Alaska Medicaid: ACS

Please follow the Enrollment Instructions below to become an electronic submitter for Alaska Medicaid

 

The following documents are required enrollment documents that must be completed, signed and returned to the ACS office prior to initiation of electronic claims submission or inquiry.


Providers, please print and fill out these forms:

1. Provider Submission Agreement
2. Electronic Remittance (835) Authorization Form

Billing Services please print and fill out this form:

1. Billing Agent Submission Agreement

If the above links do not work properly, please download them from:
http://medicaidalaska.com/providers/hipaa/agreements.shtml

If you have any questions regarding any of the documents, please call the ACS EDI Technology Support Center at 907-644-6800.

 

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

 

Provider Submission Agreement

Section Header:

  • Fill in the Provider’s name in the first paragraph

Section 16:

  • Please select “ HIPAA-Compliant Information”

Section 17:

  • Please select “Electronic” for both questions

Section 18:

  • Please select the following:

    • 835 Remittance Advice

    • 837 Institutional or 837 Professional

Section 19:

  • If you will be sending claims through ClaimShuttle from your office please select Option A. “ Directly from my office system to the state”

  • If you will be using a Billing Service please select Option D “Through a Billing Agent or Clearinghouse to the state” and skip to question #21.

Section 20:

  • Please enter the information for the software or vendor that creates your 837 files you need ClaimShuttle to transfter for you.

  • If you have paid for our SolAce billing software please call our support line for our SolAce software information.

Section 21:

  • If you are using a Billing Agency please enter the Billing Agency’s information here

Section 22:

  • Enter the information for the main contact person for your office

Section 23:

  • Please complete this section with the Provider’s information and signature.

 

Provider Electronic Remittance (835) Authorization

Section 1:

  • Please Select “Self” if you will be using ClaimShuttle to submit claims directly from your office

  • Please Select “Billing Agent” if you will be using a Billing Service and would like your Billing Service to receive your Electronic EOB’s.

Section 2:

  • Please enter your Business or Practice Name, Contact Name, and Phone number

Section 3:

  • Please enter the Provider’s name, State PIN, and corresponding NPI #

Signature:

  • Please have an Authorized Representative for your office or the Provider sign and date this section

 

Billing Services

Billing Agent Submission Agreement

Section Header:

  • Billing Services, please enter your business name in the first paragraph

Section 14:

  • Please select “ HIPAA-Compliant Information”

Section 15:

  • Please select “Electronic” for both questions

Section 16:

  • If you will be sending claims through ClaimShuttle from your office please select Option A. “Directly from my Billing Agent office system to the State.”

Section 17:

  • Please select the following:

    • 835 Remittance Advice

    • 837 Institutional or 837 Professional

Section 18:

  • Please enter the information for the software or vendor that creates your 837 files you need ClaimShuttle to transfter for you.

  • If you have paid for our SolAce billing software please call our support line for our SolAce software information.

Section 20:

  • Please complete this section with your information as well as the provider’s for whom you will be billing.

  • For Section I. enter the Billing Agency's Fax number, the authorized representative's name, title, date, and signature

NOTE: Each of the Providers you will be billing for must complete a Provider Submission Agreement and Provider Electronic Remittance (835) Authorization in order to authorize you to send their claims and receive their EOBs. Instructions on how to fill out these forms are above under the “Providers” section.

 

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:

 

Xerox
HIPAA Provider Support Team
P.O. Box 240808 Anchorage, AK 99524-0808
Fax number: (907) 644-8126
 

If you fax these documents, please be sure to mail the originals.

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

 

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the Technology Support Center toll-free at 907-644-6800.

 

Testing

Once you have received your Submitter ID and Password from ACS Health, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup and Test Transmission to ACS Health.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.