ERA Enrollment Rule 382 requires an electronic option for providers and trading partners to complete and submit the ERA enrollment effective January 1, 2014. An online ERA enrollment link from the emomed provider portal home page will take the user to the new online ERA enrollment form to create a new enrollment, to change or cancel enrollments. Providers are automatically enrolled to receive a printable electronic remittance advice, but a Trading Partner Agreement (TPA) has to be on file with either the provider or their clearing house/billing agent in order to receive an 835 transaction. All providers will now be required to enroll in the new online ERA form to receive an 835 or have it sent to a clearinghouse or agent. Providers who currently receive an 835 will not need to complete a new ERA enrollment form; however, any updates to ERA information will require a new ERA enrollment form to be completed. The online ERA form will also include the outbound TPA form as a separate page which will be required if the provider is opting to receive an 835 via INET (emomed). If the provider is opting to receive an 835 via FTP or NDM vendor that is listed in the drop down box for Method of Retrieval, then an outbound TPA form for the provider is not required. Wipro will still require an outbound TPA on file for the clearing house or billing agency that covers all providers.
ERA Enrollment Form Enrolling Through emomed Page 2
Method of Retrieval defaults with INET (emomed) but providers are able to change with the dropdown arrow showing the FTP and NDM vendors. Vendors will only be added to the dropdown as a choice after Wipro has received a signed outbound TPA agreement that covers all providers. Page 3
ERA Enrollment Form Without TPA To enroll for an ERA without a TPA, the user has to enter all required fields, select a FTP or NDM vendor for the Method of Retrieval. Once the user has completed the form and selected the appropriate Method of Retrieval, the user can click on the Continue button and navigates to a confirmation screen. The user can click on the Continue button on the ERA Enrollment screen to submit the ERA enrollment form. The confirmation screen displays so the user can verify and submit the form. The confirmation screen will have the option to Print or the user can select to Edit. Once the user clicks on the Submit button, they will receive a confirmation message ERA Enrollment Received. ERA Enrollment Form With TPA To enroll for an ERA with TPA, the user will enter all the ERA required fields and leave the default of INET (emomed) as Method of Retrieval. Then the user can click on the Continue button. Click the Continue button, and the TPA form displays. The TPA fields pre-populate from the ERA enrollment data and include the new TPA agreement information. The TPA form fields are non-editable and to edit any of the fields, click on the Edit button to make changes on the ERA enrollment form. Click on Continue button to confirm, review, verify, and submit the forms. The confirmation screen will have the option to Print or the user can select to Edit. Click the Submit button to receive a confirmation message. Page 4
ERA Instructions Provider Information Provider Name* Complete legal name of institution, corporate entity, practice or individual provider. Provider Identifiers Information Provider Identifiers Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity National Provider Identifier (NPI)* - 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 Provider Contact Name Contact* - Name of a contact in provider office for handling ERA issues Telephone Number* - Associated with contact person Email Address* - An electronic mail address at which the health plan might contact the provider Provider Agent Information Provider Agent Name Name of provider s authorized agent Provider Agent Contact Name Name of a contact in agent office for handling EFT issues Telephone Number Associated with contact person Email Address An electronic mail address at which the health plan might contact the provider Page 5
Electronic Remittance Advice Information Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)* - Provider preference for grouping (bulking) claim payment remittance advice must match preference for EFT payment. ERA data will always be linked by the MO HealthNet trading partner ID related to the NPI/taxonomy. Select one and fill in the number. Provider Tax Identification Number (TIN) National Provider Identifier (NPI) Method of Retrieval* - The method in which the provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.) Electronic Remittance Advice Clearinghouse Information Clearinghouse Name Official name of the provider s clearinghouse Clearinghouse Contact Name Name of a contact in clearinghouse office for handling ERA issues Telephone Number Telephone number of contact Email Address An electronic mail address at which the health plan might contact the provider s clearinghouse Submission Information Reason for Submission* - New Enrollment, Change Enrollment, Cancel Enrollment Authorized Signature* Electronic Signature of Person Submitting Enrollment - 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 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 MO HealthNet emomed User Trading Partner Agreement Submitter Demographic Data Business Name - Complete legal name of institution, corporate entity, practice or individual provider Provider Contact Name* - Name of a contact in provider office for handling ERA issues Email Address* - An electronic mail address at which the health plan might contact the provider National Provider Identifier (NPI)* - 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 Page 6
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. Telephone Number* - Associated with contact person Researching Missing/Late Files To resolve a late or missing 835, you will need to contact the Wipro Technical Help Desk (573) 635-3559. If you are inquiring about a missing or late EFT payment, you will need to contact your financial institution. Page 7