MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027
|
|
- Reginald Todd
- 5 years ago
- Views:
Transcription
1 MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS HOW LONG DOES PRE-ENROLLMENT TAKE? Please allow 3 weeks for processing. HOW DO I ENROLL / WHAT FORM(S) SHOULD I DO? Option 1: Enroll Online via the Portal: Option 2: Complete the paper Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement. The form can be found on page 6 of this packet. For instructions on how to enroll online or on paper see the ERA Enrollment Guide (page 2-5 of this packet). WHERE SHOULD I SEND THE FORMS? Mail original form to: Regular Mail: Overnight/Express Delivery: PO Box Executive Center Circle West, Suite 100 Tallahassee, FL Tallahassee, FL HOW DO I CHECK STATUS? If after 3 weeks you do not receive ERA files, contact the EDI Operations Team at (866) to inquire. Office Ally P.O. Box Vancouver, WA Phone: Fax:
2 X Electronic Remittance Advice (ERA) Enrollment Guide AFFORDABLE CARE ACT CHANGES TO X ENROLLMENT NOVEMBER 19, 2013 To comply with changes mandated by the Affordable Care Act, enrollment to receive X files is now available in the Secure Web Portal via the Electronic Remittance Advice (ERA) Enrollment panel. ERA enrollment can also be completed using the Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement. Requirements for ERA Enrollment Note: Providers already enrolled to receive X electronic files DO NOT need to re-enroll. Providers wishing to enroll must be fully-enrolled providers with an active or pending Electronic Funds Transfer (EFT) agreement on file. Only users with the MEUPS user type of Provider can complete ERA enrollment. Additionally, Section 1104 of the Affordable Care Act requires health plans to offer an EFT/ERA re-association number that allows providers to link an ERA to a specific EFT payment. It is optional for providers to receive the EFT/ERA re-association number. Providers interested in utilizing the benefits of the EFT/ERA re-association number should contact their financial institution to arrange for the delivery of the required data elements. For More Information Center for Medicaid Services For more information regarding policies related to ERA, visit the CMS website at -and-guidance/hipaa- Administrative- Simplification/Affordable-Care- Act/OperatingRulesandStandards foreftandremittanceadviceera. html HP Enterprise Services For assistance with completing the ERA Enrollment form, contact Provider Enrollment at the HP Provider Services Contact Center: , Option 4. Once ERA enrollment is complete, the provider can add agents to their MEUPS account and give those agents permission to download X files on their behalf. For directions on how to add or modify agent permissions on a provider account for ERA Enrollment, see Section 3 of the Web Portal User Guide on the Provider Handbooks page of the public Web Portal.
3 ERA Enrollment Guide 2 Completing Online ERA Enrollment To complete enrollment, log into MEUPS and navigate to Demographic Maintenance ERA Enrollment. To complete the form, click the check box next to Authorized Signature, then click the save button at the bottom right of the panel. Note: The header information in the ERA Enrollment panel is pre-filled using current information from the provider account. The Requested ERA Effective Date field defaults to the current date. The enrollment form cannot be dated for a past or future date. Once enrollment is complete, or if the provider account is already enrolled, the panel appears with the check box marked.
4 ERA Enrollment Guide 3 Completing the Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement To access the paper ERA Authorization Agreement, navigate to the Florida Medicaid public Web Portal and select EDI Registration Forms. Note: The form must be typed or printed legibly using blue or black ink. Fields marked with an asterisk (*) are required. Fields marked with a carat (^) are required if the information is available.
