New Jersey Medicaid
Please follow the Enrollment Instructions below to become an electronic submitter for New Jersey 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 NJ Medicaid office prior to initiation of electronic claims submission or inquiry.
1. EDI 101 New Submitter Agreement
2. EDI 201 Submitter Provider Agreement
3. EDI 801 Electronic Remittance Agreement
If the links listed above do not work properly, you can download the forms from here:
https://www.njmmis.com/documentDownload.aspx?fileType=93661110-6DC5-406B...
The first drop down, Select “Provider”
The second drop down Select “HIPAA”
Press “Submit”
If you have any questions regarding the documents and process listed please call the NJ Medicaid EDI Support Center at: 609-588-6051
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.
Please Note: If you are using a Billing Service, your Billing Service is the “Submitter” and you will only put your information in the Provider Sections. Since your Billing Service is the one submitting and receiving on your behalf, please have them fill in the Sections for Submitter with their information.
EDI 101 New Submitter Agreement
Header:
Check the box for “Medicaid”
Section 1:
Enter the name of the Submitter, whether it be provider, clearinghouse, or billing service
Enter the demographic and contact information of the submitter
Enter the contact information for the main contact
The Submitter Representative’s signature should be the person who has liability authority of the business
Print name and Date the application
Section 2:
Check the box in the 5010 section for 837 Claim Professional
For Certification Vendor Name enter: the information for the software or vendor that creates your 837 files you need ClaimShuttle to transfer for you. If you have paid for our billing software please call our support line for our vendor information.
Check the box for “No”
Section 3:
Please enter the information for the software or vendor that creates your 837 files you need ClaimShuttle to transfer for you. If you have paid for our billing software please call our support line for our software information.
EDI 201 Submitter Provider Agreement
Header: Check Medicaid
Section 1:
Enter the name of the Submitter, whether it be the provider, clearinghouse or billing service
If you are a provider applying for a New Submitter ID, leave the Submitter ID blank
If you are a Billing Service who already has an ID, enter your Submitter ID
Enter the Name, Address, and Contact information for the Submitter’s Authorized Representative
As Billing Services: you must fill out this form for each provider you will be submitting on behalf of
Section 2:
Check the Box to “Add New Provider”
Enter the Provider’s Name, Medicaid Number, and NPI
Enter the Provider’s Address and Contact information
The Provider, or authorized representative, must print their name, sign and date the application
Section 3:
Please enter the information for the software or vendor that creates your 837 files you need ClaimShuttle to transfer for you. If you have paid for our billing software please call our support line for our software information.
ERA EDI Agreement
Please fill out this form after receiving your Submitter ID.
Section 1:
Check the box for “Medicaid”
Section 2:
Check the box to Add New Provider
Enter the Providers name
Enter the Submitters name (Either the name of the Provider, Billing Service, or Clearinghouse)
The date entered should be on a Monday, per their recommendation
Print Name, Sign and Date the application
Enter the Medicaid Provider ID, and Group NPI
The ID listed should be the NPI of the Provider/Group that is registered with Molina Medicaid
Enter the Name of the Provider
Enter the Provider’s Demographic and Contact information
Section 3:
Enter the business name of the Provider/Submitter or Billing Agent/Submitter who will be receiving the ERAs
Enter the Submitter ID assigned to you by Molina Medicaid
Enter the demographic and contact information
Section 4:
Check the box for 5010
Submitting your Forms
It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail or Fax the enrollment forms reflecting original signatures to:
Via U.S. Mail
Provider Enrollment
Molina Medicaid Solutions
P.O. Box 4804 Trenton, New Jersey 08650 – 4804
Other Carriers
Provider Enrollment
Molina Medicaid Solutions
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619
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 2 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 confirmation nor a returned packet is received after 2 weeks, please call the NJ Medicaid EDI Support Center at: 609-588-6051
Testing
Once you have received your Submitter ID and Password from NJ Medicaid please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup.
Please ask our support team when you call if Testing is required as this is determined by what software you use.