EDI Enrollment Form BCBSKS 834 - Health and Dental

Employer Group Name - Name of organization submitting transaction.

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

BCBSKS Sales Representative - The BCBSKS employee who sells to and provides a liaison for the employer groups and non-group members/members and BCBSKS.

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

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

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.

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.

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.

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.

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

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.