MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM
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1 MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM
2
3 Instructions for Completing BCBSMA Electronic Remittance Advice (ERA) Enrollment Form For questions about this form or the electronic enrollment process, please contact the EDI Team at You must be authorized to submit 837s in order to receive 835s. The EDI support team will contact you upon receipt of the completed ERA Enrollment Form. Form Submission Fields Provider Information - please fill out completely Provider name - Legal name of institution, corporate entity, practice or individual provider Provider address - Street - The number and street where individual/organization is located City - City associated with street address field State/Province - Two character code associated with the State/Province/Region of the applicable Country ZIP code/postal code - System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities Provider identifiers National Provider Identifier (NPI) - 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). 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 Federal Tax Identification Number (TIN) - A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), used to identify a business entity Other identifier Trading Partner ID - The provider's submitter ID assigned by the health plan or the provider's clearinghouse or vendor
4 Provider contact information Provider contact name - Name of a contact in a provider office for handling ERA issues Telephone number - Associated with provider contact name address - An electronic mail address at which the health plan might contact the provider Fax number - A number at which the provider can be sent facsimiles ERA information Preference for Aggregation of Remittance Data is National Provider Identifier (NPI) Method of retrieval is determined by BCBSMA ERA clearinghouse information Clearinghouse name - Official name of the provider's clearinghouse Telephone number - Telephone number of contact address - An electronic mail address at which the health plan might contact the provider's clearinghouse Submission Information Reason for submission New Enrollment Change Enrollment Cancel Enrollment Authorized signature - Signature of an individual authorized by the provider or its agent to initiate, modify, or terminate an enrollment Electronic signature of person submitting enrollment - (usually cursive) A rendering of a name unique to a particular person used as confirmation of authorization and identity Printed title of person submitting enrollment - Printed title of the person signing the form ERA Enrollment Form submission date - Date on which the enrollment form is submitted 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 based upon a trading partner agreement with BCBSMA Researching missing / Late files ERA files that have not been received after 4 business days of receipt of the corresponding EFT file can be researched by contacting the EDI Team at edisupport@bcbsma.com.
5 You should be prepared to provide the following information for each missing/late research requests: NPI Tin Provider name Remittance Date EOB s and/or other supporting materials may also be attached the request.
TRICARE PGBA, LLC Electronic Data Interchange PO Box Augusta, GA Fax: Phone , Option #2
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Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
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