NATIONWIDE HEALTH PLANS ERA
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1 3/21/2007 Cover Page 1 PAYER ID: NATIONWIDE HEALTH PLANS ERA For Initial Enrollment with this payer: You MUST be enrolled for EDI with this payer, and have a minimum of one successful claim processed on paper before enrolling for Electronic Remittance Advice (ERA). Registration with Emdeon takes 14 business days. If enrollment is for a group, form MUST be signed by the highest ranking office. The application will not be processed without this information. Section 1 filled out to enroll for ERA. Section 2 is only necessary if you wish EFT You may obtain the form from our enrollment web site For Re-Enrollment (COS Change of Service) with this payer: If you have submitted claims electronically to this payer in the past, either directly or through another clearinghouse, and would like to submit through Emdeon, the Payer requires payer registration forms. Registration with Emdeon takes 14 business days. This payer accepts group agreements. If enrollment is for a group, form MUST be signed by the highest ranking office. The application will not be processed without this information. Invalid or inaccurate information will delay processing of this application.. You may obtain the form from our enrollment web site If you are already APPROVED by this payer to submit through Emdeon: If you have already received an approval from this payer to submit claims electronically through Emdeon, you must notify Emdeon so that we may process your approval in our enrollment systems. Please submit a Client Provided Approval Form to Enrollment for processing. o You may obtain the form from our enrollment web site by calling our Fax on Demand service at (doc# 1450). o The Client Provided Approval form must be submitted to: payerregistration@emdeon.com, or faxed to Payer Registration Reminders: Please keep a copy of all forms for your records. Please verify that all pages in the agreement are included when mailing. Please ensure that all required fields are completed and legible. Please provide a physical address below in case we need to Fed-Ex your agreement back to you. Please remember to sign and date all documents. Your software vendor must be certified to send All-Payer claims to Emdeon. Please contact your vendor if you have questions regarding certification. To obtain forms or additional payer information, visit our website:
2 3/21/2007 Cover Page 2 PAYER ID: NATIONWIDE HEALTH PLANS ERA Name* Instructions for submitting Payer Registration Forms: You must include this page when submitting Payer Registration forms to Emdeon Registration forms must be submitted to the address or fax number below To obtain forms or additional payer information, visit our website: Physical * City, State, Zip* Name* Phone Fax This Registration form is for a: Provider Group NPI ID* Group ID* Provider ID* Tax ID* SSN Site ID* Vendor Submitter ID* Vendor Name* Division ID* Additional Info * Required Information if applicable. All Approval Notifications will be sent to this address Submit Original Payer Registration forms that require original signatures to: Emdeon Business Services Attn: Enrollment Dept Donelson Corporate Ctr Bldg Lebanon Pike Ste 2000 Nashville, TN For all other forms: Fax: (615) batchenrollment@emdeon.com To avoid claim rejection, please do not submit electronic claims before receiving Emdeon Approval Notification.
