EDI Enrollment Form BCBSKS 834 - AICK

Application for Blue Cross and Blue Shield of Kansas 834 Health Care Benefit Enrollments and Maintenance for AICK

All fields are required except where marked (optional).

Employer Group Information

Employer Group Name - Name of organization submitting transaction.

Master Policy Number - Provided by the Group Consultant Marketing Representative.

Employer Group Name Master Policy Number (MPN)

Employer Group Address

Employer Group Address – Mailing address of the submitting organization, including Street, City, State and ZIP Code.

Street City State/Province ZIP Code/Postal Code

Employer Group Identifiers Information

Employer Group Identifiers – Tax Identification Number (EIN or SSN)

Employer Group Federal Tax Identification Number

Other Identifiers

Other Identifier(s) – Assigning Authority – Administrative Services of Kansas (ASK)

Trading Partner ID – If making a change, enter your 7 digit trading partner number (will begin with 0) assigned by ASK.

Assigning Authority Trading Partner ID (optional)

Employer Group Contact Information

Employer Group Contact Name

Employer Group Contact Name – Primary contact of the employer group.

Contact Telephone Number – Phone number of the contact name, including extension if available.

Email Address – A group email address is recommended, if available. Used as primary form of contact. Communications may contain PHI.

Fax Number – Fax number of the contact name.

Contact Telephone Number Telephone Number Extension (optional) Email Address Fax Number (optional)

Employer Group Vendor Information

Vendor Name – Name of the software company supporting your Human Resources software.

Vendor Contact Name – Name of technical contact at the software company.

Telephone Number – Telephone number for the technical contact at the software company.

Email Address – A group email address is recommended, if available. Used as primary form of contact. Communications may contain PHI.

Vendor Name Vendor Contact Name Telephone Number Email Address

Employer Group Connectivity Information

SSH Key

SSH Key - Providing an SSH Key allows you to bypass changing password every 90 days. SSH Key must be received prior to first file submission.

Yes (Highly recommended)

Form Submission Information

Reason for Submission

Reason for Submission – Check one box to indicate New Enrollment, Change Enrollment, or Cancel Enrollment.

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature

Authorized Signature – The name and title of the individual within the employer group office authorized by the employer to initiate, modify or terminate an enrollment.

Print Name of Person Submitting Enrollment Print Title of Person Submitting Enrollment

For questions about this form, please call the EDI Help Desk at 1-800-472-6481, option 1.

EDI Setup will be completed within 3-5 business days of receipt of this document. Once BCBSKS has completed setup; notification will be sent to email address provided in this form.

Notification will contain a confirmation letter containing the Employer Group Trading Partner Number and Data Matrix specific to the Employer Group. This information will be used in conjunction with the 5010 Companion Guide.

Edifecs Quick Start Guide provide connectivity information and Acknowledgments will provide technical information regarding status of files successfully received by BCBSKS.

We strongly encourage both Employer Group and Vendor to sign up for Email List Notification.

Kansas law applies to this business relationship.

- back -