MARYLAND PHYSICIANS CARE (00247) ERA ENROLLMENT INSTRUCTIONS

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1 MARYLAND PHYSICIANS CARE (00247) ERA ENROLLMENT INSTRUCTIONS WHICH FORM(S) SHOULD I DO? Emden EnrllNw (Click here) NOTE: This is cmpleted nline. Office Ally supprts nly the payers listed n the Emden ERA Enrllment frm belw. D nt chse payers that are listed n the Emden ERA Enrllment frm when cmpleting the EnrllNw nline frm. Emden ERA Enrllment Frm NOTE: This frm is ed t Office Ally, nt t Emden. Electrnic Remittance Advice (ERA) Authrizatin Agreement NOTE: This will be sent directly t the payer. WHERE SHOULD I SEND THE FORM(S)? Emden EnrllNw: Once cmpleted nline, click Submit. NOTE: If the payer yu re enrlling fr is nt listed n this webpage, just enter the prvider infrmatin and click Submit. The payer infrmatin will be entered n the Emden ERA Enrllment frm. Emden ERA Enrllment Frm: Once cmpleted, save and t Electrnic Remittance Advice (ERA) Authrizatin Agreement: Once cmpleted, r fax t MARYLAND PHYSICIANS CARE Fax: WHAT IS THE TURN AROUND TIME? Once Office Ally receives yur Emden ERA Enrllment Frm, we will prcess the request within hurs. Nte: Incmplete frms will delay the enrllment prcess, every field is required. The time it takes ERAs t start cming thrugh is dependent upn that individual payer. Generally, ERA s can take anywhere frm 14 t 45 days t begin cming thrugh. HOW CAN I CHECK THE STATUS OF MY ERA ENROLLMENT? T check status, call Prvider Relatins at r Office Ally P.O. Bx Vancuver, WA Phne: Fax:

2 EMDEON ERA ENROLLMENT FORM In rder t enrll t receive ERAs electrnically frm this payer, please fill ut this frm and return it via t the Subject shuld read: Emden ERA Enrllment. PAYER INFORMATION OF THE PAYER YOU ARE ENROLLING FOR ERAS FROM : MARYLAND PHYSICIANS CARE PROVIDER INFORMATION: Prvider Name: Prvider Address: PROVIDER IDENTIFIERS INFORMATION: Prvider Federal Tax Identificatin Number (TIN) OR Emplyer Identificatin Number (EIN): Natinal Prvider Identifier : PROVIDER CONTACT INFORMATION: Prvider Cntact Name: Telephne Number: : ELECTRONIC REMITTANCE ADVICE INFORMATION: Preference fr Aggregatin f Remittance Data: Select One Nte: Accunt Number Linkage t Prvider Identifier. Must match prefernce fr EFT payments. SUBMISSION INFORMATION: Reasn fr Submissin: New ERA Enrllment Authrized Signature: Nte: Electrnic Signature (typed name) f Persn Submitting ERA Enrllment. Of f ic e Al ly P. O. B x Van cu v er, W A w w w. f fi c eal ly. c m Phne: Fax:

