Transcription of Online Provider Services - Beacon Health Options
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Online Provider Services - Beacon Health Options
Page 1 of 3 Please return this form via fax to Beacon Health Options , Inc. | EDI Helpdesk | PO Box 1287, Latham, NY 12110 | Phone#: Incomplete, incorrect or illegible forms may delay or prevent proper processing ProviderConnect Online Services Account Request Form Provider , Practice or Facility Name Sp ecial Setup: Additional User Account Super User Account Military OneSource Horizon Behavioral Health Beacon Health Options Assigned ID National Provider Identifier (NPI) Provider , Practice or Facility Tax IDs to be associated to th is onlin e acc ount. If mor e than one, please list all. Add ress City Sta te Zip Code ( ) ( ) Telephone Number Fax Number Please check which Online Provide r Servi ces Options you are requesting: Electronic Batch Claim s (837) Direct Claim s Submission 277CA Acknowledgement File 999 Acknowledgement File Provider has retained a 3rd p arty B illing Agent or Clearinghouse to subm it claims on their behalf.
If you have to submit Institutional claims (submitted on a UB-92 or UB-04 form), and/or if you have a larger volume of Professional Claims, you can select Batch Claim submission.
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