EDI Enrollment Forms
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Required Enrollment Documents: |
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| DO NOT SEND THE THREE REQUIRED ENROLLMENT FORMS DIRECTLY TO OFFICE ALLY. Your claims will not be processed properly unless your enrollment paperwork is mailed directly to ActivHealthCare. This does not apply to the optional enrollment documents. | |
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AHC EDI Provider Agreement Addendum Additional document required with the Agreement. |
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Office Ally Enrollment Form The enrollment form required for set-up for electronic claims processing. |
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Office Ally Business Associate and Trading Partner Agreement |
Optional Enrollment Documents: |
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| AHC provides Medicare and Medicaid enrollment forms on the website for your convenience. You may download the documents and mail them as specified on the individual applications. AHC is not involved with the processing of Medicare, Medicaid, BCBS, or other non-AHC claims. DO NOT MAIL THESE OPTIONAL FORMS TO ACTIVHEALTHCARE. | |
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Georgia Medicare Part B Provider Application for EDI This form must be completed to electronically file Medicare claims through Office Ally. You do not need to complete this form if you will not be processing Medicare claims. |
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Georgia Medicaid Application for EDI This form must be completed to electronically file Medicaid claims through Office Ally. You do not need to complete this form if you will not be processing Medicaid claims. |
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Tennessee Medicare Part B Provider Application for EDI This form must be completed to electronically file Medicare claims through Office Ally. You do not need to complete this form if you will not be processing Medicare claims. |
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Tennessee Blue Cross Blue Shield Pre-Enrollment Form |