ACS EDI Gatewayʼs Claims Payer List

ACS EDI Gatewayʼs Claims Payer List

Last updated 12/2009

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 ACS EDI Gatewayʼs Claims Payer List

Allstate Insurance Company – Payer ID 77066! 3

Allstate Workplace Division - Payer ID 77083! 5

Banner MediSun – Payer ID 77078! 6

BrickStreet Mutual Insurance Company - Payer ID 77025! 7

Deerbrook Insurance Company – Payer ID 77069! 8

Encompass Insurance – Payer ID 77068! 10

Liberty Mutual Insurance Company – Payer ID 77138! 12

MDwise (HIP) – Payer ID 77150! 14

Peach State Health Plan – Payer ID 77084! 15

Staywell/HealthEase/Wellcare – Payer ID 77004! 16

Child Health Plus (NY)" 16

Family Health Plus (NY)" 16

Harmony Health Plan (IL, IN, MO)" 16

HealthEase (FL)" 16

HealthEase Healthy Kids (FL)" 16

Healthy Choice (NY)" 16

Ohana Health Plan (HI)" 16

PreferredOne HUSKY A (CT)" 16

PreferredOne HUSKY B (CT)" 16

Staywell (FL)" 16

Staywell Healthy Kids (FL)" 16

WellCare (GA, OH)" 16

XL Health/Care Improvement Plus – Payer ID 77082! 17

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 ACS EDI Gatewayʼs Claims Payer List

Allstate Insurance Company – Payer ID 77066

http://www.allstate.com/
ACS EDI Direct is currently accepting electronic medical bills for Allstate Insurance
Company. Providers may submit X12 837 Professional and Institutional transactions
and retrieve electronic EOBs for:
• Allstate Insurance Company
• Allstate Property & Casualty Insurance Company
• Allstate Indemnity Company, and Allstate Fire and Casualty Insurance
Company
ACS EDI Direct supports the following submission methods for Allstate Insurance
Company:
• ACS EDI Claims Data Entry website (data-keying claims on our internet site)
• ediDIRECT File Exchange web portal (batch submission)
• SFTP connection (secure file transfer protocol)
• A software vendor, billing agent, or clearinghouse (through your current vendor)
Enrollment for Batch Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form

Provider Authorization for X12 835

Vendors requesting to retrieve the 835 transaction (electronic EOB) must have
authorization from their provider customer. The following form must be completed by
EACH provider in order to retrieve an 835.
Provider 835 Authorization Form
Enrollment for ediDIRECT Online Claims Entry and Submission
If you are a provider and you would like to data-enter and submit claims directly to
ACS using ediDIRECT, please complete the following form.
ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

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 ACS EDI Gatewayʼs Claims Payer List

Special Requirement for Allstate, Deerbrook, and Encompass Submitters

If you are enrolling to submit electronic medical bills for Allstate Insurance company,
Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also
fax or mail a signed Trading Partner Agreement.

Trading Partner Agreement Form

Attachments
Attachments required to be submitted with an Allstate Insurance medical bill (X12N
837 transaction) can be mailed. Please be sure to include the Claim Number in the
upper right-hand corner and send to:
Allstate Insurance
P.O. Box 440519
Kennesaw, Georgia, 30160

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 ACS EDI Gatewayʼs Claims Payer List

Allstate Workplace Division - Payer ID 77083

(Also known as American Heritage Life Insurance)

http://www.ahlcorp.com/

ACS EDI accepts X12 837 Professional, Institutional, and Dental electronic
transactions for Allstate Workplace Division a.k.a American Heritage Life
Insurance.
Allstate Workplace Division (AWD) is the marketing name for American Heritage Life
Insurance Company, a wholly-owned subsidiary of The Allstate Corporation. All
products are underwritten by American Heritage Life Insurance Company, Jacksonville,
Florida.
Enrollment for Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form
Special Requirement for Allstate, Deerbrook, and Encompass Submitters
If you are enrolling to submit electronic medical bills for Allstate Insurance company,
Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also
fax or mail a signed Trading Partner Agreement.
Trading Partner Agreement Form

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 ACS EDI Gatewayʼs Claims Payer List

Banner MediSun – Payer ID 77078

http://www.medisun.com/

ACS EDI Direct accepts X12 837 Professional and Institutional transactions for
Banner MediSun.
If you are a provider, software vendor, clearinghouse, or a billing agent who will be
submitting electronic medical transactions directly to ACS EDI in the ANSI X12N
format, please complete the following:
Enrollment for Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form. In addition, you must also fax or mail a signed Trading Partner Agreement.

ACS EDI Gateway Trading Partner Enrollment Form

Trading Partner Agreement Form

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 ACS EDI Gatewayʼs Claims Payer List

BrickStreet Mutual Insurance Company - Payer ID

77025
(Formerly WVWC)

http://www.brickstreet.com/

ACS EDI Direct accepts X12 837 Professional and Institutional transaction for
BrickStreet Mutual Insurance.

