Instructions for Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation Page 1 Please use is guide to prepare/complete your Electronic Funds Transfer (EFT) Auorization Agreement Form. Missing, illegible or incomplete information wiin e agreement form will delay e benefits of participating in EFT. The following is a reference guide only, do not fax or email e instructions wi e completed auorization form. Return Pages 2-3 ONLY. If you prefer to enroll/change/cancel electronically, please go to our website at www.aetnabetterheal.com/newyork for e electronic form and instructions. If you have questions about e auorization agreement form or e enrollment process, please call Provider Relations at or email us at NY_ProviderRelations@aetna.com. Please note at e descriptions for e data elements contained in e Electronic Funds Transfer (EFT) Auorization Form have been placed in an Appendix to make it easier to complete e form. Please refer to e Appendix when completing e form. Are you using one auorization agreement form per tax id number? Enrollment forms containing more an one tax id will be returned. Did you remember to put e NPI # on e auorization agreement form? Enrollment forms wiout an NPI number (if e provider is required to have an NPI) will be returned. List additional NPI numbers to be enrolled in e space provided at e end of e enrollment form. Have you attached a pre-printed voided check wi e account holder imprinted on e check or bank letter for new enrollments or changes in bank information? Enrollment requests cannot be processed wiout is information. A voided check/bank letter must accompany e form. Deposit Slips, starter checks, handwritten or altered checks will not be accepted. The banking information on e voided check/bank letter must match what is listed on e form. Need to change or cancel an existing enrollment? Complete a new auorization agreement form to make changes to an existing enrollment or to cancel an existing enrollment. Complete all parts of e form and mark e appropriate choice in e Submission Information section of e form. You are responsible for notifying Aetna Better Heal of New York of any changes in your information. Has e form been signed by e appropriate individuals? Unsigned forms will be returned. Have you completed all sections? Please type or print all requested information clearly. Incomplete and/or illegible fields will cause e form to be returned. Have a completed form to submit? Forms can be submitted by fax or email. Completed new or change auorization agreement forms wi voided check and/or bank letter and completed cancellation auorization agreement forms can be submitted rough one of e following meods: Fax to: Aetna Better Heal of New York Finance at 1-855-230-7546. Only one form per fax. Faxes containing multiple forms will be returned. Email to: NYFinanceEFTEnrollment@aetna.com. Only one form per email. Emails containing multiple forms will be returned. Need to check e status of your EFT enrollment? Please allow 10-15 business days for processing once enrollment is received. Processing times may vary depending on number of enrollments received, accuracy of e information provided and how legible e form is. A confirmation letter will be sent to e Provider Address on e enrollment form once setup is complete. A $0.00 pre-note test transaction will be sent to your financial institution. The pre-note period can take 10-15 days from e processing date of e approved Electronic Funds Transfer (EFT) Auorization Agreement Form. Changes to existing banking information will trigger a new 10 to 15 day pre-note period. The online instructions on our website at www.aetnabetterheal.com/newyork will instruct you to contact Provider Relations at or email NY_ProviderRelations@aetna.com wi any questions or to check enrollment status. Have you contacted your financial institution to arrange for e delivery of e CORE-required Minimum CCD+ Reassociation Data Elements from e NACHA ACH/EFT payment file? Your financial institution must be a participating member of e Automated Clearinghouse Association (ACH) and accept e CCD+ format. You must proactively contact your financial institution to arrange for e delivery of e CORE-required Minimum CCD+ Data Elements necessary for e successful reassociation of e EFT payment wi e ERA remittance advice. Do you have a Late or Missing EFT payment or ERA remittance advice? If you have not received your EFT payment or e corresponding ERA remittance advice by e 4 business day after you receive eier e EFT payment or ERA remittance advice, contact your Provider Relations representative at or email us at NY_ProviderRelations@aetna.com or fax us at 1-855-222-6621.
