Please follow the Enrollment Instructions below to become an electronic submitter for Hawaii Medicaid Med-QUEST. 

Required Documents for those applying for new Submitter IDs

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

1. Electronic Data Interchange Request (DHS1188A)

To obtain the form listed above please send an email to: hi.ecstest@xerox.com

If you have any questions regarding the enrollment form please send an email to the address listed above.

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.

Electronic Data Interchange Request

Section I. 

• This section should be prefilled for you. The boxes checked should be: Add User, Upload, and Download

Section II. 

• Please enter your Business/Practice or Provider Name, Address, and contact information

• Leave the Submitter ID field blank

• For ClaimShuttle's IP Address please call us at 602-439-2525 option 1

• Note: Feel free to make up any four digit PIN for the "last four of SSN" field. Please remember to write it down in the event they need to confirm your identity for security measures

• Enter a point of contact for all EDI requests

• Enter a point of contact for all technical issues

• If you are a Billing Service, the provider you will be submitting for goes in this section and your information will go in Section III.

Section III.

• If you are a Business/Practice or Provider submitting for yourself please reenter your information

• If you are a Billing Service submitting on behalf of a Business/Practice or Provider, please enter your information in this section

Section IV. 

• The box for 837 Claims Transactions will automatically be checked

• Please check the box for 835 Remittance Advice if you wish to receive your Explanation of Benefits electronically

Section V. 

• The Affirmation Attached box will be checked for you

Section VI.

• Please skip this section

External User Affirmation Statement

Please read through this statement and have the signing authority in your office print their name, enter their signature and todays date

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Fax or Email the forms to:

Email: hi.ecstest@xerox.com

Fax: 808-952-5595 ATTENTION: EDI Coordinator

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. 

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a response is received after two weeks, contact the HI Medicaid EDI Department at: hi.ecstest@xerox.com

Testing

Once you have received your Submitter ID and Password from HI Medicaid, please call the ClaimShuttle Support Team at 602-439-2525 option 1 to set an appointment for a Mailbox setup and Test Transmission.

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.