Unless otherwise directed below (or in a
mailbox broadcast), print the applicable forms, fill them out and mail them to:
ET&T ClearingHouse
Attn: Enrollment Supervisor
PO Box 14150
Mesa, AZ 85216-4150
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Noridian [Fargo,ND]: Medicare
(OR,WA,AK,AZ,NV,HI,IA,CO,ND,SD,WY)
BCBS (ND,WY) ... MEDICAID
(ND) |
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Noridian's 837P Claim Registration
- Form that will register your providers for ANSI production claims. You may be assigned a
new submitter# by Noridian |
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Noridian's new CMS agreement
- Form that supersedes your prior HCFA agreements with Noridian.
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Champus TRICARE (prior to 07/01/2004 or if NOT in the new
"West" Region) |
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New REQUIRED
agreement - Form that supersedes your prior agreement(s) with Tricare.
Please list ET&T as the Vendor on page 3.
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Champus "West" Region to be handled by WPS after 07/01/2004 |
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NEW REQUIRED agreement - Form that
will link your offices with WPS through ET&T.
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ANSI ReportCode Listings
you may right click and Save Target As to your computer.
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| .doc |
Useful document - Full documentation of "Claim Status" codes.
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| .doc |
Useful document - Full documentation of "Claim Adjustment Reason" codes.
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| .doc |
Useful document - Full documentation of "Remittance Advice Remark" codes.
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| .doc |
Useful document - Full documentation of "Healthcare Decision" reason codes.
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