220 Burnham Street South Windsor, CT Vox Fax

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1 NEBRASKA MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES CKNE1 Paper Remittance Advice Statements and Refund Request Reports statements will cease to be mailed upon approval of this enrollment. To obtain your Refund Request Report please log into your Emdeon Dental Connect (EDC) account and click the Reports link. If you do not have a EDC account please visit and choose Register for Dental Connect to create your account. in Electronic Funds Transfer (EFT) is required for enrollment in ERAs. If you are not currently receiving EFT from NE Medicaid please complete the MS-84 form located at 84(fillable)extended.pdf ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Participation in Dental Electronic Remittance Advice (ERA) is limited to those providers whose practice management software vendor is participating in ERA with Emdeon or to those providers who have a Dental Provider Services (DPS) account. Please contact your software vendor to verify participation or register for a DPS account at Emdeon Dental Provider Form Please complete all requested information. Nebraska Medicaid Trading Partner Authorization and Form 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 proprietary paper claim remittance advices. Page 1 of : dlv

2 CCD+ REASSOCIATION SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS 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 220 Burnham Street South Windsor, CT Attn: Provider ERA enrollments take approximately 5-7 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. Also, each provider must submit a Nebraska Medicaid Trading Partner Authorization listing an end date for the current Trading Partner. Page 2 of : dlv

3 LATE/MISSING EFT & ERA PROCEDURE EFT: The provider must contact the Medicaid Inquiry Line at to report the missing EFT. Nebraska Medicaid will verify the EFT enrollment by: o Verifying if an EFT payment was generated o Verifying the Bank Account information is accurately enrolled and active Upon determining the cause of the missing/late EFT, Nebraska Medicaid will contact the provider with the resolution. ERA: The Trading Partner must contact the EDI Help Desk to report the missing remittance advice. The Trading Partner can contact the EDI Help Desk at or by at DHHS.MedicaidEDI@Nebraska.gov. The Nebraska Medicaid EDI Help Desk will begin researching to determine the following: Confirm if the file was created and delivered to the Trading Partner. Determine if an enrollment issue was present which may have prevented the delivery of the ERA. o If an enrollment issue is found, the Trading Partner will need to ensure the provider completes the Trading Partner Authorization and for Electronic Remittance Advice (ERA) 835 Transaction form. Upon determining the cause of the missing/late 835, the EDI Help Desk will contact the Trading Partner with the resolution. DISCONTINUING ERA 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. Providers who wish to discontinue receiving ERAs through Emdeon need to submit a Nebraska Medicaid Trading Partner Authorization form listing an end date. Page 3 of : dlv

4 CONTACT PHONE NUMBERS Nebraska Medicaid EDI Help Desk Nebraska State Treasurer Emdeon Dental Provider opt. 2 Page 4 of : dlv

5 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

6 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

7 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

Department of Health and Human Services - State of Nebraska 5010 NEBRASKA MEDICAID TRADING PARTNER AUTHORIZATION AND ENROLLMENT for Electronic Remittance Advice (ERA) 835 Transaction Form READ

8 Department of Health and Human Services - State of Nebraska 5010 NEBRASKA MEDICAID TRADING PARTNER AUTHORIZATION AND ENROLLMENT for Electronic Remittance Advice (ERA) 835 Transaction Form READ INSTRUCTIONS HERE BEFORE COMPLETING This Authorization and form is required of all Nebraska Medicaid Providers who wish to receive the 835 Electronic Remittance Advice transactions directly or through a third party, such as a clearinghouse, from Nebraska Medicaid (hereinafter known as NE Medicaid ). The receiver of such transactions or any reference to clearinghouse is hereinafter known as Trading Partner. NOTE: l When receiving the 835, the Refund Requests Report will be provided electronically. l Electronic Fund Transfer (EFT) enrollment is required for a provider to enroll with Nebraska Medicaid. l When a Trading Partner is no longer authorized for the provider number/entity listed and/or the 835 transactions, a new Authorization and form must be completed providing the End Date. l If a provider adds or changes the NPI, taxonomy and/or zip+4 reported to Medicaid Provider, a new 835 Transaction form is required to continue to receive the 835, even if continuing with the same Trading Partner. l Only one Trading Partner can be authorized per 835 transaction at a time and the authorized dates may not overlap. l When authorizing for multiple provider numbers/entities, please complete a separate 835 Transaction form for each. Please Complete the Following (required fields are indicated with *) Enter the 11-digit Nebraska Medicaid-assigned Provider Number*: Check if atypical provider NE Medicaid is required to provide a paper Remittance Advice (RA) for three payment cycles for all newly approved 835 transaction for production, if requested. To select this option, check the box to continue to receive paper RA(s) for three payment cycles after receiving the 835 in production: If switching from one Trading Partner to another, please indicate the previous Trading Partner to discontinue for the 835 transaction. Discontinue Trading Partner (Name) Effective Date (mm/dd/ccyy): Trading Partner Authorization & ERA Form MS-86 (19043 Rev. 4/14 Page 1 of 3

