220 Burnham Street South Windsor, CT Vox Fax

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1 DELTA DENTAL OF ILLINOIS GROUP PLANS DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES Participation with Direct Deposit (EFT) is required for receipt of Electronic Remittance Advice (ERA). Direct Deposit of funds is a safe, easy and efficient transaction allowing weekly deposits directly into the bank account designated. Providers have the option of receiving direct deposit Explanation of Payments (EOP) either by notification of bank deposits with delivery of EOP s to Delta Dental of Illinois Group Plans Web site or by fax notification and faxed EOP s. ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Emdeon Dental Provider Form Please complete all requested information. Direct Deposit Authorization If you are currently receiving Direct Deposits from Delta Dental of Illinois Group Plans you may note this on the top of the form and are not required to complete. If you are not currently receiving Direct Deposits from Delta Dental of Illinois Group Plans, please complete all requested information. Please attach a voided check or preprinted deposit slip as required. 835-Electronic Remittance Advise (ERA) Authorization Please complete all requested information. Dual Delivery of v5010 X and Proprietary Paper Claim Remittance Advices As part of the Affordable Care Act (effective ), health plans are required to dual deliver the electronic (ERA/835) and paper remittance advices for a minimum of 31 calendar days or at least 3 payment cycles. At the conclusion of this time period, delivery of the paper remittance advices may be discontinued. Providers who wish to continue receiving paper remittance advices for a longer period of time may request so by contacting the health plan directly. Upon mutual agreement between the provider and the health plan, the timeframe for delivery of the paper remittance advices may be extended by an agreed-to timeframe. If the provider determines it is unable to satisfactorily implement and process the health plan s electronic v5010 X following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery of the Page 1 of : dlv

2 proprietary paper claim remittance advices. CCD+ REASSOCIATION SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS LATE/MISSING EFT & ERA PROCEDURE DISCONTINUING ERA As part of the ERA enrollment process, and to comply with the Affordable Care Act CAQH CORE Rule #370, Emdeon requests you contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements. CCD+ Record # Field # Field Name 5 9 Effective Entry Date 6 6 Amount 7 3 Payment Related Information The data contained in the Minimum CCD+ data elements will allow you to easily associate your EFT and ERA transactions. You may read more about the CAQH CORE Rule 370 at the CAQH website Emdeon Business Services 220 Burnham Street South Windsor, CT Attn: Provider Or Fax to: ERA enrollments take approximately 5-10 business days for completion. Once complete, Emdeon will notify the provider or their PMS vendor, as defined by the PMS vendor. If the Provider currently receives ERAs through another Billing Agent other than Emdeon Business Services each Provider must re-enroll following the procedures listed above. Pending payer s advice. Discontinuing ERA is a 2 step process. 1. Deactivation a. Providers receiving ERAs via their Practice Management Software need to request deactivation from their software Vendors. Please call your PMS directly. b. Providers receiving their ERAs via an Emdeon DPS account need only ignore the ERA option when logging into the DPS. 2. Payer Un-enrollment a. Each payer has their own unique process to discontinue ERAs and return to paper Remittance Advice. Please follow the below steps for this payer. Page 2 of : dlv

3 Providers are required to give Delta Dental of Illinois Group Plans written notification. Mail notifications to: Professional Relations Department Delta Dental of Illinois 801 Ogden Avenue Lisle, IL CONTACT PHONE NUMBERS Delta Dental of Illinois Professional Relations Emdeon Dental Provider opt. 2 Page 3 of : dlv

4 Emdeon Dental Provider Form Insurance Carrier: - ERA Payer ID(s) *Provider Name: (Complete legal name of institution, corporate entity, practice or individual provider) Doing Business as Name (DBA): Provider Address: *(Street) * (City) * (State/Province) * (ZIP Code/Postal Code) (Country Code) *Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): *National Provider Identifier (NPI): *Provider Contact Name: Title: *Telephone Number: Telephone Number Extension: * Address: Fax Number: *Preference for Aggregation of Remittance Data: (e.g., Account Number Linkage to Provider Identifier) Provider Tax Identification Number (TIN) Method of Retrieval: Clearinghouse National Provider Identifier (NPI) Clearinghouse Name: Emdeon Dental Vendor Name: *Reason for Submission: New Change Cancel *Authorized Signature: (The signature of an individual authorized by the provider or its agent to initiate, modify or ternate and enrollment. May be used with electronic and paper-based manual enrollment) Printed Name of Person Submitting : Printed Title of Person Submitting : Submission Date: Requested ERA Effective Date: *Required Page 3 of