3 509 Prgress Drive, Suite 117 Instructins fr Electrnic Remittance Advice (ERA) Enrllment/Change/Cancellatin Page 1 Please use this guide t prepare/cmplete yur Electrnic Remittance Advice (ERA) Authrizatin Agreement Frm. Missing, illegible r incmplete infrmatin within the agreement frm will delay the benefits f participating in ERA. The fllwing is a reference guide nly, d nt fax, r the instructins with the cmpleted authrizatin frm. Return Pages 2-3 ONLY. If yu prefer t enrll/change/cancel electrnically, please g t ur website at fr the electrnic frm and instructins. If yu have questins abut the authrizatin agreement frm r the enrllment prcess, please cntact Prvider Relatins at, r us at Please nte that the descriptins fr the data elements cntained in the Electrnic Remittance Advice (ERA) Authrizatin Frm have been placed in an Appendix t make it easier t cmplete the frm. Please refer t the Appendix when cmpleting the frm. Are yu using ne authrizatin agreement frm per tax id number? Enrllment frms cntaining mre than ne tax id will be returned. Did yu remember t put the NPI # n the authrizatin agreement frm? Enrllment frms withut an NPI number will be returned. Additinal Infrmatin Please cntact yur vendr fr additinal infrmatin n which distributin methd t utilize as each vendr/clearinghuse may have a different distributin methd. If yu d nt use a vendr and have questins, please cntact Prvider Relatins at, r If yu wuld like t link directly with Emden please cntact Emden Sales at There may be an additinal cst assciated with linking directly with Emden. Need t change r cancel an existing enrllment? Cmplete a new authrizatin agreement frm t make changes t an existing enrllment r t cancel an existing enrllment. Cmplete all parts f the frm and mark the apprpriate chice in the Submissin Infrmatin sectin f the frm. Yu are respnsible fr ntifying Maryland Physicians Care f any infrmatin changes. Has the frm been signed by the apprpriate individuals? Unsigned frms will be returned. Have yu cmpleted all sectins? Please type r print all requested infrmatin clearly. Incmplete and/r illegible fields will cause the frm t be returned. Have a cmpleted frm t submit? Frms can be submitted by fax r . Cmpleted new r change authrizatin agreement frms with vided check and/r bank letter and cmpleted cancellatin authrizatin agreement frms can be submitted thrugh ne f the fllwing methds: Fax t: Maryland Physicians Care, Prvider Relatins Only ne frm per fax. Faxes cntaining multiple frms will be returned. t: Only ne frm per . s cntaining multiple frms will be returned. Need t check the status f yur ERA enrllment? Please allw business days fr prcessing nce enrllment is received. Prcessing times may vary depending n number f enrllments received, accuracy f the infrmatin prvided and hw legible the frm is. The nline instructins n ur website at will instruct yu t cntact Prvider Relatins r with any questins r t check enrllment status. Have yu cntacted yur financial institutin t arrange fr the delivery f the CORE-required Minimum CCD+ Reassciatin Data Elements frm the NACHA ACH/EFT payment file? Yur financial institutin must be a participating member f the Autmated Clearinghuse Assciatin (ACH) and accept the CCD+ frmat. Yu must practively cntact yur financial institutin t arrange fr the delivery f the CORE-required Minimum CCD+ Data Elements necessary fr the successful reassciatin f the EFT payment with the ERA remittance advice. D yu have a Late r Missing EFT payment r ERA remittance advice? If yu have nt received yur EFT payment r the crrespnding ERA remittance advice by the 4 th business day after yu receive either the EFT payment r ERA remittance advice, cntact yur Prvider Relatins, us at r fax us at

4 509 Prgress Drive, Suite 117 Electrnic Remittance Advice (ERA) Authrizatin Agreement Page 2 Definitins fr DEG grup data elements cntained in Appendix. DEG1 PROVIDER INFORMATION Prvider Name Ding Business As Name (DBA) Prvider Address Street City State/Prvince Zip Cde/Pstal Cde DEG2 PROVIDER IDENTIFIERS INFORMATION Prvider Federal Tax Identificatin Number (TIN) r Emplyer Identificatin Number (EIN) Natinal Prvider Identifier DEG3 PROVIDER CONTACT INFORMATION Prvider Cntact Name Telephne Number Fax Number DEG7 ELECTRONIC REMITTANCE ADVICE INFORMATION Preference Fr Aggregatin f Remittance Data (e.g., Accunt Number Linkage t Prvider Identifier) - Select frm belw Prvider Tax Identificatin Number (TIN) Natinal Prvider Identifier Methd f Retrieval DEG8 Clearinghuse Name Clearinghuse Cntact Name Telephne Number DEG10 ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION Emden Enrllment Help Desk SUBMISSION INFORMATION Reasns Fr Submissin Select frm belw New Enrllment Change Enrllment Cancel Enrllment

5 509 Prgress Drive, Suite 117 Electrnic Remittance Advice (ERA) Authrizatin Agreement Page 3 Definitins fr DEG grup data elements cntained in Appendix. Authrized Signature Written Signature f Persn Submitting Enrllment Printed Name f Persn Submitting Enrllment Printed Title f Persn Submitting Enrllment Authrizatin Agreement By signing abve, I hereby agree that I have read and agree t the terms and cnditins stated in the Authrizatin Agreement belw. Authrizatin Agreement Electrnic Remittance Advice (ERA) An ERA is an electrnic versin f a payment explanatin f benefits (EOB) explaining claims payment r denial. This authrizatin is t remain in effect until Maryland Physicians Care has received an ERA cancellatin ntificatin frm me that affrds Maryland Physicians Care a reasnable pprtunity t act n it. Please allw business days fr prcessing nce enrllment is received. Prcessing times may vary depending n number f enrllments received, accuracy f the infrmatin prvided and hw legible the frm is.

