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Instructions for Completing the Electronic Funds Transfer / Electronic Remittance Advice Authorization Agreement Below are the instructions on how to complete the EFT and ERA Authorization Agreement form. If you have questions on how to complete the form please send an e-mail to [email protected]. Please allow a minimum of 30 days for processing. You will be notified in advance of the date when the electronic RAs and/or EFT process will begin. 1.

Select a Reason for Submission A reason and sub-reason for submission must be selected for the form.

2.

1.

Select a reason for submission from the Reason for Submission field.

2.

Select a sub-reason for submission from the Sub-reason for Submission field.

Complete the Provider Information Section The Provider Information section must be completed for all submission reasons.

3.

1.

Enter the legal name of the institution, corporate entity, practice or individual provider into the Provider Name field.

2.

Enter the number and street name a facility can be found into the Provider Address Street field.

3.

Enter the city associated with the provider address into the Provider Address City field.

4.

Enter the two-character code associated with the State/Province/Region of the applicable country associated with the provider address into the State/Province field.

5.

Enter the zip code/postal code associated with the provider address into the Zip Code/Postal Code field.

Complete the Provider Identifiers Section The Provider Identifiers section must be completed for all submission reasons. A Provider Federal Tax Identification Number (TIN), also known as an Employer Identification Number (EIN) is a nine-digit number used to identify a business entity. The Federal TIN must be entered exactly as it appears on your SS-4 (corporate) or Social Security card (individual). A National Provider Identifier (NPI) is a unique ten-digit identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must used the NPIs in the administrative and financial transactions adopted under HIPPA. The NPI must be used in lieu of legacy provider identifiers in the Health Insurance Portability and Accountability Act (HIPAA) standards transactions. 1.

Enter a nine-digit number into the Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) field.

2.

If the Provider has been enumerated with an NPI enter the ten-digit number into the National Provider Identifier (NPI) field; add all of the NPIs associated with the TIN/EIN to be included with this election.

Revised Dec. 2013

Instructions for Completing the Electronic Funds Transfer / Electronic Remittance Advice Authorization Agreement 4.

Complete the Provider Contact Information Section The Provider Contact Information section must be completed for all submission reasons.

5.

1.

Enter the name of a contact in the provider office for handling EFT issues into the Provider Contact Name field.

2.

Enter the electronic mail address at which the health plan might contact the provider in the Email Address field.

3.

Enter the telephone number associated to the contact person in the Telephone Number field.

4.

Enter a number at which the provider can be sent facsimiles in the Fax Number field.

Complete the Financial Institution Information Section The Financial Institution Information section must be completed for all EFT submissions. **Note: Effective 12/28/09 a voided check is required to be attached to form if you are electing EFT payment; mail the voided check to the address listed below. Without a voided check, this may delay the EFT and/or RA set up.** UCare Attn: Accounting/PPE Dept. P.O. Box 52 Minneapolis, MN 55440-0052 1.

Select the payment method from the Payment Method field.

2.

When the payment method is EFT select the type of account the provider will use to receive EFT payments, e.g., Checking, Saving into the Type of Account at Financial Institution field.

3.

When the payment method is EFT enter the official name of the provider’s financial institution into the Financial Institution Name field.

4.

When the payment method is EFT enter the nine-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited into the Financial Institution Routing Number field.

5.

When the payment method is EFT enter the provider’s account number at the financial institution to which EFT payments are to be deposited into the Provider’s Account Number field.

6.

When the payment method is EFT enter the provider preference for claim payments – must match preference for v5010 X12 835 remittance advice. If you’ve entered NPIs into the Provider Identification section you need to enter all of them in this section. If you do not have an NPI enter the provider TIN into the Provider Tax Identification Number (TIN) field.

Revised Dec. 2013

Instructions for Completing the Electronic Funds Transfer / Electronic Remittance Advice Authorization Agreement 6.

Complete the Electronic Remittance Advice Clearinghouse Information Section The Electronic Remittance Advice Clearinghouse Information section must be completed for all ERA submissions. If your RA selection is with the paper check option, please fax the completed form to our Accounting Dept. at: 612-8842030.

7.

1.

Select the method in which the provider will receive the ERA from the health plan from the Method of Retrieval field. **Note: If you are choosing a clearinghouse, you must be contracted with the clearinghouse to receive the 835 transaction prior to submitting this form to UCare. Also, the paper RA option is not available to Minnesota providers (according to MN Statute 62J.536).**

2.

When the method of retrieval is Clearinghouse select the official name of the provider’s clearinghouse from the Clearinghouse Name field.

3.

When the payment method is EFT enter the provider preference for claim payments – must match preference for v5010 X12 835 remittance advice. If you’ve entered NPIs into the Provider Identification section you need to enter all of them in this section. If you do not have an NPI enter the provider TIN into the Provider Tax Identification Number (TIN) field.

Complete the Authorized Signature Section The Authorized Signature section must be completed for all submission reasons. 1.

Enter the name of the person signing the form in the Electronic Signature of Person Submitting Enrollment field.

2.

Enter the printed title of the person signing the form in the Printed Title of Person Submitting Enrollment field.

Revised Dec. 2013

Electronic Funds Transfer / Electronic Remittance Advice Authorization Agreement *Reason for Submission:

New Enrollment

Change Enrollment

Cancel Enrollment

*Sub-Reason for Submission:

EFT and ERA

EFT

ERA

Provider Information

(Name must match Tax ID Number [TIN] records. Only one TIN per form.)

*Provider Name: *Provider Address: Street

City

State/Province

Zip Code / Postal Code

Provider Identifiers

Note: Enter Federal ID name exactly as shown on your SS-4 (Corporate) or Social Security Card (Individual) and enter all of the facility number(s) that will be included in this election

*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): National Provider Identification Number (NPI):

Provider Contact Information *Provider Contact Name: E-mail Address: *Telephone Number:

-

-

-

Fax Number:

-

Financial Institution Information *Payment Method:

Paper Check

Electronic Funds Transfer (EFT)

Complete the financial institution information below if you’ve selected the EFT Payment Method Note: You must attach a voided check to this form if you selected EFT

*Type of Account:

Checking

Savings

*Financial Institution Name: *Financial Institution Routing Number: *Provider’s Account Number with Financial Institution:

Electronic Remittance Advice Clearinghouse Information *Method of Retrieval:

UCare Provider Portal

Clearinghouse

RAs will be available only online at www.ucare.org/providers/pages/pro viderportal.aspx

You must choose one of the following methods to receive your RA

1.

Paper Not available for MN providers

Clearinghouse - Please select the clearinghouse that you are registered with for receiving 835s. NOTE: You must register with a clearinghouse to receive 835s before UCare can send 835s to your clearinghouse and before you complete and submit this form.

Availity ClaimLynx Cortex EDI Emdeon

eProvider Solutions GE Healthcare Infotech Global Inc., aka MN e-Connect PNC Bank

RelayHealth Rycan Technologies SSI Group ZirMed

Authorized Signature Authorized Signature (MUST be signer on applicable bank account.)

Title

Print Name

Date

Revised Dec. 2013

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