PROVIDER ELETRONIC REMITTANCE ADVICE (835) TRANSACTION AGREEMENT
Provider Electronic Remittance Advice (835) Transaction Agreement
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Provider Number (7 digits) Provider Name:
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Submitter Number (7 digits) (Of entity to receive electronic RA)
Provider Address: Name of entity to receive Electronic Remittance Advice (835 transaction)
I authorize the Medicaid Fiscal Intermediary to send all HIPAA required data in the 835 transaction which includes claims information; payment information; and bank account information, provided by me and currently on file if enrolled in Electronic Funds Transfer, to the submitter identified above. This authorization will remain in effect until discontinued by written request or changed by a future request.
Provider Signature
Date
The Provider must complete and submit this form to the Unisys Provider Enrollment Department, P.O. Box 80159, Baton Rouge, Louisiana 70898-0159. Processing time may require up to three (3) weeks. DO NOT submit this form prior to completion of required testing with Unisys EMC Department.
NOTE: ATTACH COPY OF TESTING ACCEPTANCE RECEIVED FROM THE EMC DEPARTMENT WITH THIS FORM. FAILURE TO SUBMIT THE ATTACHMENT WILL RESULT IN REJECTION OF THIS REQUEST.
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INSTRUCTIONS FOR COMPLETION OF PROVIDER ELECTRONIC REMITTANCE ADVICE (835) TRANSACTION AGREEMENT Completion of this form indicates that the provider requests that Louisiana Medicaid remittance advice data be returned electronically to the submitter indicated. Once approved, this agreement will remain in effect until further written notice.
1. Enter the 7-digit Medicaid Provider Number.
2. Enter the 7-digit Medicaid Submitter Number of the entity that will receive the electronic remittance advice (835) transaction.
3. Enter the name of the provider requesting the electronic remittance advice.
4. Enter the provider address.
5. Enter the name of the entity to receive the electronic remittance advice (835) transaction. This is the name associated with the submitter number entered above. 6. Attach a copy of the testing acceptance verification letter stating that testing has been completed and you are now authorized to submit claims electronically. Failure to submit this verification will result in rejection of request.
This form must be signed and dated by the provider after reading the authorization request. Only an original, handwritten signature is acceptable. Faxed forms, stamped signatures or initials are not acceptable.
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SUBMITTER ELECTRONIC REMITTANCE AGREEMENT
Electronic Remittance Agreement Unisys EMC Department Date:_____________________ EMC submitter number: 45__________.
The provider or billing agency (name)_____________________________________________________ is requesting to receive an electronic remittance advice in the following data format (check only one box). Current Proprietary Electronic Format The requested media is: Bulletin Board System 835 Transaction Tape CD
Provider Number(s): (attach sheet if additional space is needed)
Provider Group Number(s):
This section does not apply to the 835 Transaction. I, the provider or billing agency, (name)_____________________________________________________ agree to the $___________.___ amount to be billed quarterly. Number Claims per Week: _____________. If you have any questions, please contact __________________________________________________ at telephone __________________ or Fax number _________________. Return to: Debbie Perry Unisys/EMC Coordinator Telephone # 225-237-3239 Fax # 225-237-3334
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Instructions for Completing the Electronic Remittance Advice Agreement Follow the steps below to complete the agreement: 1. Enter the current date in MMDDCCYY format, where: MM = DD = CCYY = 2. 3. 4. Month Day of the Month Century and Year
Complete with the appropriate EMC submitter number as assigned by Unisys. Enter the name of the provider, submitter, or billing agency that has elected to receive the electronic RA. Check the box that corresponds to the data format of the electronic RA that is being requested. The current proprietary electronic RA will be discontinued beginning with the checkwrite of October 21, 2003 or as determined by DHH. Check the box that corresponds to the media type that is being requested. Complete the Provider Number(s) and/or Provider Group Number(s) fields as appropriate. These fields should contain the 7-digit Medicaid provider numbers for whom the electronic RA will be received. If more space is needed, attach a sheet with the additional provider numbers. If the 835 Transaction is the chosen format, there will be no charge for receipt of the information. Do not enter a name, dollar amount, or number of claims per week. Skip to step 8. If the proprietary ERA is chosen, enter the name of the entity that will be responsible and the amount of the quarterly charge. Call the Unisys EMC Department to obtain the amount that will be charged per week. Complete with an estimate of the approximate number of claims that will be received per week.
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Enter a contact name, along with either the telephone number or fax number where he may be reached.
Once the electronic remittance advice option has been selected, that choice will remain in effect until such time as a written request for changes and/or discontinuance is received and processed by Unisys. Processing time may require up to three (3) weeks.
NOTE: The “Provider Electronic Remittance Advice (835) Transaction Agreement” must also be completed by each provider that has elected to have remittance advice data sent via the 835 Transaction. The provider’s 835 agreement(s) is to be mailed to the Unisys Provider Enrollment Unit once successful testing of the 835 Transaction has been completed. A provider may designate only one entity to receive an electronic remittance advice on his/her behalf. All claims submitted by the provider(s), whether hardcopy or electronic, will appear on the remittance advice. If the provider already has a designated entity to receive the ERA, but wishes to change to a different entity for receipt of the ERA, the provider MUST complete and submit another Electronic Remittance Advice 835 Transaction Agreement.
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