220 Burnham Street South Windsor, CT Vox Fax

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1 LOUISIANA BLUE CROSS BLUE SHIELD DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER SPECIAL NOTES ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CCD+ REASSOCIATION SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS If a provider does not have a 10 byte (digit) alpha numeric Louisiana Blue Cross Blue Shield provider ID the provider must contact Louisiana Blue Cross Blue Shield to obtain one. Only in state providers may apply for a provider number. 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 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 Emdeon 220 Burnham Street South Windsor, CT Attn: Provider Enrollment Or to: dentalenrollment@emdeon.com Or Fax to: ERA enrollments take approximately 5-7 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. Page 1 of : dlv

2 LATE/MISSING EFT & ERA PROCEDURE ERA (835) files are available weekly in Trading Partner mailboxes on Mondays, and no later than Wednesday, except during holidays or unexpected office closures. If you do not receive your ERA by close of business on Wednesday, you may contact EDI Services at or Please include the Trading Partner ID, check number, check amount, check date and NPI. EFT transactions are typically available at the provider s bank on Wednesday. If you have not received your deposit by close of business on Wednesday, you may contact EDI Services by calling the LINKLine at or 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 logging into the DPS. 2. 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. Submit a new Electronic Remittance Advice (ERA) Enrollment Form directly to LA BCBS denoting the Reason for Submission as Cancel Enrollment. CONTACT PHONE NUMBERS EDI LA BCBS Emdeon Dental Provider Enrollment opt. 2 Page 2 of : dlv

3 Emdeon Dental Provider Enrollment 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 Enrollment Change Enrollment Cancel Enrollment *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 Enrollment: Printed Title of Person Submitting Enrollment: Submission Date: Requested ERA Effective Date: *Required Page 3 of

4 Electronic Remittance Advice (ERA) Enrollment Form By completing this form, you are enrolling for the receipt of an ERA (835), to be delivered to the Trading Partner ID you are specifying in this enrollment. All fields must be completed in order for us to complete processing of the enrollment. PROVIDER INFORMATION Provider Name Provider Address: Street City State/Province Zip Code/Postal Code PROVIDER IDENTIFIERS INFORMATION Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) Trading Partner ID PROVIDER CONTACT INFORMATION Contact Name Title Telephone Number Address Fax Number ELECTRONIC REMITTANCE ADVICE INFORMATION Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Provider Tax Identification Number (TIN): National Provider Identifier (NPI): Method of Retrieval From Health Plan From Clearinghouse Secure FTP SOAP/MIME ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION Clearinghouse Name Clearinghouse Contact Name Telephone Number Address ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION Vendor Name Vendor Contact Name Telephone Number Address ~Over~ 18NW /13 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

5 SUBMISSION INFORMATION Reason for Submission New Enrollment Change Enrollment Cancel Enrollment Authorized Signature This information is to remain in full force and effect until Blue Cross and Blue Shield of Louisiana has received written notification from me of its change or cancellation in such time and in such manner as to afford Blue Cross a reasonable opportunity to act on it. Electronic Signature of Person Submitting Enrollment Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Printed Title of Person Submitting Enrollment Submission Date If you have any questions about this form or your ERA enrollment status, please call EDI at: p m. Attn: EDI / BCBSLA P.O. Box Baton Rouge, LA f e. EDICH@bcbsla.com Internal Use Only TPM set-up completed on: Employee ID No.: 18NW /13 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company