MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027

MEDICAID FLORIDA ELECTRONIC REMITTANCE ADVICE ENROLLMENT INSTRUCTIONS 77027 HOW LONG DOES PRE-ENROLLMENT TAKE? Please allow 3 weeks for processing. HOW DO I ENROLL / WHAT FORM(S) SHOULD I DO? Option 1: Enroll Online via the Portal: https://public.flmmis.com/ Option 2: Complete the paper Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement. The form can be found on page 6 of this packet. For instructions on how to enroll online or on paper see the ERA Enrollment Guide (page 2-5 of this packet). WHERE SHOULD I SEND THE FORMS? Mail original form to: Regular Mail: Overnight/Express Delivery: PO Box 7070 2671 Executive Center Circle West, Suite 100 Tallahassee, FL 32314-7070 Tallahassee, FL 32301 HOW DO I CHECK STATUS? If after 3 weeks you do not receive ERA files, contact the EDI Operations Team at (866) 586-0961 to inquire. Office Ally P.O. Box 872020 Vancouver, WA 98687 www.officeally.com Phone: 360-975-7000 Fax: 360-896-2151

X12 835 Electronic Remittance Advice (ERA) Enrollment Guide AFFORDABLE CARE ACT CHANGES TO X12 835 ENROLLMENT NOVEMBER 19, 2013 To comply with changes mandated by the Affordable Care Act, enrollment to receive X12 835 files is now available in the Secure Web Portal via the Electronic Remittance Advice (ERA) Enrollment panel. ERA enrollment can also be completed using the Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement. Requirements for ERA Enrollment Note: Providers already enrolled to receive X12 835 electronic files DO NOT need to re-enroll. Providers wishing to enroll must be fully-enrolled providers with an active or pending Electronic Funds Transfer (EFT) agreement on file. Only users with the MEUPS user type of Provider can complete ERA enrollment. Additionally, Section 1104 of the Affordable Care Act requires health plans to offer an EFT/ERA re-association number that allows providers to link an ERA to a specific EFT payment. It is optional for providers to receive the EFT/ERA re-association number. Providers interested in utilizing the benefits of the EFT/ERA re-association number should contact their financial institution to arrange for the delivery of the required data elements. For More Information Center for Medicaid Services For more information regarding policies related to ERA, visit the CMS website at http://www.cms.gov/regulations -and-guidance/hipaa- Administrative- Simplification/Affordable-Care- Act/OperatingRulesandStandards foreftandremittanceadviceera. html HP Enterprise Services For assistance with completing the ERA Enrollment form, contact Provider Enrollment at the HP Provider Services Contact Center: 1-800-289-7799, Option 4. Once ERA enrollment is complete, the provider can add agents to their MEUPS account and give those agents permission to download X12 835 files on their behalf. For directions on how to add or modify agent permissions on a provider account for ERA Enrollment, see Section 3 of the Web Portal User Guide on the Provider Handbooks page of the public Web Portal.

ERA Enrollment Guide 2 Completing Online ERA Enrollment To complete enrollment, log into MEUPS and navigate to Demographic Maintenance ERA Enrollment. To complete the form, click the check box next to Authorized Signature, then click the save button at the bottom right of the panel. Note: The header information in the ERA Enrollment panel is pre-filled using current information from the provider account. The Requested ERA Effective Date field defaults to the current date. The enrollment form cannot be dated for a past or future date. Once enrollment is complete, or if the provider account is already enrolled, the panel appears with the check box marked.

ERA Enrollment Guide 3 Completing the Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement To access the paper ERA Authorization Agreement, navigate to the Florida Medicaid public Web Portal and select EDI Registration Forms. Note: The form must be typed or printed legibly using blue or black ink. Fields marked with an asterisk (*) are required. Fields marked with a carat (^) are required if the information is available.

ERA Enrollment Guide 4 The below chart contains detailed information about each field: Field Name Provider Information Field Information Complete legal name and street address of institution, corporate entity, practice, or individual provider (required). Enter D/B/A name, if applicable (optional). Provider Identifiers: TIN/EIN/NPI Other Identifiers: Florida Medicaid Provider Identification Number, Trading Partner ID Provider Contact Information Electronic Remittance Advice Information Electronic Remittance Advice Clearinghouse Information Submission Information Enter Federal Tax-Identification Number or Employer Identification Number (required) and National Provider Identifier (required if available). Enter Florida Medicaid Provider Identification Number (required) and Trading Partner ID (required if available). Enter provider name, telephone number, email address, and fax number for the person who should be contacted regarding ERA issues. Only the name and telephone number are required. An email address is required if available. Select preference (TIN or NPI) for aggregation of remittance data. Note: Selection MUST match preference submitted on EFT enrollment. Enter clearinghouse name, telephone number, and email address (required if available). Form must include the authorized signature and printed name and title of the person submitting the enrollment. The form should be dated when signed. For fastest processing, fax the completed form to (866) 270-1497. The form can also be mailed to one of the following addresses: For regular mail: P.O. Box 7070 Tallahassee, FL 32314-7070 For overnight or express delivery: 2671 Executive Center Circle West, Suite 100 Tallahassee, FL 32301 For more information on X12 835 Transactions, please contact the HP Electronic Data Interchange (EDI) Department at 1-866-586-0961.

For Fiscal Agent Use: Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement Provider Information* Provider Name* Doing Business As Name (D/B/A) Provider Address Street * (Street Name and Number NOT a P.O. Box) Provider Address (Suite, Room, etc.) City* State* ZIP* Provider Identifiers Information* Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)* National Provider Identifier (NPI)^ Other Identifiers* Assigning Authority Florida Medicaid Provider Identification Number* Trading Partner ID^ Provider Contact Information for ERA Issues* Provider Contact Name* Telephone Number* E-mail Address^ Fax Number Electronic Remittance Advice Information* Preference for Aggregation of Remittance Data* (Must match preference submitted on EFT) Provider Tax Identification Number (TIN) National Provider Identifier (NPI) NOTE: This information is being collected in the event Florida Medicaid changes ERA aggregation (which is currently done by Medicaid Provider Identification Number). Electronic Remittance Advice Clearinghouse Information^ Clearinghouse Name Telephone Number E-mail Address Submission Information* Authorized Signature* Printed Name of Person Submitting Enrollment* Printed Title of Person Submitting Enrollment* Submission Date* Instructions for completing the ERA Authorization Agreement The online registration form may be accessed via the secure web portal (http://home.flmmis.com) under the Provider Demographic heading. Please type or print legibly in black or blue ink. Fields marked with an asterisk (*) are required. Fields marked with a carat (^) are required if the information is available. Please allow 3 weeks for processing. If after 3 weeks you do not receive ERA files, contact the EDI Operations team at (866) 586-0961 to inquire. AHCA Form 2200-0003 (November 2013) Page 1 of 1