North Carolina Department of Public Safety

Please follow the Enrollment Instructions below to become an electronic submitter for North Carolina Department of Public Safety (NCDPS).

 

Required Documents for those applying for new Submitter ID's

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

1. Electronic Trading Partner Agreement

2. TPA Rider Form

 

If the links above do not work properly, you can download the from


http://www.pgba.com/correctional_claims/

If you have any questions regarding any of the documents in this package, please call the NCDPS EDI Contact number at 1-844-218-5802.

 

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.

 

Trading Partner Agreement

Please complete this form if you will be submitting your claims directly to Palmetto.

  • Please leave the Agreement line blank

  • Enter today's date and your Business/Practice or Provider name in the first paragraph (you are the Trading Partner)

  • Please complete section 9.1 on page 13 with your information (this tells PGBA who they should send notices to)

  • Complete the Trading Partner section on the left side of page 16

  • Complete Exhibit A

    • Enter your information in the Trading Partner section

    • Please enter the information for the software vendor you are using to create your electronic claims (837's)

    • If you are using a Billing Service, please enter the Billing Services information in the Billing Service Information section

  • On Exhibit A, Page 2, please write in under Means of Electronic Access please write in "Secure FTP will use Axiom Systems Inc's IP and Certificate"

     

Trading Partner Business Associate Authorization Rider

Please complete this form if you will be authorizing a Billing Service to submit your claims

(Please note, ClaimShuttle is not a Billing Service, we are just providing the connection to their system)

  •  Please enter your Business/Practice or Provider Information in the first section

    • Please enter the Billing Service in the "Business Associate Specifics" section

    • For Means of Electronic Access please write in "Secure FTP will use Axiom Systems Inc's IP and Certificate"

    • Please provide the information for the types of transactions the Business Associate (billing service) will be sending on your behalf

    • Please complete your information on the left hand side of Page 4 as the Trading Partner

 

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 to:

 

 PGBA Correctional Claims
 PO Box 100110
 Columbia, SC 29202-3110



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 filling claims electronically. If neither a confirmation nor a returned packet is received after two weeks, contact the Technology Support Center toll-free at 1-844-218-5802.

 

Testing

Once you have received your Submitter ID and Password from Palmetto, please call the SolAce Support Team at 602-439-2525, to schedule an appointment for a Mailbox setup and Test transmission.


Please have 25 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 contact valid patient procedure, diagnosis, and provider information.