220 Burnham Street South Windsor, CT Vox Fax

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1 220 Burnham Street South Windsor, CT Vox Fax KANSAS MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER CKKS1 SPECIAL NOTES 1. Upon approval of the Kansas MMIS Electronic Data Interchange Application an will be sent to the address listed on the application from KMAP. Contained in this will be an electronic link to the Kansas 835 Maintenance Guide. 2. Each provider will need to log into their KMAP account at Once logged in providers need to go to the Account Maintenance page and add WEBMDDENTAL to their KMAP account as the receiver for 835s. Receiver Transaction Type Remittance Advice Provider/Business Assoc. WEBMDDENTAL ***Paper RAs will cease to be mailed upon approval of the application.*** ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Dual Delivery of v5010 X and Proprietary Paper Claim Remittance Advices Participation in Dental Electronic Remittance Advice (ERA) is limited to those providers whose practice management software vendor is participating in ERA with Change Healthcare 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 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 Page 1 of : dlv

2 220 Burnham Street South Windsor, CT Vox Fax health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices. CCD+ REASSOCIATION SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS LATE/MISSING EFT & ERA PROCEDURE As part of the ERA enrollment process, and to comply with the Affordable Care Act CAQH CORE Rule #370, Change Healthcare 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 Change Healthcare 220 Burnham Street South Windsor, CT Attn: Provider Or to: dentalenrollment@changehealthcare.com Or Fax to: ERA enrollments take approximately 5-7 business days for completion. Once complete, Change Healthcare 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 Change Healthcare each Provider must reenroll following the procedures listed above. Pending payer s advice. 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 Change Healthcare DPS account need only ignore the ERA option when logging into the DPS. 2. Payer Un-enrollment Page 2 of : dlv

3 220 Burnham Street South Windsor, CT Vox Fax 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. If a provider wishes to discontinue receiving ERAs from Change Healthcare they need to login to their KMAP account and remove WEBMDDENTAL as the receiver of 835s. 835s will than begin being delivered to the provider s KMAP account. Should a provider wish to return to paper RAs he needs to call the KMAP Customer Service line at option 1, option 3#. CONTACT PHONE NUMBERS KMAP EDI Helpdesk option 1, option 3#. Change Healthcare Provider opt. 2 Page 3 of : dlv

4 220 Burnham Street, South Windsor, CT Phone Fax Change Healthcare Dental Provider Form Insurance Carrier: *Provider Name: (Complete legal name of institution, corporate entity, practice or individual provider) - ERA Payer ID(s) Doing Business as Name (DBA): P r o v i d e r A d d r e s s : *(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: *Telephone Number: * Address: Title: Telephone Number Extension: 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 Clearinghouse Name: Change Healthcare Dental Vendor Name: National Provider Identifier (NPI) *Reason for Submissi on: 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 1 or : dlv

5 220 Burnham Street, South Windsor, CT Phone Fax 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 Provider Identifiers Provider Contact Name 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 ZIP Code/Postal Code ISO Two Character Code associated with the State/Province/Region of the applicable Country. 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 Alpha Required DEG1 Alphanumeric, 15 characters Country Code ISO Country Code Alphanumeric, 2 characters PROVIDER IDENTIFIERS INFORMATION (Data Element Group 2 is a Required DEG) 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) Required Required DEG1 DEG1 DEG2 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 Number Telephone Number Extension Address Associated with contact person Numeric, 10 digits An electronic mail address at which the health plan might contact the provider Required Required; not all providers may have an address Fax Number A number at which the provider can be sent facsimiles DEG3 DEG2 DEG3 DEG3 DEG3 Page 2 of : dlv

6 220 Burnham Street, South Windsor, CT Phone Fax 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 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 SUBMISSION INFORMATION (Data Element Group 10 is a Required DEG) 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 DEG7 DEG7 DEG7 DEG7 CCYYMMDD Page 3 of : dlv

7 Kansas MMIS Electronic Data Interchange Application INSTRUCTIONS FOR EDI APPLICATION An EDI application is necessary for billing entities submitting electronic transaction files and is not applicable if submitting PAPER claims or submitting claims on the Kansas Medical Assistance Program (KMAP) Web site. Section 1 Fill in the entity type and contact information. Section 2 Indicate the software the billing entity will use. If the software is not Provider Electronic Solutions, please indicate the name of the software that will be used. Section 3 Select only one submission method. This is the method by which the billing entity intends to deliver the electronic information to KMAP. Section 4 Select all of the transaction types the billing entity will submit to or retrieve from KMAP. Section 5 This section contains information on how to return the completed EDI application to KMAP. All applications must include, name, signature, title, and date of completion. For assistance with this form please call the EDI Help Desk at then 3# or EDI.KMAP@EDS.COM.

8 Kansas MMIS Electronic Data Interchange Application 1. Complete this section: Billing Entity Type: Billing Agent Provider KMAP Provider ID Business Name: Address: City: State: Zip: Contact Person: Contact Telephone: Address: 2. Please choose any that apply: What software will the billing entity use? EDS Provider Electronic Solutions Other Software Name 3. Please select only one submission method: RAS file transfer CD-ROM Tape/Cartridge (Trade Files-Batch) 3480 Internet File Transfer Diskette (3.5 inch) 3490 (Trade Files-Batch) 4. Select ALL electronic transaction types you wish to test using media type selected in section 3: 837 Professional 276/277 Claim Status 834 Benefit 837 Institutional 270/271 Eligibility 835 Remittance/277 Pended Claims 837 Dental 278 Prior Auth 820 Capitation Payments 5. Complete this form and return it: For EDS Use Only: By Fax: By Mail: EDS EDI Department 3600 SW Topeka Blvd., Suite 204 Topeka KS, Signature Title Date Printed Name Last Revised 7/19/2006 Important: Disregard this application if the billing entity is ONLY submitting paper claims or using Direct Data Entry on the KMAP website