Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Transcription

1 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 Tax ID Client ID Site ID Address City STATE ZIP Contact Name Address Telephone Fax 2 Vendor (Change Healthcare certified vendor used to submit files to Change Healthcare) Vendor Name Vendor Submitter ID Contact Name Address 3 Payer Payer ID Group ID Individual Provider ID NPI ID 4 Confirmations Send Change Healthcare Claim Confirmations To: Special Instructions: All Payer Registration forms must contain signatures when applicable, stamped signatures or photo copies are accepted. SUBMIT COMPLETED FORM TO: Fax: (615) batchenrollment@changehealthcare.com PROVIDERS MUST BE SENDING ELECTRONIC CLAIMS TO RECEIVE ELECTONIC REMITTANCE EFT IS REQUIRED IN ORDER TO RECEIVE ERA CHANGE HEALTHCARE REVISION FORM DATE:

2 NEW INSTRUCTIONS FOR COMPLETING THE EFT/ERA AUTHORIZATION AGREEMENT PART I: PROVIDER INFORMATION Line 1 Enter the provider s/supplier s legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue service (IRS). The account to which EFT payments made must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity to be paid by Optima Health. Line 2 Enter the provider s Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) Note: All Optima Health vendor number(s) associated with this TIN will be enrolled for EFT/ERA. If there are specific vendor numbers you only want to enroll, those should be identified in Line 7. You can contact your Provider Relations Representative or Network Educator for a complete list of your vendors. Line 3 Enter the provider s National Provider Identifier (NPI) Note: This is a unique ten-digit identification number required by HIPAA for all health care providers in the United States. Providers must use their NPI to identify themselves in all HIPAA transactions. Line 4 Enter the name of a contact person who can answer questions about information submitted on Electronic Payment/Remittance Authorization Agreement form. Line 5 Enter the contact person s telephone number. Line 6 Enter the address of the person the provider would like notifications of deposit sent to. Line 7 Enter the Optima Health vendor number(s) this enrollment is being submitted for. Note: This field MUST be completed for enrollment to be processed. Please refer to notation under Line 2. PART II: FINANCIAL INSTITUTION INFORMATION Line 8 Enter your Financial Institution s name (this is the name of the bank or qualifying depository that will receive the funds). Note: The account name to which EFT payments will be paid is to the name submitted on Part I of this form. Line 9 Enter the bank or financial institutiona s nine-digit routing number, including applicable leading zeros. 1 Optima CORE Version June 2012

3 NEW Line 10 Select the account type Line 11 Enter the depositor s account number, including applicable leading zeros. Line 12 Enter the provider s Federal Tax Identification Number (TIN). This will be used to link the EFT and ERA files for the provider s reconciliations. PART III:ELECTRONIC REMITTANCE ADVICE INFORMATION Line 13 Same as Line 12 Line 14 Select Print from if you wish to print your remits for manual posting. Note: You MUST include your or login id for enrollment to be processed. Line 15 Select Clearinghouse if you have a relationship with a clearinghouse and would like your Optima remits delivered to you by them. Note: Your clearinghouse MUST have a relationship with Optima s clearinghouse of choice, Misys-Payerpath or have a relationship with them through a third party. You should also confirm that you are setup appropriately with your clearinghouse before submitting enrollment to Optima. Line 16 Select Access directly from Optima secure FTP site if you would like to pick up an electronic 835 file directly from Optima. PART IV:ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION Line 17 Enter your clearinghouse name PART V:SUBMISSION INFORMATION Line 18a Select New Enrollment if you currently receive paper checks and remits for any of your Optima vendor numbers and would like to begin receiving these payments and remits electronically. Line 18b Select Change Enrollment if you currently receive EFT/ERA but need to notify Optima of a change to your Financial Institution, Electronic Remittance Advice, or Provider Contact information. 2 Optima CORE Version June 2012