5 ERA Enrollment Guide 4 The below chart contains detailed information about each field: Field Name Provider Information Field Information Complete legal name and street address of institution, corporate entity, practice, or individual provider (required). Enter D/B/A name, if applicable (optional). Provider Identifiers: TIN/EIN/NPI Other Identifiers: Florida Medicaid Provider Identification Number, Trading Partner ID Provider Contact Information Electronic Remittance Advice Information Electronic Remittance Advice Clearinghouse Information Submission Information Enter Federal Tax-Identification Number or Employer Identification Number (required) and National Provider Identifier (required if available). Enter Florida Medicaid Provider Identification Number (required) and Trading Partner ID (required if available). Enter provider name, telephone number, address, and fax number for the person who should be contacted regarding ERA issues. Only the name and telephone number are required. An address is required if available. Select preference (TIN or NPI) for aggregation of remittance data. Note: Selection MUST match preference submitted on EFT enrollment. Enter clearinghouse name, telephone number, and address (required if available). Form must include the authorized signature and printed name and title of the person submitting the enrollment. The form should be dated when signed. For fastest processing, fax the completed form to (866) The form can also be mailed to one of the following addresses: For regular mail: P.O. Box 7070 Tallahassee, FL For overnight or express delivery: 2671 Executive Center Circle West, Suite 100 Tallahassee, FL For more information on X Transactions, please contact the HP Electronic Data Interchange (EDI) Department at
6 For Fiscal Agent Use: Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement Provider Information* Provider Name* Doing Business As Name (D/B/A) Provider Address Street * (Street Name and Number NOT a P.O. Box) Provider Address (Suite, Room, etc.) City* State* ZIP* Provider Identifiers Information* Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)* National Provider Identifier (NPI)^ Other Identifiers* Assigning Authority Florida Medicaid Provider Identification Number* Trading Partner ID^ Provider Contact Information for ERA Issues* Provider Contact Name* Telephone Number* Address^ Fax Number Electronic Remittance Advice Information* Preference for Aggregation of Remittance Data* (Must match preference submitted on EFT) Provider Tax Identification Number (TIN) National Provider Identifier (NPI) NOTE: This information is being collected in the event Florida Medicaid changes ERA aggregation (which is currently done by Medicaid Provider Identification Number). Electronic Remittance Advice Clearinghouse Information^ Clearinghouse Name Telephone Number Address Submission Information* Authorized Signature* Printed Name of Person Submitting Enrollment* Printed Title of Person Submitting Enrollment* Submission Date* Instructions for completing the ERA Authorization Agreement The online registration form may be accessed via the secure web portal ( under the Provider Demographic heading. Please type or print legibly in black or blue ink. Fields marked with an asterisk (*) are required. Fields marked with a carat (^) are required if the information is available. Please allow 3 weeks for processing. If after 3 weeks you do not receive ERA files, contact the EDI Operations team at (866) to inquire. AHCA Form (November 2013) Page 1 of 1
MEDICAID PENNSYLVANIA ERA ENROLLMENT INSTRUCTIONS - MCDPA
MEDICAID PENNSYLVANIA ERA ENROLLMENT INSTRUCTIONS - MCDPA HOW LONG DOES PRE-ENROLLMENT TAKE? Please allow four (4) weeks for the enrollment application process. If after five (5) weeks you do not start
More informationAuthorization Agreement
Authorization Agreement For Electronic Health Care Claim Payment / Advice 835 Thank you for your interest in the Electronic Health Care Claim Payment/Advice (835), also known as Electronic Remittance Advice
More informationHEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS
HEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Electronic Remittance Advice (ERA) Authorization Agreement Electronic Funds Transfer (EFT) Authorization Agreement WHERE SHOULD