6 509 Prgress Drive, Suite 117 Appendix - Data Element Names and Descriptins T be used fr cmpleting the Electrnic Remittance Advice (ERA) Authrizatin Agreement Page 4 DEG1 PROVIDER INFORMATION Data Element Name Descriptin Prvider Name Cmplete legal name f institutin, crprate entity, practice r individual prvider A legal term used in the United States meaning that the trade name, r fictitius Ding Business As Name (DBA) business name, under which the business r peratin is cnducted and presented t the wrld is nt the legal name f the legal persn(s) wh actually wn it and are respnsible fr it Prvider Address - Street The number and street name where a persn r rganizatin can be fund Prvider Address - City Prvider Address State/Prvince Zip Cde/Pstal Cde City assciated with prvider address field ISO tw character cde assciated with the State/Prvince/Regin f the applicable Cuntry System f pstal-zne cdes (zip stands fr zne imprvement plan ) intrduced in the U.S. in 1963 t imprve mail delivery and explit electrnic reading and srting capabilities DEG2 PROVIDER IDENTIFIERS INFORMATION Data Element Name Descriptin Prvider Federal Tax Identificatin Number (TIN) r Emplyer Identificatin Number (EIN) Natinal Prvider Identifier A Federal Tax Identifier Number, als knwn as an Emplyer Identificatin Number (EIN), is used t identify a business entity A Health Insurance Prtability and Accuntability Act (HIPAA) Administrative Simplificatin Standard. The NPI is a unique identificatin number fr cvered health care prviders. Cvered healthcare prviders and all health plans and healthcare clearinghuses must use the NPIs in the administrative and financial transactins adpted under HIPAA. The NPI is a 10-psitin, intelligence-free numeric identifier (10-digits number). This means that the numbers d nt carry ther infrmatin abut the healthcare prviders, such as the state in which they live r their medical specialty. The NPI must be used in lieu f legacy prvider identifiers in the HIPAA standards transactins DEG3 Data Element Name Prvider Cntact Name Telephne Number Fax Number PROVIDER CONTACT INFORMATION Descriptin Name f a cntact in prvider ffice fr handling ERA issues Assciated with cntact persn An electrnic mail address at which the health plan might cntact the prvider A number at which the prvider can be sent facsimiles

7 509 Prgress Drive, Suite 117 Appendix - Data Element Names and Descriptins T be used fr cmpleting the Electrnic Remittance Advice (ERA) Authrizatin Agreement Page 5 DEG7 ELECTRONIC REMITTANCE ADVICE INFORMATION Data Element Name Descriptin Preference fr Aggregatin f Remittance Data (e.g., Accunt Number Linkage t Prvider Identifier) - Select frm belw Prvider Tax Identificatin Number (TIN) Natinal Prvider Identifier Methd f Retrieval Prvider preference fr gruping (bulking) claim payment remittance advice must match preference fr EFT payment The methd in which the prvider will receive the ERA frm the health plan (e.g., dwnlad frm health plan website, clearinghuse, etc.) DEG8 ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION Data Element Name Descriptin Clearinghuse Name Official name f the prvider s clearinghuse Clearinghuse Cntact Name Name f a cntact in clearinghuse ffice fr handling ERA issues Telephne Number Telephne number f cntact An electrnic mail address at which the health plan might cntact the prvider s clearinghuse DEG10 SUBMISSION INFORMATION Data Element Name Descriptin Reasn fr Submissin - Select frm belw New Enrllment Change Enrllment Cancel Enrllment The signature f an individual authrized by the prvider r its agent t initiate, Authrized Signature mdify r terminate an enrllment. May be used with electrnic and paper-based manual enrllment. Written Signature f Persn A (usually cursive) rendering f a name unique t a particular persn used as Submitting Enrllment cnfirmatin f authrizatin and identity Printed Name f Persn The printed name f the persn signing the frm; may be used with electrnic and Submitting Enrllment paper-based manual enrllment Printed Title f Persn The printed title f the persn signing the frm; may be used with electrnic and Submitting Enrllment paper-based manual enrllment

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