220 Burnham Street South Windsor, CT Vox Fax

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1 MISSISSIPPI MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED Dual Delivery of v5010 X and Proprietary Paper Claim Remittance Advices CKMS1 Effective January 1, 2007 paper remittance advice reports are no longer available from Mississippi Medicaid. Participation in Dental Electronic Remittance Advice (ERA) is limited to those providers whose practice management software vendor is participating in ERA with Emdeon or to those providers who have a Dental Provider Services (DPS) account. Please contact your software vendor to verify participation or register for a DPS account at As part of the Affordable Care Act (effective ), health plans are required to dual deliver the electronic (ERA/835) and paper remittance advices for a minimum of 31 calendar days or at least 3 payment cycles. At the conclusion of this time period, delivery of the paper remittance advices may be discontinued. Providers who wish to continue receiving paper remittance advices for a longer period of time may request so by contacting the health plan directly. Upon mutual agreement between the provider and the health plan, the timeframe for delivery of the paper remittance advices may be extended by an agreed-to timeframe. If the provider determines it is unable to satisfactorily implement and process the health plan s electronic v5010 X following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices. CCD+ REASSOCIATION As part of the ERA enrollment process, and to comply with the Affordable Care Act CAQH CORE Rule #370, Emdeon requests you contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements. CCD+ Record # Field # Field Name 5 9 Effective Entry Date 6 6 Amount 7 3 Payment Related Information The data contained in the Minimum CCD+ data elements will allow you to easily associate your EFT and ERA transactions. You may read more about the CAQH CORE Rule 370 at the CAQH website Page 1 of : dlv

2 SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS LATE/MISSING EFT & ERA PROCEDURE Emdeon 220 Burnham Street South Windsor, CT Attn: Provider Or to: Or Fax to: ERA enrollments take approximately 7-10 business days for completion. Once complete, Emdeon will notify the provider or their PMS vendor, as defined by the PMS vendor. If the Provider currently receives ERAs through another Billing Agent other than Emdeon Business Services each Provider must re-enroll following the procedures listed above. EFT: The provider needs to contact the Xerox Call Center at ( ) to submit a Call Reference Number to the Banking department. The Banking department will contact the provider to verify their banking account and reouting numbers. If the account number is correct, the Banking department will advise the provider to contact their finanacial institutions ACH department. If the banking account or routing number isn t correct, the Banking department directs the provider toupdate their banking account information via the Direct Deposit Authorization/Agreement form which is available on the Mississippi Medicaid website at under Provider-.Provider for online submission to be downloaded. Missing ERA: The provider will submit a research request to the Xerox EDI Support Unit ( , option 2 then 4). If possible, the electronic remittance advice will be reposted within 3-5 business days. Late ERA: The provider will submit a research request to the Xerox EDI Support Unit ( , option 2 then 4. If it was found that the files are late posting, then the files will be made available within 24 to 48 hours. DISCONTINUING ERA Discontinuing ERA is a 2 step process. 1. Deactivation a. Providers receiving ERAs via their Practice Management Software need to request deactivation from their software Vendors. Please call your PMS directly. b. Providers receiving their ERAs via an Emdeon DPS account need only ignore the ERA option when Page 2 of : dlv

3 2. logging into the DPS. Payer Un-enrollment a. Each payer has their own unique process to discontinue ERAs and return to paper Remittance Advice. Please follow the below steps for this payer. Pap er remittance advice statements are no longer available from Mississippi Medicaid. Should a provider wish to stop receiving ERAs from Emdeon the provider needs to re-enroll for ERA retrieval through the Mississippi Medicaid web portal or re-enroll electing another entity to retrieve their ERAs from Mississippi Medicaid. CONTACT PHONE NUMBERS Mississippi Medicaid EDI Tech Support Emdeon Dental Provider opt. 2 Page 3 of : dlv

4 Emdeon Dental Provider Form Insurance Carrier: - ERA Payer ID(s) *Provider Name: (Complete legal name of institution, corporate entity, practice or individual provider) Doing Business as Name (DBA): Provider Address: *(Street) * (City) * (State/Province) * (ZIP Code/Postal Code) (Country Code) *Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): *National Provider Identifier (NPI): *Provider Contact Name: Title: *Telephone Number: Telephone Number Extension: * Address: Fax Number: *Preference for Aggregation of Remittance Data: (e.g., Account Number Linkage to Provider Identifier) Provider Tax Identification Number (TIN) Method of Retrieval: Clearinghouse National Provider Identifier (NPI) Clearinghouse Name: Emdeon Dental Vendor Name: *Reason for Submission: New Change Cancel *Authorized Signature: (The signature of an individual authorized by the provider or its agent to initiate, modify or ternate and enrollment. May be used with electronic and paper-based manual enrollment) Printed Name of Person Submitting : Printed Title of Person Submitting : Submission Date: Requested ERA Effective Date: *Required Page 3 of

