Tsev > Rau Cov Kws Pab Kho Mob > Provider Resources > Cov Kev Thov > EDI Claims Enrollment Form

EDI Claims Enrollment Form

This application is used to enroll providers as Trading Partners for various EDI transactions, such as 837 Electronic Claims Submission, 835 Electronic Remittance Advice and others.

Submit a EDI Claims Enrollment Form online or click image below to open a PDF form:

Contact Provider Services

General	831-430-5504
Cov Kev Thov Billing questions, claims status, general claims information	831-430-5503
Authorizations General authorization information or questions	831-430-5506
Authorization Status Checking the status of submitted authorizations	831-430-5511
Lub Tsev Muag Tshuaj Authorizations, general pharmacy information or questions	831-430-5507