Submit a request – Ayin Help Center

If this is your first time submitting a request, you will be required to verify your email address to ensure your request is received. After submission, please check your email, including the spam/junk folder, for our verification message.

Your email address

Subject

Do not include protected health information in the subject field.

Please select the most appropriate topic

Please select which issue you are having regarding the CIM account(optional)

Please select which issue you are having regarding the SFTP/MoveIt account(optional)

Please select which issue you are having regarding your claim(s) or eligiblity(optional)

Please select which issue you are having regarding a provider assignment(optional)

Please select which request you need from the mail room(optional)

Is this an out of state enrollment request?

Which plan are you seeking reimbursement from?

Will you be seeking reimbursement/billing Oregon DMAP/Fee for Service/Open Card in addition to a Managed Care Plan?

What plan are we submitting this enrollment on behalf of?(optional)

What type of enrollment is this?

An OHA 3974 Disclosure Statement form is required. Do you need a copy of the OHA 3974 Disclosure Statement form?

OHA 3974 Disclosure Statement form: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/de3974.pdf

An OHA 3975 Provider Enrollment Agreement form is required. Do you need a copy of the OHA 3975 Provider Enrollment Agreement form?

OHA 3975 Provider Enrollment Agreement form: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le3975.pdf

Electronic or Paper Submission?(optional)

Electronic or Paper Rejection?(optional)

Please select the most appropriate topic

Is this an urgent request?(optional)

If this is needed urgently, please contact CIM Support directly at 503-584-2169 option 2 Monday-Friday 8AM-5PM.

Please select the appropriate option

Effective date of change

Please describe why you are requesting data entry override.

Who has approved the request?

Attachments to support request i.e. benefit plans etc(optional)

Volume of claims impacted

Item or service impacted

Specific claim examples

Claim type

Is this for Medicaid or Medicare?

Medicaid/Medicare Plans - Select appropriate plan

Approved by, if required

Effective date of override, if applicable(optional)

Case closure date

Attachment included?(optional)

Desired Username(optional)

User Full Name(optional)

User Email(optional)

User Phone Number(optional)

First Name

Last Name

New User Email Address(optional)

Username

First name (user to deactivate)

Last name (user to deactivate)

Username (user to deactivate)

Office

What start date are we requesting for this billing/organizational provider's Oregon Medicaid number?

What start date are we requesting for this individual provider's Oregon Medicaid number?

Provider's full name: (first, middle, last)

Provider Date of Birth: (MM/DD/YYYY)

*NOTE: Required by CMS Rule CMS-6028-FC*

Provider Social Security Number: (xxx-xx-xxxx)

*NOTE: Required by CMS Rule CMS-6028-FC*

Provider NPI

The NPI must be 10 digits in length.

Provider taxonomy:

The taxonomy must be 10 characters in length.

Provider type:

Do you hold a Provider State License or Certification?

License/Certificate number

Expiration Date

Effective Date

Physical Office Adress (Street, City, State, Zipcode)

Office Phone

Office Fax(optional)

Business/facility license number

Billing/Organization NPI

The NPI must be 10 digits in length.

Organization Name

Organization Physical Address

Organization taxonomy:

How many owners have a controlling interest of 5% or more within the organization?

The Name, Title, SSN, and Date of Birth must be supplied for all owners and officers with a controlling interest of 5% or more in the organization. If no one person is an owner or has a controlling interest of 5% or more, this information will need to be supplied for the CEO, CCO, or controlling officer in the organization. This is required by CMS Rule CMS-6028-FC.

Name of Employee 1

Title of Employee 1

Date of Birth for Employee 1 (MM/DD/YYYY)

SSN of Employee 1 (xxx-xx-xxxx)(optional)

Name of Employee 2

Title of Employee 2

Date of Birth for Employee 2 (MM/DD/YYYY)

SSN of Employee 2 (xxx-xx-xxxx)(optional)

Did you remember to attach a signed and dated W-9, a copy of business or facility license and the completed OHA form(s)?

