Payer List

Please follow the Enrollment Instructions below to become an electronic submitter for New Jersey Medicaid.

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the NJ Medicaid office prior to initiation of electronic claims submission or inquiry.

1. EDI 101 New Submitter Agreement
2. EDI 201 Submitter Provider Agreement
3. EDI 801 Electronic Remittance Agreement

If the links listed above do not work properly, you can download the forms from here:
https://www.njmmis.com/documentDownload.aspx?fileType=93661110-6DC5-406B...

The first drop down, Select “Provider”
The second drop down Select “HIPAA”
Press “Submit”

If you have any questions regarding the documents and process listed please call the NJ Medicaid EDI Support Center at: 609-588-6051

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

Please Note: If you are using a Billing Service, your Billing Service is the “Submitter” and you will only put your information in the Provider Sections. Since your Billing Service is the one submitting and receiving on your behalf, please have them fill in the Sections for Submitter with their information.

EDI 101 New Submitter Agreement

Header:

• Check the box for “Medicaid”

Section 1:

• Enter the name of the Submitter, whether it be provider, clearinghouse, or billing service
• Enter the demographic and contact information of the submitter
• Enter the contact information for the main contact
• The Submitter Representative’s signature should be the person who has liability authority of the business
• Print name and Date the application

Section 2:

• Check the box in the 5010 section for 837 Claim Professional
• For Certification Vendor Name enter: AXIOM Systems, Inc. formerly Ivertex
• Check the box for “No”

Section 3:

• Software Vendor Name: AXIOM Systems Inc. formerly Ivertex
• Enter the address and contact information listed in the box above
• Product Name SolAce EMC
• Version is 4.0.11
• Release date: Sep 18th 2012

EDI 201 Submitter Provider Agreement

Header: Check Medicaid

Section 1:

• Enter the name of the Submitter, whether it be the provider, clearinghouse or billing service
  • If you are a provider applying for a New Submitter ID, leave the Submitter ID blank
  • If you are a Billing Service who already has an ID, enter your Submitter ID
• Enter the Name, Address, and Contact information for the Submitter’s Authorized Representative
• As Billing Services: you must fill out this form for each provider you will be submitting on behalf of

Section 2:

• Check the Box to “Add New Provider”
• Enter the Provider’s Name, Medicaid Number, and NPI
• Enter the Provider’s Address and Contact information
• The Provider, or authorized representative, must print their name, sign and date the application

Section 3:

• Please enter the Software Vendor information listed above for your convenience
• Version is 4.0.11
• Release date: Sep 18th 2012

ERA EDI Agreement

Please fill out this form after receiving your Submitter ID.

Section 1:

• Check the box for “Medicaid”
• Check the box for “Web”

Section 2:

• Check the box to Add New Provider
• Enter the Providers name
• Enter the Submitters name (Either the name of the Provider, Billing Service, or Clearinghouse)
• The date entered should be on a Monday, per their recommendation
• Print Name, Sign and Date the application
• Enter the Medicaid Provider ID, and Group NPI
  • The ID listed should be the NPI of the Provider/Group that is registered with Molina Medicaid
• Enter the Name of the Provider
• Enter the Provider’s Demographic and Contact information

Section 3:

• Enter the business name of the Provider/Submitter or Billing Agent/Submitter who will be receiving the ERAs
• Enter the Submitter ID assigned to you by Molina Medicaid
• Enter the demographic and contact information

Section 4:

• Check the box for 5010

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail or Fax the enrollment forms reflecting original signatures to:

Via U.S. Mail
Provider Enrollment
Molina Medicaid Solutions
P.O. Box 4804 Trenton, New Jersey 08650 – 4804

Other Carriers
Provider Enrollment
Molina Medicaid Solutions
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately 2 weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after 2 weeks, please call the NJ Medicaid EDI Support Center at: 609-588-6051

Testing

Once you have received your Submitter ID and Password from NJ Medicaid please call the SolAce Support Team and set an appointment for a Mailbox setup.

Testing is not required at this time; we are an approved vendor for Professional Claims Submission and Inquiry with NJ Molina Medicaid. If you bill institutional claims (UB04) and wish to use SolAce to submit to NJ Medicaid, Please call the SolAce Support Team at 602-439-2525.