More informationInstructions for Completing the Paper Electronic Remittance Advice (ERA) Enrollment Application
Instructions for Completing the Paper Electronic Remittance Advice (ERA) Enrollment Application General Instructions for completing the Paper ERA Enrollment Application: Please type or print legibly Complete
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationTRICARE West Region Electronic Data Interchange PO Box Augusta, GA Fax:
Dear Provider: Thank you for your interest in Electronic Remittance Advice (ERA) with PGBA, LLC. Please take a moment to review the enrollment guidelines (Appendix A). Once you have reviewed the guidelines,
More informationFeel free to scan and return the attached paperwork to or fax to HealthComp at (559) IMPORTANT:
Thank you for your interest in EFT/ERA. Attached you will find the forms to register for EFT and ERA with HealthComp. Please Note: You must fully complete all three of the included forms or your enrollment
More informationTRICARE PGBA, LLC Electronic Data Interchange PO Box Augusta, GA Fax: Phone , Option #2
TRICARE PGBA, LLC Fax: 803-264-9864 Phone 1-800-325-5920, Option #2 Dear Provider: Thank you for your interest in Electronic Remittance Advice (ERA) with PGBA, LLC. We also offer Electronic Funds Transfer
More information220 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
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
THE 2018 HNFS ENROLLMENT IS ALSO REQUIRED WHEN FILLING THIS OUT PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationBLUE CROSS BLUE SHIELD LOUISIANA (53120) ERA ENROLLMENT INSTRUCTIONS
BLUE CROSS BLUE SHIELD LOUISIANA (53120) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Electronic Remittance Advice (ERA) Enrollment Form WHERE SHOULD I SEND THE FORM(S)? Email to: edich@bcbsla.com;
More informationBCBS LOUISIANA PRE-ENROLLMENT INSTRUCTIONS 53120
BCBS LOUISIANA PRE-ENROLLMENT INSTRUCTIONS 53120 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard Processing time is 3 business days WHAT FORM(S) DO I COMPLETE? BCBS LA EDI Transaction Addendum Business Associate
More informationBCBS LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS
BCBS LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? BCBS LA Business Associate Profile Electronic Remittance Advice (ERA) Enrollment form If you would like to receive ERAs through
More informationMASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM
MASSACHUSETTS BCBS SB700 SUBMITTER ID - U076 12B14 SUBMITTER ID 00444PVRM https://provider.bluecrossma.com/providerhome/portal/home/forms/forms/era Instructions for Completing BCBSMA Electronic Remittance
More informationEDI-ERA Provider Agreement and Enrollment Form (Page 1 of 5)
(Page 1 of 5) Please complete the following Mississippi Medicaid EDI ERA Provider Agreement and Enrollment Form. Please print or type. Complete all areas of the form, unless otherwise indicated. Once the
More information220 Burnham Street South Windsor, CT Vox Fax
LOUISIANA BLUE CROSS BLUE SHIELD DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 23739 SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ REASSOCIATION SEND
More information1304 Vermillion Street Hastings, MN Ph Fax
Page 1 of 1 2/24/2014 NEW MEXICO MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBERS CKNM1 ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ Reassociation SEND REGISTRATION
More information220 Burnham Street South Windsor, CT Vox Fax
WASHINGTON BLUE CROSS BLUE SHIELD (PREMERA) DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 47570 ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ REASSOCIATION SEND
More informationEDI Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Online Enrollment Instructions
Welcome to the instructions for online enrollment for your EFA and EFT. Please follow the instructions below to improve your experience in enrolling and receiving your electronic transactions. If at any
More informationERA Enrollment Form Enrolling Through emomed
ERA Enrollment Rule 382 requires an electronic option for providers and trading partners to complete and submit the ERA enrollment effective January 1, 2014. An online ERA enrollment link from the emomed
