General Information
- Please allow 7 to 10 business days for your enrollment to be completed. If you don’t start receiving EFT payments after 10 days, contact the EDI Helpdesk.
- The provider must contact his or her financial institution to arrange for the delivery of the CORE required Minimum CCD+ data elements needed for reassociation of the payment and the ERA. See Phase III CORE EFT & ERA Reassociation (CCD+/835) Rule Version 3.0.0.
http://www.caqh.org/Host/CORE/EFT-ERA/EFTERA_Reassociation_Rule.pdf
- Researching Missing / Late Files: If you don’t receive EFT files after 4 banking days of receiving the corresponding ERA, call the EDI Helpdesk.
- For questions about the EFT enrollment process, please call the EDI Helpdesk at 1-800-777-3622 or 1-801-578-5600 in the Salt Lake City area.
Provider Information
-- Please fill out completely
Provider Name – Complete legal name of institution, corporate entity, practice or individual provider.
Doing Business As Name (DBA) – Legal term meaning that the trade name, or fictitious business name, under which the business is conducted is not the legal name of the person 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.
City – City associated with provider address field.
State/Province – ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country.
Zip Code/Postal Code – System of postal-zone codes (zip stands for “zone improvement plan”) introduced in the U.S. in 1963 to improve delivery and exploit electronic reading and sorting capabilities.
Provider Identifiers – Both are required
Provider Federal Tax Identification Number (TIN) – A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity.
National Provider Identifier (NPI) – A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Other Identifiers
Assigning Authority – Organization that issues and assigns the additional identifier requested on the form. If submitting transactions through UTransend or UHINet II, the Utah Health Information Network is the assigning authority for Trading Partner ID’s.
Trading Partner ID – The provider’s submitter ID assigned by the health plan or the provider’s clearinghouse or vendor.
Provider Contact Information
Provider Contact Name – Name of a contact in the provider office for handling EFT issues.
Telephone Number – Associated with contact person.
Email Address – An electronic mail address at which the health plan might contact the provider.
Note: Confirmation of enrollment for EFT will be sent to this email address.
Financial Institution Information
Financial Institution Name – Official name of the provider’s financial institution.
Financial Institution Routing Number – A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited.
Type of Account at Financial Institution – The type of account the provider will use to receive EFT payments, e.g.,Checking, Saving
Provider’s Account Number with Financial Institution – Provider’s account number at the 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.
Provider Tax Identification Number (TIN) – 9 digit. System will default to the TIN entered above.
National Provider Identifier (NPI) – 10 digit. System will default to the NPI entered above.
Reason for Submission
New Enrollment – provider is not currently enrolled to receive EFT payment.
Change Enrollment – provider is enrolled to receive EFT payment but requires a change to previously submitted enrollment information.
Cancel Enrollment – provider wishes to discontinue receiving EFT payment and will revert to paper checks.
Include with Submission A voided check is
required if checking account is being used.
Voided check – A voided check is attached to provide confirmation of identification/Account numbers.
Bank letter – A letter on bank letterhead that formally certifies the account owners routing and account number.
Authorized Signature – The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment.
Written Signature of Person Submitting Enrollment – A rendering of a name unique to a particular person used as confirmation of authorization and identity.
Printed Title of Person Submitting Enrollment – The printed title of the person signing the form.
Requested EFT Start/Change/Cancel Date – The date on which the requested action is to begin.