835 Enrollment Form

Request For 835 Enrollment

Please fill out the following form to request that MEDENT enroll your practice for 835 files for specific insurance companies.

Once our Support team has completed the enrollment, your practice will be notified via email to the contact below. 835 enrollments can take up to 8 weeks to be processed by the payer.

If additional enrollment paperwork or information is required, this will be emailed to the contact below.

MEDENT Account Number:*

Directory (if not main):

Contact Name (First and Last Name):*

Contact Email:*

Practice Name:*

Practice Street Address:*

Practice City:*

Practice State:*

Practice Zip:*

Phone Number:*

Fax Number:

Tax ID#:*

NPI# (Group for Group Practices, Individual for Sole Provider Practices)*

MVP requests requires the Payee ID Number from the EOB

Choose Clearinghouse*

Optum iEDI
PNT
RPA

Note: If are are choosing to enroll this payor with Availity or Waystar you should not fill out and submit this form.

Availity: 835 enrollments are done in the Availity portal. Contact Availity directly if you need assistance.

Waystar: Contact Waystar directly for 835 enrollments.

Please completely fill out at least one request below

PAYER ID INSTRUCTIONS:

Only valid Payer ID numbers can be enrolled. 98999 is not a valid Payer ID. To locate the insurance Payer ID numbers we are able to enroll: CLICK HERE

Optum iEDI payers that are designated as Non-Par have a fee of $0.45 per claim. RPA clients can disregard the payer Par/Non-Par status. The additional fee does not apply to RPA clients.

If you are not an RPA client and still want to be enrolled for a Non-Par payer, check this box to agree to pay the fee:

REQUEST #1

Insurance Company Name

Insurance Company Number(s) in your MEDENT system