Lifewise Health Plan of Washington Premera 837 and 835

Payer ID: 91049, 47570
Lifewise Health Plan of Washington
Premera
837 and 835
EDI Enrollment Instructions:
• Please save this document to your computer. Open the file in the Adobe Reader
program and type directly onto the form. Open the applicable form (Professional,
Institutional, or Dental) and type directly into the fields.
• Complete the form using the provider’s billing/group information as credentialed
with this payer.
• Once completed, save for your records, print and obtain appropriate signature(s).
• A typed signature is acceptable.
• ERA Enrollment timeframe with Premera is approximately 5 days.
• For help with filling out the form, refer to the attached Instructions.
837 Claim Transactions:
Enrollment applies to ERA only and is not necessary prior to sending claims.
835 Electronic Remittance Advice:
835/Electronic Remittance Advice Enrollment Form
Select the form that best fits your needs: Professional, Institutional or Dental.
Complete the form as appropriate, using the information provided below.
Assigning Authority = Leave blank
Submit Completed Form:
1. Fax to Premera, Attn: EDI Team at:
425-918-4234
2. Fax to ClaimRemedi at:
707-573-1066
2016-06-03