Providers have the capability to submit (HCFA-1500 and UB92) Workers'

Compensation claims electronically to ACS. Providers may choose from the following
options:
• The free ACS WINASAP2003 software
• A system vendor, billing agent, or clearinghouse using the ANSI X12N FORMAT
Enrollment for Electronic Claim Submission
If you are a provider, software vendor, clearinghouse, or a billing agent who will be
submitting electronic medical transactions directly to ACS EDI for BrickStreet Mutual
Insurance, please use the following form:

ACS EDI Gateway, Inc Commercial Division Trading Partner Enrollment Form for
BrickStreet
Upon receipt of your completed form, ACS will acknowledge your enrollment in
Electronic Data Interchange (EDI) by returning a Logon Information Sheet. The Logon
Information Sheet will contain the information necessary for you to begin electronic
filing.

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 ACS EDI Gatewayʼs Claims Payer List

Deerbrook Insurance Company – Payer ID 77069

http://www.deerbrook.com/
ACS EDI Direct accepts electronic medical bills for Deerbrook Insurance Company.
Providers may submit X12 837 Professional or the X12 837 Institutional transactions
and retrieve electronic EOBs for Deerbrook Insurance Company using the following
options:
• ACS EDI Claims Data Entry website (data-keying claims on our internet site)
• ediDIRECT File Exchange web portal (batch submission)
• SFTP connection (secure file transfer protocol)
• A software vendor, billing agent, or clearinghouse (through your current vendor)

Enrollment for Batch Electronic Claims Submission

If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form

Provider Authorization for X12 835

Vendors requesting to retrieve the 835 transaction (electronic EOB) must have
authorization from their provider customer. The following form must be completed by
EACH provider in order to retrieve an 835.
Provider 835 Authorization Form

Enrollment for ediDIRECT Online Claims Entry and Submission

If you are a provider and you would like to data-enter and submit claims directly to
ACS using ediDIRECT, please complete the following form.
ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

Special Requirement for Allstate, Deerbrook, and Encompass Submitters

If you are enrolling to submit electronic medical bills for Allstate Insurance company,
Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also
fax or mail a signed Trading Partner Agreement.

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 ACS EDI Gatewayʼs Claims Payer List

Trading Partner Agreement Form

Attachments
Attachments required to be submitted with a Deerbrook Insurance medical bill (X12N
837 transaction) can be mailed. Please be sure to include the Claim Number in the
upper right-hand corner and send to:
Deerbrook Insurance
P.O. Box 440456
Kennesaw, Georgia, 30160

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 ACS EDI Gatewayʼs Claims Payer List

Encompass Insurance – Payer ID 77068

http://www.encompassinsurance.com/
ACS EDI Direct accepts electronic medical bills for Encompass Insurance Company.
Providers may submit X12 837 Professional or the X12 837 Institutional transactions
and retrieve electronic EOBs for Encompass Insurance Company using the following
options:
• ACS EDI Claims Data Entry website (data-keying claims on our internet site)
• ediDIRECT File Exchange web portal (batch submission)
• SFTP connection (secure file transfer protocol)
• A software vendor, billing agent, or clearinghouse (through your current vendor)
Enrollment for Batch Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form
Provider Authorization for X12 835
Vendors requesting to retrieve the 835 transaction (electronic EOB) must have
authorization from their provider customer. The following form must be completed by
EACH provider in order to retrieve an 835.
Provider 835 Authorization Form

Enrollment for ediDIRECT Online Claims Entry and Submission

If you are a provider and you would like to data-enter and submit claims directly to
ACS using ediDIRECT, please complete the following form.
ediDIRECT Claims Direct Data Entry (DDE) and Submission enrollment form

Special Requirement for Allstate, Deerbrook, and Encompass Submitters

If you are enrolling to submit electronic medical bills for Allstate Insurance company,
Deerbrook Insurance Company, and/or Encompass Insurance Company, you must also
fax or mail a signed Trading Partner Agreement.
Trading Partner Agreement Form

Attachments

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 ACS EDI Gatewayʼs Claims Payer List

Attachments required to be submitted with an Encompass Insurance medical bill

(X12N 837 transaction) can be mailed. Please be sure to include the Claim Number in
the upper right-hand corner and send to:
 
Encompass Insurance
P.O. Box 440457
Kennesaw, Georgia, 30160

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 ACS EDI Gatewayʼs Claims Payer List