Electronic Funds Transfer (EFT) Auorization Agreement Form Page 2 Definitions for DEG group data elements contained in Appendix. DEG1 Provider Information DEG2 Provider Name Doing Business As Name (DBA) Provider Address Street City ZIP Code/Postal Code Provider Identifiers Information Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) DEG3 Provider Contact Information Provider Contact Name Telephone Number Email Address Fax Number DEG7 Financial Institution Information Financial Institution Name Financial Institution Address Street City ZIP Code/Postal Code Financial Institution Routing Number Type of Account at Financial Institution Provider s!ccount Number wi Financial Institution Account Number Linkage to Provider Identifier - Select from one of e two below Provider Tax Identification Number (TIN) National Provider Identifier (NPI)
55 W. 125 St., Suite 1300 Electronic Funds Transfer (EFT) Auorization Agreement Form Page 3 - Definitions for DEG group data elements contained in Appendix. DEG8 Submission Information Reason for Submission Select from below New Enrollment Change Enrollment Cancel Enrollment Include wi Enrollment Submission Select from below Voided Check Bank Letter Auorized Signature Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Printed Title of Person Submitting Enrollment Auorization Agreement By signing above, I hereby agree at I have read and agree to e terms and conditions stated in e Auorization Agreement below. In addition, I represent and warrant at all of e information at I have provided to Aetna Better Heal is accurate and complete. Electronic Funds Transfers (EFT) Auorization Agreement We, e Provider, certify at e bank account information listed on is form is under our direct control. We auorize Aetna Better Heal of New York to initiate credit entries to e account at e bank listed on is form for all claims payments. We auorize and request e bank to accept credit entries by Aetna Better Heal of New York to such account and to credit e same to such account. We, e Provider, understand at if our account is closed and a new Electronic Funds Transfer (EFT) Auorization Agreement Form has not been submitted and processed, we will not receive payment until our bank returns e funds to Aetna Better Heal of New York. This auorization remains in effect until we submit an updated Electronic Funds Transfer (EFT) Auorization Agreement Form requesting termination or change and until such time at Aetna Better Heal of New York has had a reasonable opportunity to act on such request or Aetna Better Heal of New York notifies us at is service has been terminated. If our depository information changes, we agree to submit an updated Electronic Funds Transfer (EFT) Auorization Agreement Form to at effect. Aetna Better Heal of New York will not debit or deduct funds directly from my bank account for claim overpayments and or refund requests but, If Aetna Better Heal of New York credits more money an e correct benefits amount to e account, due to duplicate electronic funds transfers (where duplicate is defined as multiple electronic funds transfers received for e same services rendered, e same membership and e same dates of service) or erroneous electronic funds transfers (where erroneous is defined as complete electronic funds transfers received in error), Aetna Better Heal of New York will pursue immediate repayment wi e Provider.* *Aetna Better Heal of New York strictly adheres to e National Automated Clearing House Association (NACHA) guidelines.
Additional National Provider Identification (NPI) to be enrolled
Appendix - s and s To be used for completing e Electronic Funds Transfer (EFT) Auorization Agreement Form Page 4 DEG1 PROVIDER INFORMATION Provider Name Complete legal name of institution, corporate entity, practice or individual provider A legal term used in e United States meaning at e trade name, or fictitious business name, under Doing Business As Name (DBA) which e business or operation is conducted and presented to e world is not e legal name of e legal person(s) who actually own it and are responsible for it Provider Address - Street The number and street name where a person or organization can be found Provider Address - City City associated wi provider address field Provider Address ISO 3166-2 two character code associated wi e /Region of e applicable Country DEG2 PROVIDER IDENTIFIERS INFORMATION Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) A Federal Tax Identifier Number, also known as an Employer Identification Number (EIN), is used to identify a business entity A Heal Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered heal care providers. Covered healcare providers and all heal plans and healcare clearinghouses must use e NPIs in e administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digits number). This means at e numbers do not carry oer information about e healcare providers, such as e state in which ey live or eir medical specialty. The NPI must be used in lieu of legacy provider identifiers in e HIPAA standards transactions DEG3 Provider Contact Name Telephone Number Email Address Fax Number PROVIDER CONTACT INFORMATION Name of a contact in provider office for handling EFT issues Associated wi contact person An electronic mail address at which e heal plan might contact e provider A number at which e provider can be sent facsimiles
55 W. 125 St., Suite 1300 Appendix - s and s To be used for completing e Electronic Funds Transfer (EFT) Auorization Agreement Form Page 5 DEG7 FINANCIAL INSTITUTION INFORMATION Financial Institution Name Financial Institution Address - Street Financial Institution Address - City Financial Institution Address Financial Institution Address ZIP Code/Postal Code Financial Institution Routing Number Type of Account at Financial Institution Provider s!ccount Number wi Financial Institution Official name of e provider s financial institution Street address associated wi receiving depository financial institution name field City associated wi receiving depository financial institution address field ISO 3166-2 two character code associated wi e /Region of e applicable Country System of postal-zone codes (zip stands for zone improvement plan ) introduced in e U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities A 9-digit identifier of e financial institution where e provider maintains an account to which payments are to be deposited The type of account e provider will use to receive EFT payments, e.g., Checking, Saving Provider s account number at e financial institution to which EFT payments are to be deposited Account Number Linkage to Provider Identifier Provider preference for grouping (bulking) claim payments must match preference for v5010 X12 835 remittance advice DEG8 SUBMISSION INFORMATION Include wi Enrollment Submission Voided Check Include wi Enrollment Submission Bank Letter Auorized Signature Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Printed Title of Person Submitting Enrollment A voided check is attached to provide confirmation of Identification/Account Numbers A letter on bank letterhead at formally certifies e account owners routing and account numbers The signature of an individual auorized by e provider or its agent to initiate, modify or terminate an enrollment. May be used wi electronic and paper-based manual enrollment A (usually cursive) rendering of a name unique to a particular person used as confirmation of auorization and identity The printed name of e person signing e form; may be used wi electronic and paper-based manual enrollment The printed title of e person signing e form; may be used wi electronic and paper-based manual enrollment