District of Columbia Medicaid: ACS

Please follow the Enrollment Instructions below to become an electronic submitter for Disctrict of Columbia Medicaid ACS.

Required Documents

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

 

  1. EDI Provider Enrollment Form
  2. EDI Trading Partner Agreement

To obtain the forms above, please download them from:

https://www.dc-medicaid.com/dcwebportal/providerSpecificInformation/providerInformation

 

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.

 

EDI Provider Enrollment Form

Section 1

  • Please select the appropriate classification for your business, either Individual or Group

Section 2

  • If submitting claims yourself using ClaimShuttle please select Vendor Software

  • If you plan to have a billing agency submit claims on your behalf please select Billing Agent Clearinghouse and then complete form 11 titled EDI Authorization for Billing Agents, Clearinghouses, and Software Vendors

Section 3

  • Fill in your demographic and contact information

  • Please ensure you enter the correct Provider Number (Solo NPI) or Group Number (Group NPI)

Section 4

  • Leave this section blank since you are applying for a new submitter ID

Section 5

  • Please enter the demographic and contact information for two contacts in your office

Section 6

  • Select Software Vendor if using ClaimShuttle and have either purchased SolAce software or have another software that creates your 837 files

  • Select Billing Agent if you will be using a billing agency

  • If you have paid for our SolAce billing software please call our support line for our SolAce software information. If not please enter the information for the information software or vendor that creates your 837 files you need ClaimShuttle to transfer for you

  • If you are using a Billing Agency enter that company’s demographic and contact information

Section 6b

  • If you are using SolAce to submit your claims please call our support line for our SolAce software information. If not please enter the information for the information software or vendor that creates your 837 files you need ClaimShuttle to transfer for you

Section 6c

  • If you are using a Billing Agency you will need to get their ID

  • If you are using ClaimShuttle as a direct submitter please leave this blank

Section 7a

  • Please Skip

Section 7b

  • If you going to be sending professional claims select X12N 837P

  • If you are going to be sending institutional claims select X12 837I

Section 8

  • Leave blank for default

Section 9

  • Select the following options:

  • X12 277CA

  • X12N999

  • X12N 835

Section 10

  • Please add any additional providers on this last page

 

Trading Partner Agreement

  • Please complete the Submitter Section on the last page.

  • New Applicants can enter Provider Name as Submitter and leave Trading Partner ID blank.

  • Please Sign, enter Title, and Date this application.

 

Authorization Form for Billing Agents and Clearinghouses

Only fill out this form if using a billing service

Section A

  • Please indicate your appropriate classification, either Individual Provider or Group Practice

  • Fill in your Contact and Demographic information

  • Please ensure you enter the correct Provider Number (Solo NPI) or Group Number (Group NPI)

Section B

  • Please type your name (the name of the provider) and then enter the name and submitter ID of the billing service you wish to authorize to submit claims on your behalf.

  • If you would like the EOB’s and Reports to be sent to the Billing Service, please select: 277CA, 999, and 835

  • The Provider must print their name, sign and date

 

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records.  Please MAIL the forms listed above to:

 

     Xerox State Healthcare, LLC

     Technical Support/Enrollment

     PO Box 34734

     Washington DC 20043-4761

    Fax to: 202-906-8399

 

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 notification, nor a returned enrollment packet is received after 2 weeks, please call 866-752-9231 option 2 then option 3 for EDI; then option 1 for DC Medicaid

 

Testing

Once you have received your Submitter ID and Password from Medicaid, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup. Testing is optional for this payer.