H835/U277 Request for Electronic Remittance Advice (ERA) (8/21/2013 revision)
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1 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 June Read the Kentucky Medicaid 835/U277 Electronic Remittance Advice enrollment form instructions regarding the completion of the new form. Complete each section in its entirety to eliminate delays in processing the ERA 835 enrollment request. The HP/EDI Helpdesk will process each 835 request within the same week of receipt The 835 s and U277 are generated weekly after a Friday payment processing cycle. An 835 form must be completed per provider. 1. Provider Information Enter DBA (doing business as) of the KY Medicaid provider 2. Provider Identifiers Enter the appropriate provider TIN or EIN, NPI and KY Medicaid provider ID 3. KY Medicaid Trading Partner ID Enter the KY Medicaid trading partner ID assigned by the EDI Helpdesk. This ID will be linked to the KY Medicaid provider ID (entered in section 2 of the form) in order to electronically generate the 835 through the financial payment cycle. 4. Provider Contact Information Enter the provider contact with knowledge of the 835 enrollment request. 5. Clearinghouse Information Enter the KY Medicaid trading partner contact information. 6. Submission Information Select the most appropriate reason of the request. 7. Submission Date The date the form was completed 8. Effective Date The date the 835 enrollment should become effective 9. Authorized Signature The responsible party to address any questions from the EDI Helpdesk to assist in the enrollment process. 10. Title of the Responsible party List the job/office title of responsible party completing the form. Contact the EDI Helpdesk regarding the completion of this form, Monday through Friday 7am to 6pm EST or KY_EDI_Helpdesk@hp.com Please submit this form by one of the methods listed below: Clicking the button on the ERA835 form to send via . Saving a copy of the completed ERA form and then: o to: KY_EDI_Helpdesk@hp.com o Fax to: (502) Print a copy of the ERA form and mail to: HP EDI Helpdesk 656 Chamberlin Ave. Frankfort, KY
2 Instructions for creating a Digital ID to be used as an Electronic Signature 1. After clicking in the Electronic Signature field of the ERA835 form, the Sign Document window will appear allowing you to select a pre-existing digital ID or create a new one. 2
3 2. If you already have a digital ID you d like to use, you can select it from the dropdown list and then click the Sign button to complete the Electronic Signature. Otherwise, to create a new digital ID click the Sign As dropdown, scroll to the bottom of the list, and select New ID 3
4 3. Select the second option, A new digital ID I want to create now. Click the Next button. 4
5 4. Select Windows Certificate Store to store your newly created digital ID on the computer. Click the Next button. 5
6 5. Fill in the requested information. The defaults in the last two dropdown items (Key Algorithm and Use digital ID for) are fine. Click the finish button to complete the creation of the new digital ID. 6
7 6. Click the Sign button to use the newly created digital ID. The digital signature (as shown below) will then appear in the Electronic Signature box of the ERA835 form. 7
8 Instructions for sending the ERA835 Form via Webmail 1. After clicking the Submit ERA Form button, the following pop-up will be displayed. If there is no default application being used on the PC (e.g. Outlook, Outlook Express, etc.) then the first option will be grayed out, as shown below. If there is a default application to use, additional instructions can be found at the end of this document pertaining to the use of that method. 2. Click the dropdown and select the desired webmail option from the list or choose Add Other to use one not listed. 8
9 3. This example will use Gmail (other webmail accounts should work similarly). In the Add New Gmail Account pop-up window type the desired Gmail address. 4. Click the Continue button. 9
10 5. The Google Account sign in window is opened 10
11 6. Click Allow Access to allow Adobe Reader access the requested account. 11
12 7. An , with the ERA835 Form as an attachment, will be created in the Drafts folder of your account. 12
13 8. Click on the Drafts folder to open the and send it to the Kentucky Helpdesk. 13
14 Instructions for sending the ERA835 Form via Desktop 1. After clicking the Submit ERA Form button, the following pop-up will be displayed. Select Desktop Application. 14
15 2. A new message is opened with the ERA835 Form as an attachment. Click Send to send it to the Kentucky Helpdesk for processing. 15
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