eRx Network - Services Enrollment

eRx Services Enrollment

eRx DME billing services pre-enrollment form • 800-879-6153 option 4 • 866-543-7083 (fax)

Thank you for choosing eRx Network as your clearinghouse!

Pre-Enrollments submitted on line will be processed and the pharmacy will be contacted via telephone to complete the enrollment. Once your enrollment is completed, you will receive access to the following services:

Electronic Claims Processing for the following plans as applicable:
- Medicare Part B DME
- Medicare Part B for Flu and Pneumonia vaccinations
- Medicaid DME
eRx Network’s Support Help Desk via a toll free telephone number
The secured customer area of eRx Network’s website which provides:
- Access to view claims history
- The latest industry news
- EOB On Demand Tool
- ICD-9 Lookup Tool
- A downloadable copy of our Medicare Billing Manual-free of charge
  The billing manual contains the following helpful information:
  - HCPC Codes and covered item list
  - OCNA Codes for billing secondary insurances
  - Documentation Requirements, etc.

Please supply the following information:

NCPDP#		Store# (if applicable)
Legal Business Name		Doing Business As Name

Location		Billing Address
Street Address		Street Address
City		City
State		State
Zip		Zip

Phone Number		Fax Number
Email Address		Contact Person
Referred by		Federal Tax ID
Best Time to Call		Switch Company
Software Vendor

Please indicate provider number for each plan you would like to set up for DME billing:

Medicare DME Provider Number
Participation Status with Medicare program	Participating Non-Participating
NPI Number
Medicare Part B Provider Number For processing your Influenza and Pneumonia claims
Medicaid DME Provider number
Currently processing DME claims in the following states Please select state
Michigan Blue Cross Blue Shield Provider Number

Additional Information:

Are you an independent pharmacy with one location	Yes No
Please indicate number of stores
Are any of your other locations currently enrolled with our billing services?	Yes No
Do you currently submit electronic claims to Medicare?	Yes No
Are you interested in eRx Recovery Services?	Yes No

Additional comments or questions:

An Enrollment Specialist will contact you shortly to complete the enrollment process. If you have any questions at this time, please contact our Enrollment department at (800) 879-6153, option 4.

Thank you again for choosing eRx Network as your clearinghouse. We look forward to working with you.


			Products/Services

	eRx Network provides network, reconciliation, and billing services to the pharmacy industry. Click one of the headings below to learn more about our offerings.

	Network Services

			eRx Connect
			Claims switching supported by most pharmacy management applications and compatible with Internet, network, and dial-up connections.

			eRx Edit
			Real-time pre- and post- third-party claim editing services for independent and chain pharmacy.

			eRx Pad
			Electronic prescribing solutions which connect pharmacy and physicians through eRx’s nationwide network.

	Reconciliation Services

			eRx Claim Reconciliation
			Pharmacy claim reconciliation services for independent pharmacy.

			eRx Recovery
			Reconciliation and recovery of denied Medicare and Flu claims.

	Medicare/Medicaid DME Services

			eRx Medicare DME
			Electronic billing of Medicare DME claims at point of fill using the existing pharmacy management system.

			eRx Medicaid DME
			Electronic billing of state Medicaid DME claims.

			eRx Flu
			Electronic billing of flu and pneumonia vaccinations to Medicare.

			eRx Services Pre-Enrollment
			eRx DME billing services pre-enrollment form.

	Business Intelligence

			eRx Visual Intel
			eRx Visual Intel is an interactive visual tool used for opportunity analysis of prescription sales information.