Electronic Remittance Advice (Era) Authorization Agreement Sample Contracts
Medi-Cal Rx Electronic Remittance Advice (ERA) Authorization Agreement FormElectronic Remittance Advice (Era) Authorization Agreement • November 30th, 2021
the “835-Transaction.” The ERA Authorization Agreement must be filled out by an active Medi-Cal Rx provider. Non-providers can receive electronic remittances if designated as a receiver by a provider; however, the authorizing provider must submit the agreement. This authorization remains in effect until Medi-Cal Rx receives written notification from the provider of its termination, or until Medi-Cal Rx or appointing authority deems it necessary to terminate the agreement.
Standard Contracts
ContractElectronic Remittance Advice (Era) Authorization Agreement • December 18th, 2013
This document is intended to establish Electronic Remittance Advice (ERA) enrollment. This document shall become effective when submitted by the provider. The responsibilities and obligations contained in this docu- ment will remain in effect as long as claims are submitted to WPS. Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the event that the notice
Health Net of California Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • January 7th, 2015
This authorization is to remain in effect until written notice in the form of an ERA Authorization Agreement form marked as a cancellation or change form is submitted to Health Net. Any changes to the providers agent, clearinghouse or vendor must be submitted on an ERA Authorization Agreement form as a change. The termination or change shall be effective 20 days subsequent to Health Net's receipt of the updated form.
Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • November 8th, 2016
Provider Identifiers Information (DEG2) Provider Federal Tax Identification Number (TIN)/Employer Identification Number (EIN) National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI)* (Note: Attach a list if there are more Billing NPIs or UMPIs to be included in Authorization.)
Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • October 9th, 2012
Providers and clearinghouses, complete the ERA form by logging on to www.enshealth.com. If you need assistance with your OptumInsight user name or password, please call
Complete the Electronic Remittance Advice (ERA) Authorization Agreement (Pages 3-5)Electronic Remittance Advice (Era) Authorization Agreement • November 25th, 2024
The District of Columbia (DC) Medicaid offers providers claims payment information in an electronic format. The Electronic Remittance Advice (ERA), also known as the 835, is the HIPAA-required X12N transaction set. Medicaid Providers must submit this form prior to receiving the ERA either directly or through a billing service or clearinghouse. When enrolling, please complete a separate Electronic Remittance Advice (ERA) Authorization Agreement Form for each Billing Provider or Tax Identification Number.
Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • October 9th, 2012
Providers and clearinghouses, complete the ERA form by logging on to www.enshealth.com. If you need assistance with your OptumInsight user name or password, please call
ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENTElectronic Remittance Advice (Era) Authorization Agreement • April 22nd, 2016
• Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • February 19th, 2019
Electronic Remittance Advice (ERA) Authorization AgreementElectronic Remittance Advice (Era) Authorization Agreement • December 11th, 2013
In order to start receiving your ERAs DeCare - Horizon Blue Cross Blue Shield (Commercial) through EDS, you will need to complete the attached ERA Application.
