EDI 837 Claims Enrollment Form

To submit claims electronically through a clearinghouse.

* Indicates required information.

50%

Date*
Date Format: MM slash DD slash YYYY
Select your Health Plan(s)*
- Virginia Premier Medallion 4.0 (Medicaid)
- Virginia Premier (Medicaid)
- CCC Plus Plan
- DSNP (Dual Special Needs)
- MAPD (Medicare)
Please select the Health Plan you wish to submit claims electronically with.

If your clearinghouse instructs you to send this form directly to VPHP, either:
- Email the completed form (as an attachment) to: vphpelitefaxpdt@vapremier.com
- or Fax the completed form to 877-719-7362
1) Submitter Information
To be completed by the Clearinghouse.
Medallion 4.0 Clearinghouse:*
Select one (1) Medallion 4.0 Clearinghouse
Medicaid Clearinghouse:*
Select one (1) Medicaid Clearinghouse
CompleteCare Clearinghouse:*
Select one (1) CompleteCare Clearinghouse
CCC Plus Clearinghouse:*
Select one (1) CCC Plus Clearinghouse
Dual Special Needs Clearinghouse:*
Select one (1) Dual Special Needs Clearinghouse
Medicare Clearinghouse:*
Select one (1) Medicare Clearinghouse
Other Clearinghouse:
Clearinghouse Contact Name*
Clearinghouse Contact Email Address*
Virginia Premier will send enrollment confirmation to this address.
2) Provider Group Information
W-9 required
Group / Provider Name*
Group / Provider Tax ID*
Group / Provider NPI*
If applicable.
Attach W-9*
Please attach a copy of your W-9 form (PDF).
Accepted file types: pdf.
3) Group / Provider Remittance / Billing Address
Address*
Street Address Address Line 2 City State ZIP Code

Provider Name (including title, eg. MD, DO, DPM, etc.)	Provider Specialty (eg Family Practice)	Provider NPI # (10 digits)	Provider Taxonomy Code	Par (Participating) or Non-Par

1) Submitter Information