UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629

UCARE 835 ERA PRE ENROLLMENT INSTRUCTIONS 52629 HOW DO I ENROLL TO RECEIVE 835s/ERAs? STEP 1: Complete the Availity Multi Payer ERA Enrollment Form. (Standard processing time is 1 week) Fax the form to (972) 383 6450; or Mail the form to: Availity PO Box 833905 Richardson, TX 75098 3905 PLEASE READ: FAILURE TO FOLLOW THE PROCEDURES BELOW WILL RESULT IN DENIAL AND/OR DELAY UCARE REQUIRES THAT OFFICE ALLY GOES THRU AVAILITY IN ORDER TO RECEIVE ELECTRONIC REMITTANCE ADVICE (ERA/835). AVAILITY REQUIRES THAT THE PROVIDER COMPLETE THEIR MULTI PAYER ENROLLMENT FORM. THIS TAKES APPROXIMATELY 1 WEEK. IF AFTER 7 BUSINESS DAYS YOU HAVE NOT RECEIVED AN EMAIL NOTIFYING YOU OF A DENIAL FROM OFFICE ALLY THEN YOUR ARE SET UP AND MAY PROCEED WITH STEP 2. YOU MUST COMPLETE STEP 1 PRIOR TO MOVING ONTO STEP 2. UCARE REQUIRES THAT YOU BE ENROLLED WITH AVAILITY TO RECEIVE ELECTRONIC REMITTANCE ADVICE (ERA/835) BEFORE THEY WILL PROCESS YOUR APPLICATION. STEP 2: Complete the UCare Payment Election Form and mail it to UCare with Original signatures. *Note: Section F Remittance Advice (RA) has been completed for you. You will receive your 835s in your Office Ally account after your application has been approved; however this is done through Availity per a requirement by UCare. Mail the completed, original form to: UCare Attn: Accounting/PPE P.O. Box 52 Minneapolis, MN 55440 0052 Enrollment with UCare requires a minimum of 30 days for processing. You will be notified in advance of the date when the electronic remits and/or payment process will begin. Office Ally P.O. Box 872020 Vancouver, WA 98687 www.officeally.com Phone: 866 575 4120 Fax: 360 896 2151

Multi-Payer Electronic Remittance Advice (ERA) Enrollment Form Availity supports the exchange of electronic remittances for various payers in the ASC X12 835, version 4010A1 format. The enrollment process establishes an electronic mailbox where we will place the electronic remittance file(s) received from payer(s). The Tax ID is a requirement to establish an ERA Receiver mailbox and will also be used to parse remittance transactions from the various payers. The assigned electronic ERA Receiver ID and password will be returned via fax to the contact and fax number provided on the enrollment form. Note: If you are a Billing Service or Clearinghouse wishing to receive the ERA on behalf of the provider, each provider must complete the enrollment documents authorizing you to retrieve their remittance files or a copy of your power of attorney must be submitted with the enrollment form. Once in production, a letter will be required on the provider s letterhead if a change is requested. If you have any questions regarding the enrollment process you may contact the EDI Helpline at 877.334.8446.

Electronic Remittance Advice (ERA) Enrollment CHANGE to ERA Receiver ID: Add New Payer to ERA Account Change ERA Account Information Delete ERA Account ADD New ERA Receiver ID Create New ERA Account Change or Add a New ERA Account (Select one) Indicate who will receive the file: Billing Service Clearinghouse Availity User ID (Required) Receiver Name Receiver Address City State Zip Contact Name Email Address Tel. Fax Vendor Name/ID (if applicable) Payer Name Payer ID (see Payer List) Tax ID BCBS # National ID (NPI) Regence Legacy ID Name (print) Address City State Zip Signature Date Please return this form to: Availity PO Box 833905 Richardson, TX 75098-3905 Or fax to: 972.383.6450