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More informationMISSISSIPPI MEDICAID ERA CONTRACT INSTRUCTIONS (SKMS0)
MISSISSIPPI MEDICAID ERA CONTRACT INSTRUCTIONS (SKMS0) An original signature is required. Please MAIL all pages of your completed and signed forms to: ABILITY ATTN: Enrollment One MetroCenter 4010 W. Boy
More informationGuide to Completing the Electronic Remittance Advice (ERA) Enrollment Form
Guide to Completing the Electronic Remittance Advice (ERA) Enrollment Form The ERA service enables Blue Cross and Blue Shield of Louisiana to provide you with an electronic remittance advice, which is
More information220 Burnham Street South Windsor, CT Vox Fax
NEW HAMPSHIRE MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES CKNH1 ERAs can only be sent to one Trading Partner, if a provider has previously requested
More information220 Burnham Street South Windsor, CT Vox Fax
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
More informationData Type and Format (Not all data elements require a format specification)
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
More informationMASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0)
MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0) Submit the completed Contract Setup Form to: ABILITY Network, ATTN: Enrollment FAX: 888.837.2232 EMAIL: setup@abilitynetwork.com INSTRUCTIONS Print
More information220 Burnham Street South Windsor, CT Vox Fax
MISSISSIPPI MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Dual Delivery of v5010 X12 835 and Proprietary
More informationELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments
ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments Alameda Alliance for Health is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers who enroll in EFT will have Fee-For-Service
More information2777 Stemmons Frwy, Suite 1450 Dallas, TX Fax
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More information220 Burnham Street South Windsor, CT Vox Fax
220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 KANSAS MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER CKKS1 SPECIAL NOTES 1. Upon
More informationPAYER ENROLLMENT INSTRUCTIONS FOR
PAYER ENROLLMENT INSTRUCTIONS FOR Before enrolling please be sure your Revenue Performance Advisor contract includes the transactions you will be using. If you are unsure of the transactions you are contracted
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More information4350 E. Cotton Center Boulevard Building D Phoenix, AZ / Fax
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationAETNA BETTER HEALTH OF ILLINOIS 333 W. Wacker Drive Suite 2100, MC F646 Chicago, IL Fax
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More informationAETNA BETTER HEALTH OF OHIO 7400 W. Campus Rd. New Albany, OH Fax
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More information220 Burnham Street South Windsor, CT Vox Fax
DELTA DENTAL OF ILLINOIS GROUP PLANS DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 05030 SPECIAL NOTES Participation with Direct Deposit (EFT) is required for receipt
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationPage 1 of 10 Questions? Call (844) or for assistance
Manual Form The Provider EFT/ERA service makes it easier for Providers to receive payments and remittance from Payers by eliminating paper checks and EOB s, and depositing funds into your financial institution
More informationInstructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More informationAETNA BETTER HEALTH OF LOUISIANA 2400 Veterans Memorial Blvd., Suite 200 Kenner, LA Fax
Instructions for Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Remittance Advice (ERA) Authorization Agreement Form.
More informationCAQH Solutions TM EnrollHub TM Provider User Guide Chapter 3 - Create & Manage Enrollments. Table of Contents
CAQH Solutions TM EnrollHub TM Provider User Guide Chapter 3 - Create & Manage Enrollments Table of Contents 3 CREATE & MANAGE EFT ENROLLMENTS 2 3.1 OVERVIEW OF THE EFT ENROLLMENT PROCESS 3 3.2 ADD PROVIDER
More information220 Burnham Street South Windsor, CT Vox Fax
220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 DELTA DENTAL OF ILLINOIS GROUP PLANS DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 05030