3 INSTRUCTIONS FOR COMPLETING THE AUTHORIZATION AGREEMENT FOR ELECTRONIC EXPLANATION OF PAYMENT AND/OR DIRECT DEPOSIT OF PAYMENTS SECTION 1 EOP 1. Enter X to indicate the type of transaction: Add indicates a new authorization Change indicates a change to an existing authorization Delete indicates a request for termination of authorization. Enter X to indicate if this agreement is for the electronic EOP request or both EOP & EFT. Complete section 1 only, if this is an 835 EOP Request. Complete Sections 1 & 2 if this is for EOP & EFT Enter the complete name and address of the company or individual participating in the EOP/EFT program. Circle Y or N to indicate if there are multiple billing addresses for this Federal Tax Identification/Social Security #. Enter your company s Federal Tax Identification number or your Social Security # if you, as an individual are participating. Enter your receiver id number. Indicate whether you will receive the EOP/EFT direct from NHP or via WebMD. 4. If application is NOT for an individual, the name and official title of the highest-ranking officer of the company must be provided. The application will not be processed without this information. SECTION 2 - EFT If you are requesting the EFT, please complete this section in addition to the information provided in Section Enter the name and address of the ACH member financial institution authorized to conduct transaction. The requirement of the Uniform Depository Act, Chapter 135 of the Ohio Revised Code, is applicable to EFT banking transactions. 2. Enter the financial institution s Transit Routing/ABA number in the spaces provided. This is a nine-digit number that is shown on your check. It may also be obtained by contacting your financial institution and requesting its Transit Routing/ABA number. 3. Enter the account number to which the EFT transactions are to be accredited. If less than 17 characters are needed, begin at the left margin and leave any unused spaces blank. Mark an X for the type of account to which funds are to be deposited. *** ***If you elect to deposit in a checking account, please attach one of your checks with the signature space marked void. Forward the signed authorization form with voided check (if applicable) to: Nationwide Health Plans Provider Maintenance Dept. CO Park Center Circle Dublin, OH (fax) If you have any questions, contact the Provider Maintenance department at opt.7 or or us at NHPPROSR@Nationwide.Com.
4 AUTHORIZATION AGREEMENT Electronic EOP and/or Automatic Deposit of Payments To sign up for the EOP/EFT, read page 1 of this form and TYPE or PRINT the information requested in Sections 1 and 2. Then sign, date, and return it to the NHP Provider Maintenance department. Any account changes must be reported to the NHP Provider Maintenance department thirty (30) days prior to actual change. Payee must keep the NHP Provider Maintenance department informed of any address changes in order to receive important information about benefits. SECTION 1 1. Type of Transaction: Add Change Delete EOP EFT 2. Name of Company or Individual Telephone City State Zip Code Are there multiple addressees for this tax id? Circle o ne: Y or N 3. Circle one: Direct or via WebMD Federal Tax Id or Social Security # Receiver Id: 4. Type Name of Chief Executive Officer (If Individual Application Leave Blank) SECTION 2 5. Financial Institution Name County Telephone City State Zip Code 6. Transit Routing/ABA Number Checking Savings Type of Account 7. Account Number (at above institution) Whereby authorize Nationwide Health Plans to send an Electronic Explanation of Payment (EOP) to us direct or via Emdeon. Whereby authorize Nationwide Health Plans to initiate credit entries to our account in the financial institution identified above and also debit entries, if necessary, for any credit entries that are determined to be in error. We additionally authorize the financial institution to credit or debit the same to our account. This authorization is to remain in effect until revoked by us in writing to Nationwide Health Plans Provider Maintenance department. Applicant Signature Type Name Date
5 Emdeon ERA Provider Setup Form Fax: (615) Provider Organization Practice/ Facility Name Tax ID City/State Zip Code First Name Last Name Telephone 2 Vendor (Emdeon contracted & certified customer used to retrieve ERA files) NPI Fax Vendor Name Office Ally, LLC Submitter ID First Name Eve 3 ERA Receiver Last Name Du Bry support@officeally.com Telephone Fax Receiver ID Who will be receiving the ERA? Vendor Distribution Method (Check only one) Emdeon Office Mail to: NDM S Node Name: FTP Internet Log In ID: offalley FTP Dial-up TSO ID: GTEDS or ITS TSO ID: Do you want your ERA file split? Yes No How? Select from List Format requested A ( ) Specify 4 Payer (If additional rows are required for payer ID selection, complete additional ERA Provider Setup Forms.) Payer ID Group ID Individual Provider ID Payer ID Group ID Individual Provider ID Confirmations Send Emdeon ERA Setup Confirmations To: Vendor - Secton 2 Send Additional ERA Setup Confirmations To: ERA Provider Setup Form Revised 04/07
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Revision History. Document Version. Date Name Comments /26/2017 Training and Development Initial Creation
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