• Alternate Access Required: Choose the submission method you wish to use, FTP or Electronic Gateway. If your packet does not list either of these methods, you may write in your desired access method.
• Business Reason: This is the type of transactions you wish to submit. You may use the transaction format number (ex. 270/278) or a description (ex. Eligibility and Service Authorization)
• Requestor Information/Requestor Name: This should be the name of the person you wish Provider Enrollment Support to contact with USER ID, PASSWORD and testing information.
Unique Identifier: This is a pass phrase the Call Center will request in situations such as a forgotten/lost password to confirm your identity. You may put anything you wish in this field but it should be something easy for you to recall like your mother’s maiden name, the street you grew up on, or a favorite pet’s name. If you need to have your password reset, please contact the Call Center at 800-343-9000.

No. Original signatures are required on this document. A faxed copy is not acceptable.

The FTP transmission method will accept 270, 276, 278, 834, and 837 (I/D/P) transactions. NCPDP 5.1 under 90 days may also be sent using this method. Select another transmission method for submitting NCPDP 5.1 claims over 90 days. You may receive 271, 277, 278, 820 and 835 transactions through FTP.

Due to the processing time involved, it can take two to three weeks before you hear from us regarding your Security Packet B. If you wish to check on the status of the document, please call Provider Enrollment Support at 800-343-9000.