Submitter Action Request Form

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ISO 9001:2000

Information for:

•	Part A: NY, CT, DE, MA
•	Part B: New Jersey
•	Part B: New York
•	People with Medicare
•	HIPAA
•	Connectivity Solutions

OMNIPRO

Electronic Media / OMNIPRO Index

Empire OMNIPRO^sm Medicare Part A Electronic Bulletins

Empire OMNIPRO^sm Medicare Part B Electronic Bulletins

Schedule of Empire OMNIPRO^sm Phone Support, Normal Hours of Operation, and Scheduled System Availability

Products Supported by Empire Medicare Services for Electronic Claim Submission

Electronic Funds Transfer

Electronic Commerce Forms

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Home > Providers > Part A > Billing > Electronic Commerce > Electronic Media/Omnipro > Submitter Action Request Form

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Submitter Action Request Form

Section I:

Entity Name: (required)

Address: (required)

City: (required)	State: (required)	Zip: (required)

FED Tax EIN: (required)

Primary Contact: (required)	Telephone: (required)

Email Address: (required)	Fax: (required)

Section II:

ADD Submitter Existing Submitter Change Submitter/Vendor

Are you a Clearinghouse or other Third Party Service? Yes No

Section III:

Line of Business:
Medicare Part A (Institutional)	Medicare Part B (Professional)

Section IV: (Please select Add or Change below)

Telecommunications Options: Add (See note below.) Change
(required)

Leased Line:

Dial Up:

File Transfer Option (please select an item below)

FTP (link to TCP/IP Guide)
E-Link
Interactive Access (Medicare Part A only)

File Transfer Option

FTP (link to TCP/IP Guide and CSA)
E-Link (link to CSA )
Interactive Access (Medicare Part A only)

Note: To establish connectivity, please follow this site for approved telecommunications vendors: omnipro/solutions/connsol.htm

Section V:

Select Transaction:

Health Care Claim (837 V4010A1) (Companion Document - Part A ) (Companion Document - Part B )

Health Care Claim Payment/Advice (835 V4010A1) (835 Request form & Companion Document )

Health Care Claim Status Request & Response (276/277 V4010A1 - Medicare only) (Companion Document )

Health Claim Request for Additional Information (277 V4050 - Medicare only) (Companion Document )

Page Last Modified: 10/30/07

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