PROMISeā„¢ ANSI X12 v 5010 OR NCPDP Interactive D.0 or Batch 1.2
Transaction Certification Registration Form


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NOTE: All fields preceded by an asterisk are required fields.
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Organization Information:

* Organization Type:  

If you selected Individual Provider or Group Provider for the organization type above, will your transactions be submitted through a billing service/clearinghouse to HP?

Tax ID:

UPIN:

* PROMISeā„¢ Provider #(s) - The format is (9-digit MPI Provider Number) + (4-digit service location)  
+ + +
+ + +
+ + +
+

* Business Name or Business Last Name:  

Business Name 2 or Business First Name:

Business Primary Address

*Address 1:  
Address 2:
Mail Stop:
*City:  
County:
*State:  
*Zip: - 

Business Secondary Address (if applicable)

Address 1:
Address 2:
Mail Stop:
City:
County:
State:
Zip: -

Contact Information:


Primary Contact

*First Name:  
*Last Name:  
*Phone Number: () - -      Ext: (not required)  
Fax Number: () - -
E-Mail Address:

Secondary Contact (if applicable)

First Name:
Last Name:
Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

MCO Information:


Select the lines of business that apply:

Enter the plan codes that apply to your MCO:
 

Transaction Information:


* Select all transaction types for which you need to be certified. Please read the transaction descriptions below carefully before selecting:

837: Inpatient
(Generally refers public or private hospitals, rehabilitation or psych facilities)

837: Outpatient
(Generally refers to: Ambulatory Surgical Centers, Short Procedure Units, Outpatient Psychiatric Centers and others.)

837: Institutional LTC
(Generally refers to private and county nursing homes, ICF/MR, state mental retardation centers)

837: Professional
(Generally refers to physicians, prescribing physicians, medical suppliers, waivers, clinics, ancillary providers and others)

837: Professional Drug
(Generally refers to prescribing physicians and clinics)

837: Dental
(Generally refers to dentists)

270/271: Interactive
(Refers to interactive eligibility verification (EVS). NOTE: You need to register to certify ONLY if you are developing software. Users of certified software need not register.)

270/271: Batch
(Refers to batch eligibility verification - EVS.)

NCPDP D.0
(Refers to online pharmacy billing. NOTE: You need to register to certify ONLY if you are developing software. Users of certified software need not register.)

NCPDP 1.2: Batch
(Refers to batch pharmacy billing)

835 for Any/All Transactions



Software Information:


Use this section to provide information about the primary and secondary (if applicable) software you intend to use to submit and receive MA transactions.

DPW provides Provider Electronic Solutions (PES) software at no cost to the user. The PES software is pre-certified; therefore, the certification process will be less comprehensive for PES users.

Software Information - Primary

*Please select the primary type of software that you intend to use to submit and receive transactions:
 

*If you will be using transmission software other than PES to submit and receive MA transactions please provide the following information regarding the primary software and the software vendor:
(All fields are required if you are not using the PES software)

Software Name:  
Software Vendor Name:  
Address 1:  
Address 2:
City:  
State:  
Zip: - 

Software Vendor Contact Information - Primary

Contact First Name:
Contact Last Name:
Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

Please provide the production Software Vendor/Certification ID supplied to you by the primary software vendor if this software product will be used transmit NCPDP D.0 interactive or 1.2 batch transactions:

Software Information - Secondary

Please select the secondary type of software that you intend to use to submit and receive transactions:


If you will be using transmission software other than PES to submit and receive MA transactions please provide the following information regarding the secondary software and the software vendor:
(All fields are required if you are not using the PES software)

Software Name:  
Software Vendor Name:  
Address 1:  
Address 2:
City:  
State:  
Zip: - 

Software Vendor Contact Information - Secondary

Contact First Name:
Contact Last Name:
Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

Please provide the production Software Vendor/Certification ID supplied to you by the secondary software vendor if this software product will be used transmit NCPDP D.0 interactive or 1.2 batch transactions:

For Software Vendors only:


For Pennsylvania Medical Assistance, what is your current eligibility verification Terminal ID?
(This is the value sent in the Terminal ID field for all eligibility transactions - EVS)


and/or NCPDP Processor Control Number.
(This is the value sent in the Processor Control Number field for all NCPDP transactions).


Your vendor certification approval status will be posted to the DPW website

Certification Information:


Your Certification Packet will be sent to you via email. If you do not have email access, then we will send the Packet via email to your Software Vendor

* Select the method in which you would like to receive the certification transaction status results:



Transmissions and Communications:


* Which medium will be used to submit test and production transactions to Pennsylvania Medical Assistance?


* Which medium will be used to receive test and production transaction results from Pennsylvania Medical Assistance?

Note: Transactions sent via the BBS can only receive results via the BBS.




Last Modified: 2/13/2012