Please follow the Enrollment Instructions below to become an electronic submitter to Connecticut Medicaid.

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 CT Medicaid office prior to initiation of electronic claims submission or inquiry.

1. Trading Partner Agreement

To fill out this online form, please go here:

If you have any questions regarding any of the documents in this package, please call the CT Medicaid EDI Technology Support Center at 1-800-688-0503.

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

• Complete the first paragraph with your business name and today’s date.

• In Article II, enter today’s date

• In Article IV, select either 837 Institutional, 837 Professional, or both.

  • Enter the number of Providers that you will be billing for

  • Enter your estimate claim volume per month

  • Enter how frequently you plan to submit claims, (for ex: daily, bi-weekly, once a week, several times in one day, etc….)

• For the second set of transaction choices please select 999 and 835, (835 is for electronic remittance advices)

• In Article VII, complete this section with the names of the providers that you will be billing for and their current HP Web user Ids.

• In Article VIII, Complete all of the Trading Partner sections with your information.

Trading Partner Online Enrollment Form

Screen 1:

• Enter your Group/Provider Name as the Trading Partner

• Enter your Demographic information

• Enter the contact information for your office

• After all required fields are entered press next

Screen 2:

• Check each transaction you will be exchanging:

  • 837 Healthcare Claim: Institutional, 5010 and/or

  • 837 Healthcare Claim: Professional, 5010 and

  • 835 Healthcare Claim Payment/Remittance Advice and

  • 999 Functional Acknowledgment

Screen 3: This section is to add providers

• Please enter your providers AVRS ID* and effective date

• Please enter the providers ID, name, and Transaction Type

• Claim Payment/Advice 5010

• 837 Healthcare Claim: Institutional, 5010

• 837 Healthcare Claim: Professional, 5010

• Repeat process to add additional providers for your practice

*As an approved Provider, you have been assigned a Personal Identification Number that will be used to access your Medicaid information through the AVRS. Your PIN is for the purpose of accessing the Automated Voice Response System, (AVRS). In order to verify Medicaid information by telephone, this PIN will be required.

Screen 4:

• The signature panel is next, read the Electronic Signature Agreement and check the box to accept

• Enter your electronic signature and today’s date

• It will allow you to review your information and then click Submit to turn in your form

Submitting your Forms

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

HP
Attn: EDI Unit
P.O. Box 2991
Hartford, CT 06104

It is very important that you complete and return the entire form as described above. Incomplete forms 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 faxed 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 at 1-800-688-0503.

Testing

Once you have received your Submitter ID and password from CT Medicaid, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup and Test Transmission.

Please have 20 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.