9 Follow NE Medicaid specific instructions for fields displayed in BOLD font. Provider Name* PROVIDER INFORMATION PROVIDER ADDRESS Street* City* State/Province* Zip Code/Postal Code* + PROVIDER IDENTIFIERS INFORMATION PROVIDER IDENTIFIERS Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) OTHER IDENTIFIERS Assigning Authority: Trading Partner ID NE Medicaid Provider Taxonomy Code Provider Contact Name* PROVIDER CONTACT INFORMATION Title* Telephone Number* Telephone Number Extension Address Fax Number ELECTRONIC REMITTANCE ADVICE INFORMATION Preference for Aggregation of Remittance Data Provider Tax Identification Number (TIN) National Provider Identifier (NPI) ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION Clearinghouse Name* Trading Partner Authorization & ERA Form MS-86 Page 2 of 3

10 REASON FOR SUBMISSION*: (Select one) SUBMISSION INFORMATION New Change Cancel Written Signature of Person Submitting 1 AUTHORIZED SIGNATURE Printed Name of Person Submitting 1 * Printed Title of Person Submitting * Submission Date* Requested ERA Effective Date (*either this field or the one directly below is required, not both) Requested ERA End/Cancel Date 1 By signing or completing Printed Name of Person Submitting, the submitting individual is attesting and acknowledging on behalf of the Nebraska Medicaid Provider listed above that: l He or she is authorized to complete and submit this 835 Authorization and Form; l The indicated Trading Partner is authorized to receive the 835 ERA for the listed Provider; l The information provided is accurate and true; l Nebraska Medicaid will not exchange the 835 transactions with a Trading Partner on behalf of a Provider without this Trading Partner Authorization & form; l The Trading Partner must have an active Trading Partner Agreement with Nebraska Medicaid or this 835 Authorization and is null and void; l Any changes to the Provider s NPI, taxonomy and/or zip code+4 will require an updated 5010 Nebraska Medicaid Trading Partner Authorization and for Electronic Remittance Advice (ERA) 835 Transaction Form; and, l This information will be kept current by completing new 835 Authorization & forms, as necessary. Please complete and submit this form to Nebraska Medicaid. If using a Trading Partner, you may be requested to return this form to the Trading Partner. If submitting this form directly to Nebraska Medicaid, send as an attachment to DHHS.MedicaidEDI@nebraska.gov or fax or mail to: FAX: Mail: Department of Health and Human Services Attn: Medicaid EDI Help Desk PO BOX Lincoln, NE Phone (In Lincoln) (Outside of Lincoln) If you have questions, please contact the Nebraska Medicaid EDI Help Desk at: DHHS.MedicaidEDI@nebraska.gov l Click HERE for Late/Missing ERA Resolution Procedures. Click here to Please be sure to save your document then attach to . Trading Partner Authorization & ERA Form MS-86 Page 3 of 3

220 Burnham Street South Windsor, CT Vox Fax

220 Burnham Street South Windsor, CT Vox Fax NEVADA MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CKNV1 Participation in Dental Electronic Remittance Advice