EFT/ERA FORMS IF YOU HAVE ANY QUESTIONS OR CONCERNS PLEASE CALL:
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1 EFT/ERA FORMS IF YOU HAVE ANY QUESTIONS OR CONCERNS PLEASE CALL:
2 EFT FORM WALK THROUGH The next slides will go over the EFT form Slides (3-9) 2
3 EFT FORM DO NOT PRINT AND SEND IN THE WEB FORM FILL IN THIS FORM ONLINE AND PRINT THE AUTHORIZATION PAGE THAT WILL POPULATE AFTER SUBMITTING. 3
4 1. The Tax Identification Number is the one used for billing 2. If you have more than one Tax ID you will need a separate form for each. 1. In this field you will enter in ALL NPI and UMPI numbers connected with the Tax ID number listed above. a) Click the circle for the type of Identifier being entered. b) Click add after entering in the number, this will add that number to the Id box below. 4
5 This information would be either the name and contact information for the person filling out the form or the person connected with Billing/Contracting 5
6 1. Please fill out all of the banking information in this section. 2. The Account number linkage is the Tax-ID number, NPI or UMPI number that you will be billing under 6
7 1. On this screen you will select New enrollment if you are setting up your EFT because of the changes for If you have made a mistake and need to correct something you can resubmit this form and select Change Enrollment 3. If you have decided you would rather have paper checks you can select the Cancel Enrollment option Please select the type of document you will be submitting 2. In order to complete the process for setting up your EFT you will need to send in a Voided Check or Bank Letter with a signed authorization form which you will get after the next step 7
8 1. In this section the person submitting the enrollment will fill out their information with their title. 1. The Requested EFT Start/Change date will be the date you submit the form 2. You MUST click Submit. After you click submit you will get to print a copy of the authorization page which you will return with the Voided check or bank letter. 8
9 EFT FORM After clicking Submit you will get a copy of the form that needs to be signed and submitted. the documents to: schaclaims@primewest.org Fax the documents to: Mail the documents to: 9
10 ERA FORM WALK THROUGH The next slides will go over the ERA form Slides (11-16) 10
11 ERA FORM THIS FORM MUST BE FILLED OUT ONLINE NO DOCUMENTS WILL NEED TO BE PRINTED AND SENT IN 11
12 1. The Tax Identification Number is the one used for billing 2. If you have more than one Tax ID you will need a separate form for each. 1. In this field you will enter in ALL NPI and UMPI numbers connected with the Tax ID number listed above. a) Click the circle for the type of Identifier being entered. b) Click add after entering in the number, this will add that number to the Id box below. 12
13 This information would be either the name and contact information for the person filling out the form or the person connected with Billing/Contracting This would be the Tax Id entered above on the form. The dropdown box will give you options based on what was entered at the top of the form. 13
14 Please select your Clearinghouse s name from the drop-down menu. New Enrollment if you have not already filled out this form for the 2019 changes. Change enrollment only if you have information to correct 14
15 This information is the person filling out this form. The ERA effective date will be 1/1/2019. Please Click Submit 15
16 ERA ENROLLMENT FORM After clicking submit your form has been processed. We do not need any documents mailed or ed in along with this form. 16
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