EDI 837 Claims Enrollment Form

We are currently experiencing technical difficulties with the electronic form.
Please download the form (PDF) and email it to VPHP_PDMsupport@VirginiaPremier.com.

Contact VPHP_PDMsupport@VirginiaPremier.com if you need assistance or have any questions.

To submit claims electronically through a clearinghouse.

* Indicates required information.

Step 1 of 2

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

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Page last updated:

February 4, 2021

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I certify I am a health care provider, an employee of a health care provider, a business associate of a health care provider, or an employee of a business associate, and the purpose of my access to any Virginia Premier System is related to the provision or payment of health care services.

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I agree to keep confidential all information related to Virginia Premier System business, including, but not limited to, quality and risk management activities as well as other confidential or personal information concerning the medical, personal, or business affairs of Virginia Premier System and its members.

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New Users

Need to register for a new account? Click here.

In order to register for an account, if you would like access to all group NPIs/APIs under a single Tax ID, please enter your Tax ID only. If you would like access to a specific group NPI/API instead, please enter it in the field provided.

For expedited registration, please provide a Claim number and the Total Billed Charges on the claim when creating your account.

You will receive an email within 3-5 business days with your username and temporary password.

Need Help?

Please call Technical Support for help with Virginia Premier’s Provider Portal at 1-877-814-9909 or email connect@healthtrio.com.

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If you have questions or need help please, contact our Provider Services department at vphpnetdev@virginiapremier.com or by calling 804-968-1529.