Common Contracts

EDI-ERA Provider Agreement and Enrollment Form

June 26th, 2017

• Filed
  June 26th, 2017

Please complete the following Mississippi Medicaid EDI ERA Provider Agreement and Enrollment Form. Please print or type. Complete all areas of the form, unless otherwise indicated. Once the form has been completed and signed, please return it to the address above for processing. You may contact the EDI Support Unit at 1-800-884-3222, Monday-Friday 8AM-5PM CST if you have any questions about the EDI ERA Provider Agreement and Enrollment Form or wish to inquire upon the status of a form that has already been submitted. If you wish to receive dual delivery (paper and electronic) of the Remittance Advices for at least 31 days or 3 payments, whichever is greater; please send a written request to the address above.