5 DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION DEFINITIONS Table: CORE-required Maximum ERA Data Set Individual Data Element Name (Term) Sub-element Name (Term) Data Element Description Data Type and Format (Not all data elements require a format specification) Data Element Requirement for Health Plan Collection (Required/ for plan to collect) Data Element Group Number (DEG#) PROVIDER INFORMATION (Data Element Group 1 is a Required DEG) Provider Name Complete legal name of institution, corporate entity, practice or individual Alphanumeric Required DEG1 provider Doing Business A legal term used in the United States meaning that the trade name, or Alphanumeric DEG1 As Name (DBA) fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it. Provider Address DEG1 Street The number and street name where a person or organization can be found Alphanumeric Required DEG1 City City associated with provider address field Alphanumeric Required DEG1 State/Province ISO Two Character Code associated with the State/Province/Region Alpha Required DEG1 of the applicable Country. ZIP System of postal-zone codes (zip stands for "zone improvement plan") Alphanumeric, 15 Required DEG1 Code/Postal Code introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities characters Country Code ISO Country Code Alphanumeric, 2 DEG1 characters PROVIDER IDENTIFIERS INFORMATION (Data Element Group 2 is a Required DEG) Provider Identifiers Required DEG2 Provider Contact Name Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions PROVIDER CONTACT INFORMATION (Data Element Group 3 is an DEG) Numeric, 9 digits Required DEG2 Numeric, 10 digits Required when provider has been enumerated with an NPI Contact Name of a contact in provider office for handling ERA issues Required DEG3 Title DEG3 Telephone Associated with contact person Numeric, 10 Required DEG3 Number digits Telephone Number Extension DEG3 Address An electronic mail address at which the health plan might contact the provider Required; not all providers may have an address Fax Number A number at which the provider can be sent facsimiles DEG3 DEG2 DEG3 Page 1 of : dlv

6 Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Method of Retrieval Clearinghouse Name Provider Tax Identification Number (TIN) National Provider Identifier (NPI) ELECTRONIC REMITTANCE ADVICE INFORMATION (Data Element Group 7 is a Required DEG) Provider preference for grouping (bulking) claim payment remittance advice must match preference for EFT payment The method in which the provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.) Required; select from below Numeric, 9 digits required if NPI is not applicable Numeric, 10 digits required if TIN is not applicable (Required if the provider is not using an intermediary clearinghouse or vendor) ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION (Data Element Group 8 is an DEG) Official name of the provider s clearinghouse Required DEG8 ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION (Data Element Group 9 is an DEG) Vendor Name Official name of the provider s vendor Required DEG9 SUBMISSION INFORMATION (Data Element Group 10 is a Required DEG) Reason for Submission Authorized Signature New Change Cancel Electronic Signature of Person Submitting Written Signature of Person Submitting Printed Name of Person Submitting Printed Title of Person Submitting The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. May be used with electronic and paper-based manual enrollment A (usually cursive) rendering of a name unique to a particular person used as confirmation of authorization and identity The printed name of the person signing the form; may be used with electronic and paper-based manual enrollment The printed title of the person signing the form; may be used with electronic and paper-based manual enrollment Required; select from below Required; select from below Submission Date The date on which the enrollment is submitted CCYYMMDD Requested ERA Effective Date Date the provider wishes to begin ERA; per Phase III CORE Health Care Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0: there may be a dual delivery period depending on whether the entity has such an agreement with its trading partner CCYYMMDD DEG7 DEG7 DEG7 DEG7 Page 2 of : dlv

7 DIRECT DEPOSIT AUTHORIZATION Direct Deposit of funds is a safe, easy and efficient transaction allowing weekly deposits directly into the bank account designated. You have the option of receiving direct deposit Explanation of Payments (EOP) either by notification of bank deposits with delivery of EOPs to Delta Dental of Illinois Web site or by fax notification and faxed EOPs. Direct Deposit will begin as soon as administratively possible. If you have multiple offices and would like direct deposit, it is necessary to complete a form for each office location, (copies of this form is acceptable). Accuracy of all information is essential. Please contact Professional Relations at if you have any questions. Business Information: Business / Dentist Name Tax Identification Number Office Address City State Zip Office Contact Person Contact Person s Phone Number Select Delivery Option (choose one): notification with delivery of Explanation of Payments to Delta Dental s Web site of person to receive direct deposit notification (required) of additional person to receive direct deposit notification Fax notification Please provide fax number (required): Bank Information: Name of Financial Institution Phone Number of Financial Institution Bank Routing Number Account Number Please check account type and include the requested document with completed form: Checking Please attach a voided check. (Please copy if faxing.) Savings Please attach a preprinted deposit slip. (Please copy if faxing.) I (we) hereby authorize Delta Dental of Illinois (DDIL) to initiate credit entries to my (our) indicated account at the financial institution named above. Authorized Signature & Title Date This authority is to remain in full force and effective until DDIL and said financial institution have received written notification from me of its termination in such time and manner as to afford DDIL and said financial institution reasonable opportunity to act on it. Delta Dental of Illinois Administrative Use Only: OR Dentist License Number / Business TIN State Office Location Number Clinic Number

8 835 - Electronic Remittance Advise (ERA) Authorization Section A Electronic Remittance Advise (ERA) Information Clearinghouse Information: Name of Clearinghouse Contact Name Phone Number Fax Number address Provider NPI (type 1) please provide NPI for each dentist in group practice Group NPI (type 2) If applicable Section B Electronic Remittance Advise (ERA) Authorization Clearinghouse Options (select one): Mercury Data Exchange (MDE) Emdeon Authorized Signature & Title This authority is to remain in full force and effective until Delta Dental of IL (DDIL) receives written notification from me of its termination in such time and manner as to afford DDIL reasonable opportunity to act on it. Date Delta Dental of Illinois Administrative Use Only: OR Dentist License Number State Office Location Number Clinic Number