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More information220 Burnham Street South Windsor, CT Vox Fax
220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 DELTA DENTAL OF WISCONSIN DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER 39069 SPECIAL NOTES
More informationUCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629
UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629 HOW DO I ENROLL TO RECEIVE 835s/ERAs? STEP 1: Complete the Availity Multi Payer ERA Enrollment Form. (Standard processing time is 1 week) Fax the form to
More informationCORE-required Maximum EFT Enrollment Data Set
CORE-required Maximum EFT Data Set The following table is taken directly from CORE Operating Rule 380 and identifies all details related to the fields contained within this document. Individual Data Element
More informationAETNA BETTER HEALTH AETNA BETTER HEALTH KIDS 2000 Market Street, Suite 850 Philadelphia, PA Fax
Instructions for Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation Page 1 Please use this guide to prepare/complete your Electronic Funds Transfer (EFT) Authorization Agreement Form. Missing,
More informationPAYER ID NUMBER SPECIAL NOTES. ELECTRONIC REGISTRATIONS Agreements Required SEND ENROLLMENT FORMS TO: ENROLLMENT CONFIRMATION
Page 1 of 1 4/17/2014 400 Vermillion Street Hastings, MN 55033 Ph 800-482-3518 Fax 651-389-9152 www.edsedi.com COLORADO MEDICAID EDI UPDATE DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER
More information220 Burnham Street South Windsor, CT Vox Fax OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
OREGON MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER CKOR1 SPECIAL NOTES Change Healthcare Dental signature is required. EDI packets must be mailed to Change Healthcare Dental
More informationWelcome to ProviderNet. ProviderNet Molina Registration Instructions Revised: January 2015
Welcome to ProviderNet ProviderNet Molina Registration Instructions Revised: January 2015 1 Introduction Alegeus Technologies is pleased to provide the following registration instructions for the ProviderNet
More informationH835/U277 Request for Electronic Remittance Advice (ERA) (8/21/2013 revision)
H835/U277 Request for Electronic Remittance Advice (ERA) (8/21/2013 revision) Instructions: The purpose of this form is to comply with the Phase III CORE 382 ERA Enrollment Data Rule version 3.0.0 June
More informationMEDICARE FLORIDA PRE ENROLLMENT INSTRUCTIONS MR025
MEDICARE FLORIDA PRE ENROLLMENT INSTRUCTIONS MR025 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 3 4 weeks. WHAT FORM(S) SHOULD I COMPLETE? If you do not currently submit electronically
More informationGroup Provider Enrollment Tutorial. Revised 4/5/18
Group Provider Enrollment Tutorial Revised 4/5/18 1 Group Provider Enrollment Documents you will need: Copy of Confirmation Letter or email from the National Plan and Provider Enumeration System (NPPES)
More informationMEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Maryland Medical Care Programs Submitter Identification Form Trading Partner Agreement o Both Forms must have original
More informationMEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD
MEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification
More informationAETNA BETTER HEALTH OF NEW YORK
Instructions for Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation Page 1 Please use is guide to prepare/complete your Electronic Funds Transfer (EFT) Auorization Agreement Form. Missing,
More informationChange Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name
More informationMEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD
MEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification
More informationVALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP
VALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 week. WHAT FORMS DO I NEED TO COMPLETE? You must complete the 2 forms listed below: o Online
More informationBCBS NJ DENTAL PRE ENROLLMENT INSTRUCTIONS 22099
BCBS NJ DENTAL PRE ENROLLMENT INSTRUCTIONS 22099 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing is 30 45 business days. WHERE SHOULD I SEND THE FORMS? The forms need to be sent to Office Ally.