5 DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION DEFINITIONS Table: CORE-required Maximum ERA Data Set 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 Collection (Required/ for plan to collect) Data Element Group Number (DEG#) PROVIDER INFORMATION (Data Element Group 1 is a Required DEG) Provider Name Complete legal name of institution, corporate entity, practice or individual Alphanumeric Required DEG1 provider Doing Business A legal term used in the United States meaning that the trade name, or Alphanumeric DEG1 As Name (DBA) fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it. Provider Address DEG1 Street The number and street name where a person or organization can be found Alphanumeric Required DEG1 City City associated with provider address field Alphanumeric Required DEG1 State/Province ISO Two Character Code associated with the State/Province/Region Alpha Required DEG1 of the applicable Country. ZIP System of postal-zone codes (zip stands for "zone improvement plan") Alphanumeric, 15 Required DEG1 Code/Postal Code introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities characters Country Code ISO Country Code Alphanumeric, 2 DEG1 characters PROVIDER IDENTIFIERS INFORMATION (Data Element Group 2 is a Required DEG) Provider Identifiers Required DEG2 Provider Contact Name Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions PROVIDER CONTACT INFORMATION (Data Element Group 3 is an DEG) Numeric, 9 digits Required DEG2 Numeric, 10 digits Required when provider has been enumerated with an NPI Contact Name of a contact in provider office for handling ERA issues Required DEG3 Title DEG3 Telephone Associated with contact person Numeric, 10 Required DEG3 Number digits Telephone Number Extension DEG3 Address An electronic mail address at which the health plan might contact the provider Required; not all providers may have an address Fax Number A number at which the provider can be sent facsimiles DEG3 DEG2 DEG3 Page 1 of : dlv

6 Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Method of Retrieval Clearinghouse Name Provider Tax Identification Number (TIN) National Provider Identifier (NPI) ELECTRONIC REMITTANCE ADVICE INFORMATION (Data Element Group 7 is a Required DEG) Provider preference for grouping (bulking) claim payment remittance advice must match preference for EFT payment The method in which the provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.) Required; select from below Numeric, 9 digits required if NPI is not applicable Numeric, 10 digits required if TIN is not applicable (Required if the provider is not using an intermediary clearinghouse or vendor) ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION (Data Element Group 8 is an DEG) Official name of the provider s clearinghouse Required DEG8 ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION (Data Element Group 9 is an DEG) Vendor Name Official name of the provider s vendor Required DEG9 SUBMISSION INFORMATION (Data Element Group 10 is a Required DEG) Reason for Submission Authorized Signature New Change Cancel Electronic Signature of Person Submitting Written Signature of Person Submitting Printed Name of Person Submitting Printed Title of Person Submitting The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. May be used with electronic and paper-based manual enrollment A (usually cursive) rendering of a name unique to a particular person used as confirmation of authorization and identity The printed name of the person signing the form; may be used with electronic and paper-based manual enrollment The printed title of the person signing the form; may be used with electronic and paper-based manual enrollment Required; select from below Required; select from below Submission Date The date on which the enrollment is submitted CCYYMMDD Requested ERA Effective Date Date the provider wishes to begin ERA; per Phase III CORE Health Care Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0: there may be a dual delivery period depending on whether the entity has such an agreement with its trading partner CCYYMMDD DEG7 DEG7 DEG7 DEG7 Page 2 of : dlv

7 EDI Provider Agreement and Form Please return to: Mississippi Medicaid Program Provider P.O. Box Jackson, Mississippi REVISED Provider Information Please print or type. Complete all areas of the Form, unless otherwise indicated. Business Name Name (Last, First, MI and Suffix) Street Address City, State and Zip Code Telephone Fax Provider Number (Required for Individuals) Group Provider Number (Required for Groups) Provider Specialty (Physicians and Dentist Only) EIN (Required for Group) Address Section 13. Electronic Response AND REPORT Retrieval Do you want a paper RA? Yes No (This is not an option if you choose to RECEIVE remits electronically) Are you interested in retrieving your response and/or reports electronically? Yes No If yes, please fill out the appropriate sections below. If no, do fil out anything further. 13a. Data Exchange (WINASAP2000 and Non Standard Transactions) I will retrieve my reports. I authorize my Billing Agent to retrieve reports on my behalf. I authorize my Clearinghouse to retrieve reports on my behalf. Reports Available After Oct 2003 Reject Reports Remittance Advice (as dataset) N/A

8 EDI Provider Agreement and Form Please return to: Mississippi Medicaid Program Provider P.O. Box Jackson, Mississippi REVISED 13b. X12N- Asynchronous Retrieval (available Oct 2003) (Note: You will not be able to receive an X12 response unless you submitted an X12 transaction) I will retrieve my reports. I authorize my Billing Agent to retrieve reports on my behalf. I authorize my Clearinghouse to retrieve reports on my behalf. Reports/Responses Available After Oct Functional Acknowledgement N/A 271- Eligibility Response N/A 277- Claims Status Response N/A 278- Prior Authorization Response N/A 835- Healthcare Claim Payment Advice N/A 824- Error Report N/A 820- Premium Payment N/A After Oct c. Web Portal (available Oct 2003) (Note: You will not be able to receive an X12 response unless you submitted an X12 transaction) I will retrieve my reports from the web. (Only available if transactions were submitted through the web portal- see Section 8) Reports/Responses Available After Oct Functional Acknowledgement N/A 271- Eligibility Response N/A 277- Claims Status Response N/A 278- Prior Authorization Response N/A 835- Healthcare Claim Payment Advice N/A 824- Error Report N/A 820- Premium Payment N/A After Oct 2003 Authorized Signature Printed Name Date This form can be faxed to or mailed to Mississippi Medicaid Program, Provider, P.O. Box 23078, Jackson, MS, 39225