Electronic Claims Enrollment

Contact Information for {practiceName4}
Name*
Phone*
E-mail*
Setup Medicare EMC
Submitter ID
Setup BCBS EMC
Submitter ID
Please note that setting up Medicare and/or BCBS means only that your software will be configured to create claim files to send through Medxpress. Any linking of practice/provider must have been previoulsy completed or in process of being completed.
Billing Company?*
Billing Company Name*

Provider Information
Enter the names and NPIs of all providers who will be submitting claims for {practiceName4}.
Provider Name
NPI
Provider Name
NPI
Provider Name
NPI
Provider Name
NPI
Provider Name
NPI

Vision Account Setup
An Change Healthcare Vision Account is required for claims management and processing.
I currently have a Vision accountI need to setup a new Vision account
Existing Account Name*
Preferred Account Name*
No spaces or special characters
Alternate Account Name*
No spaces or special characters

Confirm/Complete Enrollment
To confirm, you are enrolling {practiceName4} with Tax ID:{taxId} and Billing NPI:{billingNpi} to submit electronic claims. Please take a moment to ensure the Tax ID and Billing NPI, as they appear above, are correct.

Click SUBMIT to complete the enrollment process or PREVIOUS should you need to go back and change any of the practice information.
Vision Account Info
Form Email
NGS Submitter ID
From Name
BCBS Submitter ID
Submission Date

MonthDayYear
FolderName
- TSO
- Should be Empty: