Website/Customer Service Center

06/2018

1926 Northlake Pkwy, Suite 100 ٠ Tucker, GA 30084 ٠ 770-455-0040 ٠ 888-635-0459 ٠ www.ActivHealthCare.com

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Website –Home page

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

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Website –CA’s Corner

AHCØ1 Payor Name from ID Card

Payor Address from ID Card

Payor City, State, Zip

Network Name

John Chiropractic Center

4455 Highway 84

Tucker, GA 30084-7069

1932992610

John Chiropractic Center

4455 Highway 84

Tucker, GA 30084-7069

14322895876

14322895876

Insured’s Information

Patient’s Information

Doctor’s NPI Number

Service Address & NPI # Address/NPI number for who checks are

payable to

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Service Provider

TIN

If Mailing Paper Claims, Send Claims To:

Coventry Health Care of GA Claims

ActivHealthCare1926 Northlake Pkwy,

Suite 100Tucker, GA 30084

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All Claims for Networks

(Alliant, Beech Street, First Health, etc)

ActivHealthCare1926 Northlake Pkwy,

Suite 100Tucker, GA 30084

Note: See Network Affiliate sheet. This applies to the networks that are to be submitted through Activ.

If Filing EDI through Office Ally, Address Claims using this format:

Coventry Health Care of GA Claims

AHCØ1 Coventry25133P.O. Box 7711London, KY 40742-7711

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All Claims for Networks

(Alliant, MHP, First Health, etc)

AHCØ1 “Name of Payor”“Insurance co. payer ID”AddressCity, State, Zip

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Website –Network Resources

Benefit Verification – Tax ID #

• Payors may require your tax ID number when verifying benefits. If so, give them the ActivHealthCare tax ID number to obtain correct in-network benefits.

58-2068734

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• Do not use Activ’s tax ID # when submitting claims.

• Unauthorized use of the ActivHealthCare tax ID number is illegal.

• Activ will put the ActivHealthCare tax ID number on claims for in-network providers when you submit the claim to us.

Website-Network Affiliates

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Claims for these networks must be submitted through Activ.

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Website –EDI Enrollment forms

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Website –Forms

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Website –Feedback

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Website –Customer Service Center

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Website –Customer Service Center

User ID: Your TIN Password: Your TIN(will prompt you to change after your first log in)

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Website –Customer Service Center

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Website –Customer Service Center

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Website –Customer Service Center

A list of your open claims will display.

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Website –Customer Service Center

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Website –Customer Service Center

Contact Information

We are here to help you and your doctors with any questions or problems.

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ActivHealthCare1926 Northlake Pkwy, suite 100

Tucker, GA 30084Phone: 770-455-0040

General Fax: 770-455-6188Treatment Plan Fax: 678-990-0025

Credential Fax: 678-990-1124

Questions

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I attest that I have completed the AHC Staff Training and understand the

presented Content.

Date Training Completed: ______________________________________

Staff/Contractor Name (Printed): ________________________________

Staff/Contractor Signature: _____________________________________

Provider Name(s): ____________________________________________

After completing the training, please print and sign this page and fax to

(770) 455-6188.