Reason for modification(optional)

Access to a New Tax ID, Office, or CIM Application does not constitute a modification/update, and the New CIM Account form needs to be completed and submitted.

Plan Name

Your Associated TIN(s)

Dashboard Page Name

Measure Name

Provider Name(optional)

Provider Specialty(optional)

Billing Provider Name(optional)

Specific check number involved?(optional)

Check Amount(optional)

Payer/Insurance(optional)

Billing Provider/Vendor NPI(optional)

The NPI must be 10 digits in length.

TIN(optional)

New billing address(optional)

Billing Provider/Vendor Tax ID (Please do not include any dashes.)

The Tax ID must be 9 digits in length.

Member ID(optional)

Member Name(optional)

Date of Service(optional)

Total Billed Charge(optional)

Rejection Reason(optional)

Rejection Date(optional)

Clearinghouse(optional)

Payer ID(optional)

The Payer ID must be 5 characters in length.

DCN Number(optional)

Billing System(optional)

Preferred clearinghouse(optional)

Interested in direct submission?(optional)

CIM System?

Address

City

State

County

Zip Code

Billing address different from physical address?(optional)

Billing Address(optional)

Billing City(optional)

Billing State(optional)

Billing Zip Code(optional)

Effective Date(optional)

Contract Description (or attach your contract below)(optional)

Termination Date(optional)

Do you want claims reprocessed?(optional)

From what date?(optional)

Do you have a W9 form?(optional)

A W9 form MUST be attached below or PH TECH will not be able to process this request.

Requested change date(optional)

Requested mail date (start date for ongoing mailings)(optional)

Is this mailing Urgent?(optional)

Does this change affect CIM (name of mailing, category, etc)?(optional)

Description of change needed(optional)

Is there a document change?(optional)

Description of change (please attach document or document name below)(optional)

Is there a frequency change?(optional)

Please detail the change needed(optional)

Should this mailing be tracked in CIM?(optional)

Mailing Description(optional)

What member specific information is needed for this mailing?(optional)

For example, Member Name, Address, Language, etc.

Estimated Mailing Volume(optional)

Is this mailing reoccurring or one time?(optional)

Frequency and requested dates(optional)

Will the plan be supplying Materials?(optional)

Please provide a detailed list of materials that will be provided.(optional)

If you are providing print ready templates, please be sure to attach them to this request. For example: merge template, handbook, postcard, envelopes, or other items.

Will the plan be supplying a member list?(optional)

What membership extract from CIM should be used?(optional)

Please provide as much detail as possible. Example: All members on Plan ABC, all children up to age 18 on plan XYZ, etc.

If this is to send to full membership, would you like one sent per member or one per household?(optional)

Sending one per household will eliminate one household receiving duplicates for each family member.

How should the member be addressed?(optional)

Please specify how the member should be addressed(optional)

Please provide a list of all items to be included in the mailing. Your items should be listed in the specific order in which they should be stuffed into the mailing envelope. (optional)

What return address should appear on the exterior envelope?(optional)

Would you like a logo included in any part of this mailing?(optional)

Claim Number(optional)

Your Job Title

CIM Systems (select all that apply)(optional)

Are you a third party?

If Yes, Company Name:(optional)

We require that you attach a copy of your Business Associates Agreement (BAA).

Access Type Needed

Carrier Selection (Please select only those carriers you are contracted with or that you are submitting claims to.)

Case Name

Participant Type

Participant NPI

Participant TIN

Effective Date of Pend

Priority(optional)

(Urgent - work stoppage issue) (High - significantly impacting work) (Normal - can temporarily work around the issue) (Low - minimal business impact or inquiry)

Description

Please enter a brief summary above. You can include PHI in this description field. Requests submitted in this portal adhere to HIPAA compliance standards. Please remember to observe minimum necessary guidelines when transmitting PHI.

Attachments(optional)

Add file or drop files here