Electronic Remittance Advice Information. Preference for Aggregation of Remittance Data ☒ Provider Tax Identification Number (TIN)
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 ▪ Provider Tax Identification Number (TIN) ▪ National Provider Identifier (NPI) Submission Information: Reason for Submission: ▪ New Enrollment ▪ Change Enrollment ▪ Cancel Enrollment
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. Must select only one of the two options below. Providers Tax Identification Number (TIN) – A federal tax identification number (TIN) or Employer identification number (EIN) Numeric, 9 digits National Provider Identifier (NPI) – Unique identification number for covered healthcare providers. Numeric, 10 digits Method of Retrieval – Method in which provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.)
Electronic Remittance Advice Information. NOTE: This information is being collected in the event Florida Medicaid changes ERA aggregation (which is currently done by Medicaid Provider Identification Number). ❑ National Provider Identifier (NPI) ❑ Provider Tax Identification Number (TIN) Preference for Aggregation of Remittance Data* (Must match preference submitted on EFT) Electronic Remittance Advice Clearinghouse Information^ Clearinghouse Name Telephone Number E-mail Address xxxx.xxxxxx@xxxxxxxxxx.xxx 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 (xxxx://xxxx.xxxxxx.xxx) 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 (000) 000-0000 to inquire.
Electronic Remittance Advice Information. Account Number Linkage to Provider Identifier* O Provider Tax Identification Number (EIN/TIN) (Must Match EFT Preference) O National Provider Identification Number (NPI) Method of Retrieval* XXX-ERA Provider Agreement and Enrollment Form (Page 2 of 5) Please return to: Mississippi Medicaid Program Provider Enrollment P.O. Box 23078 Jackson, Mississippi 39225 Clearinghouse Information If you have indicated that you plan to use the services of a Billing Agent/Clearinghouse to submit your transactions electronically to Conduent EDI Gateway, please provide the following information regarding the Billing Agent/Clearinghouse. You would need to be able to provide your Billing Agent/Clearinghouse’s unique Trading Partner Name and ID. Please contact your Billing Agent/Clearinghouse for this required information. The Trading Partner ID field is located in the Provider Identifiers Information Section of this form. Clearinghouse Name
Electronic Remittance Advice Information. Account Number Linkage to Provider Identifier* - Check the Provider Tax Identification Number (EIN/TIN) radio button if the provider is an atypical provider, otherwise check the National Provider Identification Number (NPI) radio button.
Electronic Remittance Advice Information. Preference for Aggregation of Remittance Data (select one from below) □ Provider Tax Identification Number (TIN): □ National Provider Identifier (NPI): Method of Retrieval: Clearinghouse 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 Information. You agreement form must have. Please specify which item you are including with your enrollment. In the platform to us to some cases, the fullest extent permitted by upwork or its agent by enrolling and agreement authorization form to