More informationLouisiana Medicaid Management Information System (LMMIS)
Louisiana Medicaid Management Information System (LMMIS) EFT Authorization Application User Guide Date Created: 1/23/2014 Date Revised: 8/03/2018 Prepared By Technical Communications Group Molina Medicaid
More informationMEDICARE IDAHO PRE ENROLLMENT INSTRUCTIONS MR003
MEDICARE IDAHO PRE ENROLLMENT INSTRUCTIONS MR003 HOW LONG DOES PRE ENROLLMENT TAKE? Standard Processing time is 3 4 weeks WHERE SHOULD I SEND THE FORMS? Fax the form to Office Ally at 360 896 2151, or;
More informationElectronic Transaction Registration Packet
Electronic Transaction Registration Packet Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota are Independent Licensees of the Blue Cross and Blue Shield
More informationMEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID DISTRICT OF COLUMBIA (77033) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Xerox EDI Provider Enrollment Form WHERE SHOULD I SEND THE FORM(S)? ; or Mail form to: WHAT IS THE TURNAROUND
More informationMEDICARE PART B HAWAII PRE ENROLLMENT INSTRUCTIONS MR057
MEDICARE PART B HAWAII PRE ENROLLMENT INSTRUCTIONS MR057 TO COMPLETE THIS FORM YOU WILL NEED: Medicare Hawaii Provider Number (PTAN) Billing NPI on file with Palmetto for the Hawaii PTAN Name and Address
More informationJoint Venture Hospital Laboratories
Joint Venture Hospital Laboratories Version 1.4 March 2018 Page 1 of 6 By default the JVHL typically sends ERA (835) files to the submitter that sent the claim. For instance if you utilize different clearinghouses
More informationRevision History. Document Version. Date Name Comments /26/2017 Training and Development Initial Creation
Pharmaceutical Assistance Contract for the Elderly (PACE)/ Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET)Web Provider Enrollment/Provider Management Corporate User
More informationLouisiana Medicaid Management Information System (LMMIS)
Louisiana Medicaid Management Information System (LMMIS) Electronic 835 Remittance Advice (ERA) Authorization Agreement Application User Manual Date Created: 08/06/2018 Date Modified: 12/03/2018 Prepared
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More information1. Go to https://providernet.adminisource.com. 2. Click the Register button. 3. Accept the Terms and Conditions
Page 1 of 12 Change Healthcare ProviderNet Registration 1. Go to https://providernet.adminisource.com 2. Click the Register button 3. Accept the Terms and Conditions Page 2 of 12 4. Enter provider verification
More informationJURISDICTION K NEW YORK MEDICARE CONTRACT INSTRUCTIONS (SMNY0 SMNY1 SMNY2)
CONTRACT Please read the following NGS Medicare instructions carefully in order to properly complete the enrollment forms. Incorrect or incomplete provider or submitter information will cause delays in
More informationBLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801
BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801 HOW LONG DOES PRE ENROLLMENT TAKE? 3 to 5 business days WHERE SHOULD I SEND THE FORMS? Fax the form to 785 290 0720 WHAT
More informationMISSISSIPPI MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
220 Burnham Street South Windsor CT 06074 Vox 888-255-7293 Fax 860-289-0055 MISSISSIPPI MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER CKMS1 ELECTRONIC REGISTRATIONS Agreements
More informationNATIONWIDE HEALTH PLANS ERA
3/21/2007 Cover Page 1 PAYER ID: 31417 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
More informationMEDICARE Texas (TRAILBLAZERS) PRE-ENROLLMENT INSTRUCTIONS 00900
MEDICARE Texas (TRAILBLAZERS) PRE-ENROLLMENT INSTRUCTIONS 00900 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 5 business days after receipt. WHAT FORM(S) SHOULD I COMPLETE? EDI Provider
More informationTEXAS MEDICARE (TRAILBLAZERS) CHANGE FORM MR085
TEXAS MEDICARE (TRAILBLAZERS) CHANGE FORM MR085 HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 20 days WHAT PROVIDER NUMBERS DO I USE? Six digit Medicare legacy provider ID NPI Number WHAT
More informationMississippi Medicaid. Mississippi Medicaid Program Provider Enrollment P.O. Box Jackson, Mississippi Complete form and mail original to:
Mississippi Medicaid Complete form and mail original to: Blank forms may by copied. Call LTC at 888-941-8967 if you have questions. Please complete the following Mississippi Medicaid Provider EDI Enrollment
More informationAvaility TM Electronic Remittance Advice
Availity TM Electronic Remittance Advice Electronic Remittance Advice (ERA) or ANSI 835 is a HIPAA-compliant method of receiving claim payment and remittance details from Blue Cross and Blue Shield of
More informationValue Options. Submit the completed Payer Request Form to: INSTRUCTIONS
Value Options Submit the completed Payer Request Form to: ABILITY Network, ATTN: Enrollment EMAIL: setup@abilitynetwork.com INSTRUCTIONS Complete all sections of the form if - You are a billing service
More informationRailroad Medicare Electronic Data Interchange Application
Electronic Data Interchange Application Action Requested: Add New EDI Provider(s) Change/Update Submitter Information Apply for New Submitter ID Apply for New Receiver ID Delete Date: Submitter ID: ERN
More informationOverview. IHCP Provider Name and Address Maintenance. indianamedicaid.com
Overview Form indianamedicaid.com Enrolled providers use this form to update the name and address information that is part of their Provider Profile. Four name/address types are maintained for each provider
More informationProvider Billing Agent/Clearinghouse EDI, Inc Authorization Form
Provider Billing Agent/Clearinghouse EDI, Inc Authorization Form Section A. Provider Information. Business Name Provider Name (Last, First, MI and Suffix) Provider Number Federal Tax ID Number Business
More informationAMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS
AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Emdeon ERA Provider Information Form Emdeon ERA Provider Setup Form Optum ERA Setup Form WHERE SHOULD I SEND THE FORM(S)?
