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 New York Medicare directly 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 New York Medicaid directly 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 the form.
Click to Download Medicaid form
To enroll to send claims to Empire BCBS directly 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, dated and faxed to the EDI Enrollment Department. The fax number is on the printed form.
Empire BCBS EDI Enrollment Form
Section 1: Select Add.
Section 2: Select Blue Shield
Section 3: Select 835 Remittance & EDI Reports
Section 4: Select Ivans Internet VPN
Section 5: Select FTP
Section 6: Name: MDLand
Submitter ID: NY01120P
Operating as: Clearinghouse
Address: 15 E 32nd st. 2nd Floor
New York, NY 10016
Contact Name: Support
Contact Email: support@mdland.com
Phone #: 212-363-8000
Fax #: 212-937-3158
Section 7 gets left blank.
Section 8: All provider information goes in that box.
ERA Forms:
Medicaid
Commercial Insurance
Immunization Registry Forms
Please follow the instructions below for the appropriate State/City:
New Jersey:
For both New and Existing Providers: Please complete the new Interface Enrollment Request Form by clicking HERE.
VENDOR INFORMATION
Vendor Name: MDLAND
Software Name: iClinic
Contact Last Name: Sturm
Contact First Name: Jay
Phone Number: 212-363-8000
Email: jay.sturm@mdland.net
File Format/Version: HL7 2.5.1
Press the "SUBMIT" button when complete.
New York City:
Click to Download NYC CIR Confidentiality Statement