Insurance Company:

NY Medicare (National Government Services)

New York State Medicaid

HIP Health Plan of New York

NY Medicare (National Government Services) Enrollment
Procedures

To enroll to send claims to Medicare through MDLAND you will need to go to the
following two links:

http://www.ngsmedicare.com/OnlineForms/EDIEnrollmentAgreement.aspx

Complete all fields and agree to the terms then click on the "Submit" button, this form
must then be printed, signed, dated, then faxed to the EDI Enrollment Department. The
fax number will be found on the printed form.

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

The second part of the enrollment is the Provider Authorization Form

http://www.ngsmedicare.com/OnlineForms/EDIProviderAuthForm.aspx

Check the following two boxes:
ASC X12 837 Claim V4010A1ASC
ASC X12 835 Remittance V4010A1

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
40 Exchange Place, STE 1108
New York, NY 10005
Tel: 212-363-8000
Email: support@MDLAND.com

Medicaid Enrollment Form

Please have it NOTARIZED and mail it to the following address:

Provider Setup
CSC
1 CSC Way
Rensselaer, NY 12144

To check if the provider id is read 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.

HIP Enrollment Form

Please fax it to HIP at (646) 447-3185.

Check if your provider id is ready submit with our submitter id please call