4 NEW Line 18c Select Cancel Enrollment if you would like to stop receiving electronic payments and remits and begin receiving paper checks and remits again. Line 19 Select Voided Check if you will be mailing an original voided check to notify Optima of your banking information. Line 20 Select Bank Letter if you will be submitting (fax or ) a letter from your Financial Institution that contains your bank account and routing number. Line 21a Select Optima Health Plan if you would like to enroll your medical vendors for EFT/ERA Line 21b Select Optima Behavioral Health if you would like to enroll your behavioral health vendors for EFT/ERA. Line 22 By your signature on this form you are certifying that the account is drawn in the Name of the Physician or Individual Practitioner, or the Legal Business Name of the Provider or Supplier. Line 23 Legibly print or type the name of the person submitting the provider s EFT/ERA enrollment. Line 24 Enter the date that you are submitting this enrollment. Line 25 Enter the effective date if a future date is desired PLEASE NOTE: The Provider must contact its financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements needed for reassociation of the payment and the ERA. Please mail or fax completed enrollment form and bank documents to: Optima Health Plan Attn: Cindy Hunt 4456 Corporation Lane, Suite 350 Va. Beach, VA Fax: request for enrollment status to: EFT_ERA_Inquiry@sentara.com 3 Optima CORE Version June 2012

5 Electronic Payment/Remittance Authorization Agreement Detailed instructions on how to complete this form can be found at providers.optimahealth.com/billing/pages/eftera-authorizationagreement.aspx. If you have any questions, please contact Optima Finance at * An asterisk denotes required information PROVIDER INFORMATION * Provider Name PROVIDER IDENTIFIERS INFORMATION * Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) Please include TIN numbers for all practice locations EFT applies to * National Provider Number (NPI) PROVIDER CONTACT INFORMATION * Provider Contact Name * Telephone Number * Address Provider Numbers FINANCIAL INSTITUTION INFORMATION * Financial Institution Name * Financial Institution Routing Number * Type of Account at Financial Institution * Provider s Account Number with Financial Institution Checking Savings * Account Number Linkage to Provider Identifier (e.g., Preference for Aggregation of Remittance Data ) * Provider Tax Identification Number (TIN) ELECTRONIC REMITTANCE ADVICE INFORMATION * Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) * Provider Tax Identification Number (TIN) Optima CORE Version June 2012

6 PLEASE NOTE THAT BY CHOOSING TO RECEIVE YOUR PAYMENTS ELECTRONICALLY, REMITS WILL ALSO BE DELIVERED ELECTRONICALLY AND YOU MUST SELECT ONE OF THE OPTIONS BELOW. PAPER REMITS WILL CEASE. * Method of Retrieval Print from OptimaHealth.com YOU MUST HAVE AN OPTIMAHEALTH.COM USERNAME AND PASSWORD Optimahealth.com Login ID: Optimabehavioralhealth.com Login ID: If you do not have an Optimahealth.com username and password, Providers may submit a Provider Connection Enrollment Form which can be found at Optimahealth.com. ( Clearinghouse Access directly from the Optima secure FTP Site An Optima Health Finance representative will contact you to discuss specific requirements. ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION * Clearinghouse Name Your clearinghouse must have a relationship with the Optima Health clearinghouse of choice: Misys-Payerpath. SUBMISSION INFORMATION * Reason for Submission New Enrollment Change Enrollment Cancel Enrollment Voided Check A voided check is attached to provide confirmation of Identification/Account Numbers. Bank Letter A letter on bank letterhead that formally certifies the account owners routing and accounting numbers is attached. Request Type Optima Health Plan Optima Behavioral With your Signature and Printed Name, you are certifying that the account is drawn in the name of the physician or individual Practitioner or the Legal Business name of the Provider or Agent. The Provider or Agent has sole control of the account to which EFT deposits are made in accordance with all applicable Federal regulations and instructions. All arrangements between the Financial Intuition and the said Provider or Supplier are in accordance with all applicable Federal regulations and instructions with the effective date of the EFT authorization. You must notify Optima Health in writing in regards to any changes in the account in sufficient time to allow the contractor and the Financial Institution to act on the change. The EFT Authorization must be signed by an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. * Written Signature of Person Submitting Enrollment * Printed Name of Person Submitting Enrollment * Submission Date * Requested EFT Start/ Change/Cancel Date * Requested ERA Effective Date Optima CORE Version June 2012