220 Burnham Street South Windsor, CT Vox Fax

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1 NEVADA MEDICAID DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT REGISTRATION PAYER ID NUMBER ELECTRONIC REGISTRATIONS AGREEMENTS REQUIRED CKNV1 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 Services (DPS) account. Please contact your software vendor to verify participation or register for a DPS account at Emdeon Dental Form Please complete all requested information. Service Center Authorization Please complete all requested information. Original signature required. CCD+ REASSOCIATION SEND REGISTRATION TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS 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: Or to: dentalenrollment@emdeon.com Or Fax to: ERA enrollments take approximately business days for completion. Once complete, Emdeon will notify the provider or their PMS vendor, as defined by the PMS vendor. If the currently receives ERAs through another Billing Agent other than Emdeon Business Services each must re-enroll following the procedures listed above. Page 1 of : dlv

2 LATE/MISSING EFT & ERA PROCEDURE DISCONTINUING ERA Pending payer s advice. Discontinuing ERA is a 2 step process. 1. Deactivation a. s receiving ERAs via their Practice Management Software need to request deactivation from their software Vendors. Please call your PMS directly. b. s 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. If a provider wishes to discontinue ERAs with Nevada Medicaid complete a new FH-37 form completing the terminate a transaction section. Forms are available at: 37_service_center_authorization_form.pdf. CONTACT PHONE NUMBERS Nevada Medicaid EDI Emdeon Dental opt. 2 Page 2 of : dlv

3 Emdeon Dental Form Insurance Carrier: - ERA Payer ID(s) * Name: (Complete legal name of institution, corporate entity, practice or individual provider) Doing Business as Name (DBA): Address: *(Street) * (City) * (State/Province) * (ZIP Code/Postal Code) (Country Code) * Federal Tax Identification (TIN) or Employer Identification (EIN): *National Identifier (NPI): * Contact Name: Title: *Telephone : Telephone Extension: * Address: Fax : *Preference for Aggregation of Remittance Data: (e.g., Account Linkage to Identifier) Tax Identification (TIN) Method of Retrieval: Clearinghouse National 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 : Printed Title of Person : Submission Date: Requested ERA Effective Date: *Required Page 3 of

4 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 (DEG#) PROVIDER INFORMATION (Data Element Group 1 is a Required DEG) 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. 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) Identifiers Required DEG2 Contact Name Federal Tax Identification (TIN) or Employer Identification (EIN) National Identifier (NPI) A Federal Tax Identification, also known as an Employer Identification (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 digits Telephone 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 A number at which the provider can be sent facsimiles DEG3 DEG2 DEG3 Page 1 of : dlv

5 Preference for Aggregation of Remittance Data (e.g., Account Linkage to Identifier) Method of Retrieval Clearinghouse Name Tax Identification (TIN) National Identifier (NPI) ELECTRONIC REMITTANCE ADVICE INFORMATION (Data Element Group 7 is a Required DEG) 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 Written Signature of Person Printed Name of Person Printed Title of Person 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 Page 2 of : dlv

6 HP Enterprise Services Nevada Medicaid and Nevada Check Up Service Center Authorization Purpose: To authorize or terminate electronic transactions through a Service Center. A Service Center may be a clearinghouse or a provider business (direct submitter). Electronic transactions are processed only if authorized by the provider by use of this form. For Pharmacy transactions, contact the Technical Call Center at (800) Mail this form to: HP Enterprise Services, EDI Coordinator, PO Box 30042, Reno, NV Service center source: Check one. Enter the business or clearinghouse name as appropriate. I will submit claims through a clearinghouse. Clearinghouse name: HP Enterprise Services use only SC code: I will submit claims directly from my business to HP Enterprise Services (direct submitter). Business name Authorize a transaction: Check the box next to each transaction you wish to authorize. I hereby authorize the Service Center named above to submit transactions on behalf of the provider until the provider notifies HP enterprise Services otherwise by use of this form. Eligibility Request/Response (270/271) Professional claim (CMS-1500 claim: 837P) Prior Authorization Request/Response (278/278) Institutional (UB-04 claim: 8371) Claims Status Request/Response (276/277) Dental claim (Dental Claim: 837 D) Remittance Advice (835)* * Paper remittance advices will cease 30 days after electronic remittance advices begin. Although multiple Service Centers may submit claims for one provider, only one Service Center can receive the electronic remittance advice. Terminate a transaction: Check the box next to each transaction you wish to terminate I no longer authorize the Service Center named above to submit transactions on behalf of the provider unless the provider notifies HP Enterprise Services otherwise by use of this form. (Enter the effective date below.) Eligibility Request/Response (270/271) Professional claim (CMS-1500 claim: 837P) Prior Authorization Request/Response (278/278) Institutional (UB-04 claim: 8371) Claims Status Request/Response (276/277) Dental claim (Dental Claim: 837 D) Remittance Advice (835) Effective date for termination of this transaction(s): I understand that I am responsible for the information presented on claims that are submitted through the Service Center designated above and that all information presented on this authorization form is true, accurate, and complete. I further understand that payment and satisfaction of Nevada Medicaid and Nevada Check Up claims will be from federal and state funds and that false claims, statements, documents or concealment of material facts may be prosecuted under applicable federal and state laws. /entity name NPI/API (one per form) Federal Tax ID (or SSN) Will you be submitting claims that have more than one payer (COB/TBL claims)? Yes No Authorized Signature Revised: 12/05/2011 FA-37 1 / 1