752 Deerwood Park Blvd. #110, City: Jacksonville State: FL Zip: 32256, Contact Name: Client Services, Phone Number: 800-282-4548, Email address: enrollments@availity.com.