Louisiana Medicaid Management Information System (LMMIS)
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1 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 By Technical Communications Group
2 Copyright and Disclosure Statement Exercise caution to ensure the use of this information and/or software material complies with the laws, rules, and regulations of the jurisdictions with the respect to which it is used. The information contained herein is subject to change without notice upon LDH approval. Revisions may be issued to advise of such changes and/or additions. All rights reserved. This document may be copied. Date Revised: 12/03/2018 i
3 PROJECT INFORMATION Document Title Louisiana Medicaid Management Information System (LMMIS) Electronic 835 Remittance Advice (ERA) Authorization Agreement Application User Manual Author Technical Communications Group, DXC Technology LMMIS QA Revision History Date Description of Change LIFT By 08/06/2018 Initial draft N/A J. Lavigne 12/03/2018 Updated as per DXC Rebranding LIFT J. Lavigne Date Revised: 12/03/2018 ii
4 TABLE OF CONTENTS 1.0 OVERVIEW ACCESSING THE APPLICATION USING THE APPLICATION General Information Submission Screen Authorization Screen Confirmation Screen/Report Date Revised: 12/03/2018 iii
5 1.0 OVERVIEW The Electronic 835 Remittance Advice (ERA) Authorization Agreement application enables users to update their authorization to retrieve their HIPAA version 5010 electronic remittance advice (835 transaction). Date Revised: 12/03/2018 1
6 2.0 ACCESSING THE APPLICATION This section provides information on how to access the Electronic 835 Remittance Advice (ERA) Authorization Agreement application via Provider Login. It includes instructions on how to establish an online account with Louisiana Medicaid and complete the Login ID and password process. The Louisiana Department of Health (LDH) determines who is an authorized user defining all user access capabilities. Directions for establishing a valid online provider account are available on the Louisiana Medicaid website at The Provider Web Account Registration Instructions link located on the left side of the Louisiana Medicaid main menu contains the instructions for setting up an online account. Date Revised: 12/03/2018 2
7 Providers who are experiencing difficulty in establishing an account or with the application may contact the DXC Technology Technical Support Desk at , Monday Friday 8:00 a.m. 5:00 p.m. CT or request support by ing In order to access the Electronic Remit 835 application, or any other secure application, users must navigate through the Provider Login section of the Louisiana Medicaid web site. Open a web browser and enter the URL for Louisiana Medicaid at Click the Provider Login button to continue. Date Revised: 12/03/2018 3
8 At the Provider Login screen, users may read through the Notice to Users. In order to continue, users must enter their 10-digit National Provider Identifier (NPI) or 7-Digit Medicaid Provider ID in the field provided and enter the characters from the CAPTCHA image before clicking the Next button. Date Revised: 12/03/2018 4
9 At the User Login screen, users must input their Login ID and Password before clicking the Next button to continue. Note: Login ID and Password are case sensitive. Date Revised: 12/03/2018 5
10 Users will be directed to the Provider Applications page where they can access their authorized applications. Date Revised: 12/03/2018 6
11 Click the Electronic Remit 835 link to continue. Note: The list of applications shown here is comprehensive; therefore you may not see as many options on the Provider Applications page. Date Revised: 12/03/2018 7
12 3.0 USING THE APPLICATION New Functionality Please note that with the new redesign, backwards navigation throughout any application can be done by clicking on the breadcrumb trail located on the blue ribbon at the top of any screen. Users also have access to a Print screen button located on the top right hand corner of every screen. The Electronic 835 Remittance Advice (ERA) Authorization Agreement application enables users to update their authorization to retrieve their HIPAA version 5010 electronic remittance advice (835 transaction). Date Revised: 12/03/2018 8
13 3.1 General Information The General Information page provides users with instructions on how to use this application. Users must certify that they are either the Provider or Authorized Representative. Select the appropriate check box and then click Accept and Proceed to continue. Date Revised: 12/03/2018 9
14 3.2 Submission Screen The Submission Screen is prepopulated with the Provider s information. Users must complete the remaining required fields and click the Continue button to advance. 1. Provider Name The Provider name as it exists on DXC Technology s Master File. 2. Provider Federal Tax Identification Number (TIN)/or Employer Identification Number (EIN) The TIN/EIN as it exists on DXC Technology s Master File. 3. National Provider Identifier (NPI) 10-digit NPI Number as it exists on DXC Technology s Master File. 4. Assigning Authority The organization that issues and assigns the additional identifier requested on the form 5. Trading Partner ID 7-digit Louisiana Medicaid Submitter number who is authorized to retrieve your 835s. 6. Provider Contact Name Name of the person who may be contacted for questions/issues regarding the Provider. 7. Provider Contact Telephone Number Contact s telephone number. 8. Provider Contact Address Contact s Address. 9. Account Number Linkage To Provider Identifier The ERA automatically links to the Provider s Tax ID Number. 10. Method of Retrieval Select the method the Submitter will use to retrieve the user s 835s. If using a Clearinghouse, this does not override the existing method of retrieval. 11. Reason for Submission Reason for submitting this request. Date Revised: 12/03/
15 3.3 Authorization Screen The Authorization Screen requires users to provide a digital signature to continue. Users must complete the following required fields: Name of Person Submitting Initials of Person Submitting Title of Person Submitting Click the Submit button to continue. Date Revised: 12/03/
16 3.4 Confirmation Screen/Report The Confirmation of Submission screen provides users confirmation of their completion. Users may click the End button to return to the Provider Applications home page. Users may also view, print, or save a copy of the confirmation in.pdf format by clicking the Confirmation Summary Report button. Date Revised: 12/03/
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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
Page 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
AETNA 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.
AETNA 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.