Resources

Insurance Enrollment Forms

For new customers in New York state, please follow the instructions below. For customers outside of New York state please contact your Project Manager:

To enroll to send claims to Medicare through MDLand:

Step 1: Click the link below. Complete all fields and agree to the terms, then Submit. This form must then be printed, signed, date and faxed to the EDI Enrollment Department. The fax number is on the printed form.

http://apps.ngsmedicare.com/applications/EDIEnrollmentAgreement.aspx?CatID=2

Submitter Status = 'Existing Submitter'

Submitter Type = 'Clearinghouse'

Submitter Name = 'MDLAND'

NY Medicare Queens (GHI) Submitter Id = NYBQ11383

NY Medicare Downstate (Manhattan/Bronx/Brooklyn/Long Island - Empire Medicare)

Submitter ID = CH0000549

 

Step 2: Complete the Provider Authorization Form below.

http://apps.ngsmedicare.com/applications/EDIProviderAuthForm.aspx?CatID=2

Check the following two boxes:

ASC X12 837 Claim

ASC X12 835 Remittance

 

NY Medicare Queens (GHI) Submitter Id = NYBQ11383 - NGS Contractor Code = 13292

NY Medicare Downstate (Manhattan/Bronx/Brooklyn/Long Island - Empire Medicare)

Submitter ID = CH0000549 - NGS Contractor Code = 13202

MDLAND

15 East 32nd Street, Fl 2

New York, NY 10016

Tel: 212-363-8000

Email: support@mdland.net

 

To enroll to send claims to Medicaid through MDLand:

Please complete the form below, notarize and mail it to the following address:

Provider Setup

CSC

P.O. Box 4614

Rensselaer, NY 12144

 

To check if the provider ID is ready to submit with our submitter ID please call

(800) 343-9000 option 1

Please make sure that our TSN:05D can be recognized on paper.

Click to Download Medicaid form

 

ERA Forms:

Medicaid

New York ERA Enrollment Form

Commercial Insurance

MDLand Enrollment form

Commercial ERA payer list

 

Immunization Registry Forms

Please follow the instructions below for the appropriate State/City:

New Jersey:

To create an account with NJIIS, please complete Consent and Enrollment Form available by clicking HERE.

If you have an NJIIS account, Click to Download NJIIS Electronic Interface Form.

New York City:

Click to Download NYC CIR Confidentiality Statement