Electronic Remittance Advice (835) Instructional Guide
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1 Electronic Remittance Advice (835) Instructional Guide On August 10, 2012, the Department of Health and Human Services (HHS) published in the Federal Register an interim final rule with comment period (IFC) adopting operating rules for the health care electronic funds transfers (EFT) and remittance advice transactions (herein referred to as the EFT & ERA Operating Rule Set IFC) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These operating rules are authored by the Council for Affordable Quality Health Care Committee on Operating Rules for Information Exchange (CORE). The IFC is in effect now, and industry must comply with the policies adopted in that rule by January 1, Healthcare providers who want to enroll or make changes to their electronic remittance advices (835) must complete the Arkansas Blue Cross Blue Shield Electronic Remittance Advice (835) Form. Forms must be completed and submitted online The purpose of this document is to address the requirements for enrolling a healthcare provider or its agent who will engage in the receipt of the electronic remittance advices (ERA). The next several pages provide the definition of each field and the information that may be entered or is required to be entered. After completing the form, you can print, save a copy and submit the form. The form will be submitted to our enrollment department and processed within 7-14 business days. You will be contacted once your enrollment has been processed. If you have questions or need assistance please contact us at (501) or toll free at (855) You may also us at edi@arkbluecross.com. Hours of operations Monday Friday Tuesday 8:00 4:30 CST 9:00 4:30 CST
2 Provider Information Provider Name: Complete legal name of institution, corporate entity, practice or individual provider. Street: The number and street name where a person or organization can be found. City: City associated with provider address field. State/Province: ISO 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 mail delivery and exploit electronic reading and sorting capabilities. 1. Provider Name: The provider s name or business name. The information entered should be entered as you enrolled with the healthcare plan. 2. Street: Enter the physical street address. P.O. Box numbers cannot be entered in this field. 3. City: The city associated with the provider s street address. 4. State / Province: Enter the two (2) character state code. 5. Zip Code / Postal Code: Enter a five (5) or nine (9) digit zip code. Do not enter any spaces or dashes if entering a (9) nine digit zip code.
3 Provider Identifiers Information Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): 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. Assigning Authority: Organization that issues and assigns the additional identifier requested on the form, e.g., Medicare, Medicaid. Trading Partner ID: The provider s submitter ID assigned by the health plan or the provider s clearinghouse or vendor. 1. Provider Federal Tax Identification Number (TIN) or Employee Identification Number (EIN): Enter the TIN or EIN. 2. National Provider Identifier (NPI): Enter your 10 digit NPI. 3. Assigning Authority: This field has been defaulted to AR Blue Cross Blue Shield and its family of Companies. 4. Trading Partner ID: This is your electronic submitter ID number. If you are a new submitter enter the word NEW in this field. A submitter ID number will be assigned to you.
4 Provider Contact Information Contact: Name of a contact in provider office for handling ERA issues. Telephone Number: Associated with contact person. Telephone Number Extension: Extension of the telephone number. Address: An electronic mail address at which the health plan might contact the provider. Fax Number: A number at which the provider can be sent facsimiles. 1. Contact: Enter the name of the contact person in the provider s office who can be contacted regarding your ERA issues. 2. Telephone Number: Enter the 10 digit telephone number of the contact person. 3. Telephone Number Extension: Enter the telephone number extension of the contact person. If you do not have a telephone number extension then leave this field blank. 4. Address: Enter the address of the contact person. 5. Fax Number: Enter the 10 digit fax number for the provider s contact.
5 Provider Agent Information Provider Agent Name: Name of provider s authorized agent. Street: The number and street name where a person or organization can be found. City: City associated with address field. State/Province: ISO 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 mail delivery and exploit electronic reading and sorting capabilities. Provider Agent Contact Name: Name of a contact in agent office for handling ERA issues. Telephone Number: Associated with contact person. Telephone Number Extension: Extension of the telephone number. Address: An electronic mail address at which the health plan might contact the provider. Fax Number: A number at which the provider can be sent facsimiles. 1. The Provider Agent Information section is to be completed if you will be authorizing a clearinghouse or billing agent to receive the ERA on your behalf. If you will not be utilizing a clearinghouse or billing agent then do not enter any information in this section. 2. Provider Agent Name: The Provider Agent Name is the name of the clearinghouse or billing agent that will be receiving the ERA on your behalf. 3. Street: The physical street address of the billing agent or clearinghouse. 4. City: The city associated with address of the billing agent or clearinghouse. 5. State / Province: Enter the state. 6. Zip Code / Postal Code: Enter the nine digit zip code. 7. Provider Agent Contact Name: Enter the name of the contact person with the clearinghouse or billing agent. 8. Telephone Number: Enter the clearinghouse or billing agent s 10 digit telephone number. 9. Telephone Number Extension: Enter the telephone number extension of the contact person with the clearinghouse or billing agent. If you do not have a telephone number extension then leave this field blank Address: Enter the address of the contact person with the clearinghouse or billing agent. 11. Fax Number: Enter the 10 digit fax number of the clearinghouse or billing agent.
6 Electronic Remittance Advice Information Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Provider Tax Identification Number (TIN): Provider preference for grouping (bulking) claim payment remittance advice must match preference for EFT payment. Method of Retrieval: The method in which the provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.). 1. Provider Tax Identification Number (TIN): Enter your TIN. 2. The Method of Retrieval is the method in which the provider will receive the ERA from the health plan. Dependent upon how you will be receiving your ERA s, either Direct or Clearinghouse will be selected. Note: Due to system limitations multiple NPI s linked to one submitter ID number must all use the same Method of Retrieval. Electronic Remittance Advice Clearinghouse Information Clearinghouse Name: Official name of the provider s clearinghouse. Clearinghouse Contact Name: Name of a contact in clearinghouse office for handling ERA issues. Telephone Number: Telephone number of contact. Address: An electronic mail address at which the health plan might contact the provider s clearinghouse. 1. The Electronic Remittance Advice Clearinghouse Information section is to convey the contact person with the clearinghouse for handling ERA issues. If you will not be utilizing a clearinghouse or billing agent then do not enter any information in this section. 2. Clearinghouse Name: Enter the name of the clearinghouse. 3. Clearinghouse Contact Name: Enter the contact person s name. 4. Telephone Number: Enter the 10 digit telephone number of the contact person. 5. Address: Enter the address of the contact person.
7 Submission Information Reason for Submission: Used to indicate the reason for the submission of the ERA form. Printed Name of Person Submitting Enrollment: The printed name of the person signing the form; may be used with electronic and paper-based manual enrollment. Printed Title of Person Submitting Enrollment: The printed title of the person signing the form; may be used with electronic and paper-based manual enrollment. 1. Select either new enrollment, change enrollment or cancel enrollment. A. Select New if: You are a new electronic submitter and want to start receiving electronic remittance advices. B. Select Change if: You an existing electronic submitter and currently receiving electronic remittance advices and want to change the delivery of the ERA from one trading partner to another. C. Select Cancel if: You are currently receiving electronic remittance advices and you want to discontinue receiving ERA s. CAUTION: Electronic Remittance Advices cannot be created after an enrollment has been canceled. 2. Enter the name of the person who is authorized to submit the enrollment form. 3. Enter the title of the person who is submitting the enrollment form.
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