Payment Election Form Instructions To establish how your organization will receive payments and remittance advices from UCare, please carefully follow these steps to complete the Payment Election Form: Step 1: All forms submitted must contain original signatures and must be signed in ink by a signer on the account into which UCare will be depositing funds. Complete all of the sections on the Payment Election Form by using these guidelines: A. Business Mailing Address (General) Check the appropriate box at the top and fill-in your business name and address to be used for administrative purposes. New Vendor: Check this box if you are a new vendor and this is the initial setup request. New Bank Information: Check if you are currently receiving paper checks and are electing to receive ACH/EFT. Change Bank Information: Check if you are currently receiving ACH/EFT payments and are changing the banking information where the deposits are to be made. B. Business Contact Information Identify who we should contact with questions related to the form. Please be sure to include an e-mail address. C. Tax Identification Number Required (do not leave blank). Make sure to enter the Federal ID Name exactly as it appears on your SS-4 (corporate) or Social Security Card (individual). D. Facility s Legacy or NPI Number(s) Include all of the facility number(s) with the same TIN as it appears in box C that will also be using the bank account/payment method indicated in box E. If there are different TINs and/or bank accounts, a separate form must be completed. E. Payment Method Choose paper check or EFT. If electing EFT, complete the financial institution and account information and attach a voided check from the bank account that you will be using. (Write VOID over a blank check.) Note: Effective 12/28/09, a voided check will be required to be attached to the Payment Election Form if you are electing EFT payment. Without a voided check, this may delay the EFT and/or 835 set up. F. Remittance Advice (RA) Choose one of the three methods listed for receiving your remittance advice. Note: If choosing a clearing house, you must be contracted with the clearing house to receive the 835 transaction prior to submitting this form to UCare. Also, the paper remittance option is not available to Minnesota providers (MN Statute 62J.536). Step 2: Please return the original Payment Election Form and the voided check (if applicable) to: UCare Attn: Accounting/PPE P.O. Box 52 Minneapolis, MN 55440-0052 Please allow a minimum of 30 days for processing. You will be notified in advance of the date when the electronic remits and payment process will begin. Questions about the completion of this form can be directed to UCare via e-mail at: EFT835@ucare.org. Revised December 2009

Payment Election Form A. BUSINESS MAILING ADDRESS (GENERAL) (Name must match TIN records only one TIN per form) Name Address New Vendor New Bank Information Change Bank Information City State Zip Code - B. BUSINESS CONTACT INFORMATION Contact Name E-mail Address Phone - - Fax - - C. TAX IDENTIFICATION NUMBER Note: Enter Federal ID name exactly as shown on your SS-4 (Corporate) or Social Security Card (Individual). Federal ID Name Federal Tax ID # D. FACILITY S LEGACY OR NPI NUMBER(S) Note: Include all of the facility number(s) that will be included in this election. E. PAYMENT METHOD Paper Check Electronic Funds Transfer (EFT) Note: If electing EFT, complete the banking information below and attach a voided check. Attaching a voided check to this form is a requirement for EFT. Financial Institution Information NOTE: Do not use, \, *, or ~ in any fields in this section. ABA Routing # - - Circle Type of Account: Customer s Acct. # Checking Savings Financial Institution Name F. REMITTANCE ADVICE (RA) - You must choose one of the following methods to receive your RA: Clearing House - You must register with a clearing house to receive the 835s. The following clearing houses currently have an 835 connection with UCare, and the contact information for each clearing house can be found in our web site at: www.ucare.org/providers/pages/electronicfundtransfer(eft).aspx. Availity* e Solutions RelayHealth ClaimLynx GE Healthcare Rycan Technologies Cortex EDI Infotech Global Inc., aka MN e-connect SSI Group Emdeon PNC Bank ZirMed Secure Web Portal - To register for Access UCare, log on to www.ucare.org/providers/pages/accessucare.aspx. Access UCare NOTE: You will not receive an 835 or paper RA if you choose Access UCare. RAs will be available online for retrieval only. Paper Remittance Advice Paper Remittance NOTE: Not available for MINNESOTA providers. Authorized Signature (MUST be signer on applicable bank account) Title Printed Name Date *UCare is currently working with this clearing house for the 835 transaction. If you select this clearing house, your 835 files will be delayed until UCare s set up with this clearing house has been completed. UCare will notify you when the set up has been completed and when you can anticipate receiving your first 835 (and EFT, if selected). Revised March 2010