Liberty Mutual Insurance Company – Payer ID 77138

http://www.libertymutual.com/

ACS EDI Direct is your entry-point for submitting electronic medical bills to the
following Liberty Mutual Group companies for Personal Lines insurance including No
Fault and Medical Payments Coverage.
• The First Liberty Insurance Corp
• Liberty County Mutual Ins Co
• Liberty Insurance Corp
• Liberty Mutual Mid Atlantic Ins Co
• Liberty Mutual Fire Insurance
• Liberty Mutual Insurance Co
• Lm Insurance Corp
ACS EDI accepts the X12N 837 Professional and Institutional Healthcare claim
transactions and enables the retrieval of electronic EOBs using the following options:
• Submit Claims to Liberty Mutual for FREE using a Direct Data Entry web portal
(data-key claims through MD On-line)
• ediDIRECT File Exchange web portal (batch submission)
• SFTP connection (secure file transfer protocol)
• A software vendor, billing agent, or clearinghouse (through your current vendor)
PLEASE NOTE: Bills for the treatment of worker’s compensation claims will not
be processed if submitted to ACS EDI Gateway, Inc. Please contact Liberty Mutual
directly regarding worker’s compensation claims.
Enrollment for Batch Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form

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 ACS EDI Gatewayʼs Claims Payer List

Provider Authorization for X12 835

Vendors requesting to retrieve the 835 transaction (electronic EOB) must have
authorization from their provider customer. The following form must be completed by
EACH provider in order to retrieve an 835.
Provider 835 Authorization Form

MD On-line FREE Web Portal

You may submit claims to Liberty Mutual for FREE through MD On-line. MD On-line
offers a Direct Data Entry (DDE) application that allows Providers to submit medical
bills (CMS-1500s) through a web interface to Liberty Mutual Group companies. For
further details on MD On-line’s exclusive offer for Liberty Mutual providers and to
register to begin submitting claims electronically, visit MD On-Line.
Notice Regarding MD On-line: : If you intend to use or are currently using the MD On-
line FREE web portal to submit your Liberty Mutual medical bills, you DO NOT need to
enroll with ACS EDI Gateway using the Trading Partner Enrollment Form referenced
above. You only need to register with MD On-line.
Attachments
Attachments required to be submitted with a Liberty Mutual medical bill (X12N 837
transaction) can be mailed. Please be sure to include the Claim Number in the upper
right-hand corner and send to: 
Liberty Mutual
P.O. Box 1052
Montgomeryville, PA 18936
PLEASE NOTE: Do NOT send the corresponding paper claim if submitted
electronically.

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 ACS EDI Gatewayʼs Claims Payer List

MDwise (HIP) – Payer ID 77150

http://www.mdwise.org/
ACS EDI Direct accepts X12 837 Professional and Institutional transactions for the
MDwise Healthy Indiana Plan (HIP).
Enrollment for Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form. In addition, you must also fax or mail a signed Trading Partner Agreement.

ACS EDI Gateway Trading Partner Enrollment Form

Trading Partner Agreement Form

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 ACS EDI Gatewayʼs Claims Payer List

Peach State Health Plan – Payer ID 77084

http://www.pshpgeorgia.com/

ACS EDI Direct serves as the entry point for electronic medical claims for Peach State
Health Plan. ACS EDI accepts X12N 837 Professional, Dental, and Institutional
transactions for Peach State.

ACS EDI’s WINASAP2003 software is available to create and submit your electronic
Peach State Health Plan claims.

Enrollment for Electronic Claims Submission

If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form

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 ACS EDI Gatewayʼs Claims Payer List

Staywell/HealthEase/Wellcare – Payer ID 77004

http://www.wellcare.com/

ACS EDI Direct accepts electronic transactions for the following Staywell/HealthEase/
Wellcare plans:

Child Health Plus (NY)

Family Health Plus (NY)
Harmony Health Plan (IL, IN, MO)
HealthEase (FL)
HealthEase Healthy Kids (FL)
Healthy Choice (NY)
Ohana Health Plan (HI)
PreferredOne HUSKY A (CT)
PreferredOne HUSKY B (CT)
Staywell (FL)
Staywell Healthy Kids (FL)
WellCare (GA, OH)

ACS EDI Direct accepts X12 837 Professional and Institutional transaction for
Staywell/HealthEase/Wellcare plans.

ACS EDI’s WINASAP2003 software is available to create and submit your electronic
Staywell/HealthEase/Wellcare claims.

Enrollment for Electronic Claims Submission

If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form.
ACS EDI Gateway Trading Partner Enrollment Form

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 ACS EDI Gatewayʼs Claims Payer List

XL Health/Care Improvement Plus – Payer ID 77082

http://www.xlhealth.com/careimprovementplus/

ACS EDI Direct accepts X12 837 Professional and Institutional transactions for the
XL Health/Care Improvement Plus.
All direct submitters (trading partners) must first enroll with ACS EDI. Please visit
Enrollment within the Claims Gateway menu.
Enrollment for Electronic Claims Submission
If you will be submitting electronic claims directly to ACS EDI Gateway, please
complete the following form. If you are using a third party vendor to submit electronic
claims on your behalf, please contact them and have them complete the enrollment
form. In addition, you must also fax or mail a signed Trading Partner Agreement.

ACS EDI Gateway Trading Partner Enrollment Form

Trading Partner Agreement Form

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