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1 ALSO ENROLL PAYER WHEN ENROLLING PAYER EnrollNow Process- Emdeon ERA enrollment Payer enrollment information for all payers listed below is now processed through a single electronic form. The user needs to provide practice, provider, and contact information and then select all payers from whom they wish to receive ERAs. When completed, they will select the submit button to send this information to Emdeon and we will facilitate the registration process with each selected payer. This Web Form does NOT replace the need for the provider to be set up at Emdeon with the specific payer. The set up process for that step should still be done with the use of the ERA Provider set up form(s) located at through the Emdeon Enrollment Wizard* or your product specific process if not one of the two mentioned above. When filling out this Web Form the Practice Information should be the practice information that is set up with the payer. (The practice information submitted within the web Form should match the Practice Profile information on file with the selected payer). The Contact information is expected to be the Practice /Provider /Facility contact that the payer can use to confirm that the ERAs should be routed to Emdeon. This contact is also where additional communications will be sent regarding any status updates provided to Emdeon from the payer. Below listed payers are currently available through the use of the Enrollnow process
2 PROVIDER ID GROUP LEVEL CONSISITS OF 5 TO 6 ALPHA NUMERIC CHARACTERS THIS FIELD IS REQUIRED!! PROVIDER ID GROUP LEVEL CONSISTS OF 2 TO 4 ALPHA NUMERIC CHARACTERS THIS FIELD IS REQUIRED!!
3
4 1. To enroll please click or go to Once you enter data you will receive a confirmation number and an will be sent to the address entered into the form. A quick link option to add another provider is also made available.
5 Example Original Message----- From: Sent: Friday, July 08, :32 PM To: Subject: PAYER ENROLLMENT FORM - Medical World *** ENROLLMENT INFORMATION *** Receipt No: 4e b8c NPI: Tax id: Business Name: Medical World Address: 123 Anywhere City: Anywhere State: TN Zip: Contact Name: Dr. Joe Phone: none@none.com
6 2. Enter Facility or providers information. NPI & Facility and providers contact name is required. 3. Click on submit 4. When everything is entered you will receive a Thank you and a confirmation number Special Notes: * Emdeon Enrollment Wizard - The Enrollment Wizard is designed as a tool for partners using Emdeon Vision and is currently not available to provider-level users of Emdeon Vision. The Enrollment Wizard is a web-based application that enables you to Enroll new providers to receive Electronic Remittance Advice (ERA) from Emdeon without the need for Provider Set Up Forms and creates payer registration forms that are pre-populated with provider/facility. For more information about this tool, please contact your Emdeon Account Manager. * Enrollment for Cigna-Great West requires each individual Provider to be enrolled for ERA. Please complete the enrollment form for each Provider within the Practice. * Enrollment for Connecticare Requires a Connecticare provider id. No requests added for Connecticare without this id will be processed by Emdeon or Connecticare. Thank You Emdeon Enrollment Department
7 !!! IMPORTANT ERA ENROLLMENT INFORMATION REGARDING OPTUM PAYERS!!! OPTUM PAYERS Americhoice APIPA Americhoice of MD Americhoice of NE - UFNEP Americhoice of NJ - NYU01 Americhoice of TX - TEX01 Americhoice of WI - WID01 AARP Care Improvement Plus GEHA MAMSI Life & Health Medica Oxford Health Plan Pacificare of CA Spectera Three Rivers Admin ERA UHC Great Lakes UMR Wausau/UHIS Unison Health Plan United Healthcare UHC Community Plan/KS (KanCare) UHC of River Valley John Deere UnitedHealthOne All Optum payers listed above do not send approval notices. The enrollments are automatically approved once the first ERA has been received. In order for the first ERA to generate, you MUST be actively submitting claims to these payers. If you previously received ERAs from Optum payers via another clearinghouse, and automated notification will be sent to the on file at Optum. This Change of Vendor request must be approved within 5 days of receiving the . You MUST respond to the to verify the change of clearinghouse to Change Healthcare. If you do not respond to this your setup will not be completed on the payers end and you will not receive ERAs for the Optum payers. Please ensure that the that Optum has on file for you is correct, or you may not receive the Change of Vendor notification. If you know that you are currently getting your Optum payer s ERAs through another clearinghouse, and do not receive the ed COV Notification, then you can complete a COV letter for Optum found at this link:
8 This letter MUST be on the letterhead for Practice/Provider requesting this change! CHANGE OF VENDOR LETTER Date Optum (ENS) Attn: Enrollment Department ERA Setup Fax: Company Name: Street Address: City/State: Zip Code: Tin/NPI: Contact Name: Contact Contact Phone Number: Please select from the below payer ID s only. Americhoice APIPA Americhoice of MD Americhoice of NE - UFNEP Americhoice of NJ - NYU01 Americhoice of TX - TEX01 Americhoice of WI - WID01 AARP Care Improvement Plus GEHA MAMSI Life & Health Medica Oxford Health Plan Pacificare of CA Spectera Three Rivers Admin ERA UHC Great Lakes UMR Wausau/UHIS Unison Health Plan
9 United Healthcare UHC Community Plan/KS (KanCare) UHC of River Valley John Deere UnitedHealth One Currently, I am receiving my Electronic Remittance Advice through I would like to start receiving my Electronic Remittance Advice through Change Healthcare Corporation using Electronic Network Systems, Inc. This change request will also include ALL PROVIDERS associated with this tax ID. Written Signature of Person Submitting Form Printed Name of Person Submitting Form of Person Submitting Form Have the provider send the change to: enrollments@optum.com or fax PLEASE NOTE: Once notification is received stating the change of vendor letter has been processed. You must re-enter your request in the Enrollnow portal.
PAYER ENROLLMENT INSTRUCTIONS FOR
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AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS
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Authorization 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
Feel 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
220 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
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220 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
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220 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
220 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
UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629
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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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220 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
220 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
Change 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
220 Burnham Street South Windsor, CT Vox Fax
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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
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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
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220 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
Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account
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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
220 Burnham Street South Windsor, CT Vox Fax
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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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AETNA BETTER HEALTH OF ILLINOIS 333 W. Wacker Drive Suite 2100, MC F646 Chicago, IL Fax
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Blue 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
Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
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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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1304 Vermillion Street Hastings, MN Ph Fax
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