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More informationJURISDICTION 11 EDI CONTRACT INSTRUCTIONS
JURISDICTION 11 EDI CONTRACT INSTRUCTIONS Submit the completed form to: ABILITY Network, ATTN: Enrollment FAX: 888.837.2232 EMAIL: setup@abilitynetwork.com INSTRUCTIONS Refer to these instructions as you
More informationTrading Partner Account (TPA) Registration and Maintenance User Guide. for. State of Idaho MMIS
Trading Partner Account (TPA) Registration and Maintenance User Guide for State of Idaho MMIS Date of Publication: 3/8/2018 Document Number: RF019 Version: 5.0 This document and information contains proprietary
More informationSimplify Office Administrative Tasks
Quick Reference Guide Simplify Office Administrative Tasks Keep this Quick Reference Guide nearby to simplify pre-visit planning and post-visit tasks. Website: Patient care forms Pre-auth needed tool Superior
More informationEDI ENROLLMENT AGREEMENT INSTRUCTIONS
EDI ENROLLMENT AGREEMENT INSTRUCTIONS The Railroad EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed
More informationBlue Cross Blue Shield of Louisiana
Blue Cross Blue Shield of Louisiana Health Care Claim Payment/Advice (835) Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X221A1 October 1, 2013 Version 1.0
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More informationEFT/ERA FORMS IF YOU HAVE ANY QUESTIONS OR CONCERNS PLEASE CALL:
EFT/ERA FORMS IF YOU HAVE ANY QUESTIONS OR CONCERNS PLEASE CALL: 1-888-633-4055 1 EFT FORM WALK THROUGH The next slides will go over the EFT form Slides (3-9) 2 EFT FORM DO NOT PRINT AND SEND IN THE WEB
More informationBlue Shield of California and Care1st are independent licensees of the Blue Shield Association.
May 22, 2018 Dear Provider, As a courtesy, we would like to remind you that effective January 1, 2018, Care1st is no longer providing remittance advices (RAs) on paper for services provided to Care1st
More informationElectronic Payments & Statements (EPS) Frequently Asked Questions (FAQs)
Electronic Payments & Statements (EPS) Frequently Asked Questions (FAQs) As of August 25, 2014, your PAF reimbursements can be made by direct deposit. How do I enroll for direct deposit? You can enroll
More informationELECTRONIC FUNDS TRANSFER FOR PROVIDER PAYMENTS
ELECTRONIC FUNDS TRANSFER FOR PROVIDER PAYMENTS Gold Coast Health Plan along with our contractor, ACS (a Xerox Company), is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers
More informationElectronic Remittance Advice (ERA) EDI Agreement
Electronic Remittance Advice (ERA) EDI Agreement (Form EDI-801) All New Jersey Medicaid and Charity Care Providers desiring to receive a HIPAA formatted electronic remittance advice (ERA) must complete
More information