MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0)

MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0) FAX or EMAIL the completed setup form and signed EDI Enrollment request to: MD On-Line ATTN: Enrollment 888-837-2232 setup@mdol.com PRINT these instructions. Refer to them as you complete the registration process. The MassHealth 837/835 EDI enrollment request template following these instructions must be printed on the provider s letterhead, then signed and submitted to MD On-Line s enrollment team. Please read the following information carefully before completing and submitting EDI enrollment forms: Contact MassHealth at 800-841-2900 to make sure you have a current Trading Partner Agreement on file. MD On-Line cannot complete this step for you. OPTIONAL: If you want to receive ERA from this payer, MassHealth now requires that all providers enroll in EFT prior to ERA enrollment. Please note: ERA receipt for this payer is not required. The required EFT form and completion instructions are attached. Please contact MassHealth for more info. Continue reading for more information on this requirement: Submit only the EFT form directly to MassHealth. Do not submit the EFT form to MD On-Line. Do not submit the MassHealth 837/835 EDI enrollment request to MassHealth. MassHealth requires providers requesting EFT enrollment to obtain pre-notification status before requesting ERA enrollment. Providers should contact MassHealth to confirm pre-notification status before requesting ERA enrollment. EFT and ERA enrollment do not affect 837 claims enrollment; providers can enroll in 837 claims with MassHealth at any time. Completing the MassHealth 837/835 EDI Enrollment request: Please be sure to include all of the following information when requesting EDI/ERA enrollment: Group/provider name MassHealth Provider ID and NPI (contact MassHealth if you do not know this information; MD On- Line cannot obtain this information for you) Typed or hand-printed name of the person signing the form, just as if you were signing a formal letter A legible signature None of the above information should be omitted; none of the information on the template is optional. After printing the forms, sign and date them. MassHealth/Medicaid requires the signature to be legible. 082014

Fax or Email MD On-Line s setup form and the MassHealth 837/835 EDI Enrollment request to MD On-Line Enrollment only. Do not submit the setup form or the MassHealth 837/835 EDI Enrollment request directly to MassHealth. Submit the MassHealth EFT Enrollment form directly to MassHealth. Do not submit the MassHealth EFT Enrollment form to MD On-Line. FAX or EMAIL the completed setup form and signed EDI Enrollment request to: MD On-Line ATTN: Enrollment 888-837-2232 setup@mdol.com Have questions or need assistance? Contact the MD On-Line Enrollment Department at 888-499-5465 x3506 or setup@mdol.com 082014

SUBMIT COMPLETED FORMS TO ENROLLMENT BY FAX AT 888-837-2232 OR EMAIL AT SETUP@MDOL.COM Please complete one Contract Setup Form per Tax ID. Return the form to MD On-Line s Enrollment Department with your EDI documentation. All information is required. If you use a third-party billing service to prepare your claims, complete this section (if not, skip to the provider info section): Billing Service Name: TIN/MDOL ID: Contact Name: Phone: Group/Provider Name: Billing Tax ID: Indicate Tax ID: SSN: Address on file with Payer(s): City: State: ZIP+4: Street Address/Practice Location on file with Payer(s): City: State: ZIP+4: PRINT Authorized signature name, title (CEO, etc): Contact FULL NAME: Phone: Contact Fax: Email: Please list the carriers with which you wish to enroll below. Review the MDOL Payer List for enrollment requirements. PAYER ID PAYER NAME PTAN RENDERING NPI BILLING NPI CLAIMS ERA

MassHealth Enrollment Instructions Please type or copy & paste the following letter onto your provider letterhead. This letter is necessary for us to begin sending claims to Massachusetts Medicaid on your behalf: To Whom It May Concern: We would like to request 837 claim submission (insert and 835 Remittance Advice ONLY IF you would like MD On-Line to receive your EOB s electronically) under Medical Claim Corp., submitter number 110076480A. Provider name Provider Number NPI (Please list all provider names and their corresponding Medicaid provider number and NPI. If you have a group number, list the group name and Medicaid group number.) If you have any questions, please contact (insert contact name) at (phone number) or E- mail (insert E-mail address). Thank you, (signature) (typed name)

Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Electronic Funds Transfer (EFT) Enrollment/Modification Form Complete this form to enroll in electronic funds transfer (EFT) with MassHealth or to terminate or modify an existing electronic funds agreement. Additional terms of agreement on page 2 of this form must be completed. Provider Information Provider Legal Name DBA Name Street City State Zip Code Provider Identifiers Information Provider TIN or EIN NPI Provider contact Information Provider Contact Name Telephone Number Telephone Number Extension E-mail Address Federal agency information Federal Program Agency Identifier Financial Institution information Financial Institution Name Street City State Zip Code Financial Institution Routing Number Type of Account at Financial Institution Provider s Account Number with Financial Institution Provider TIN NPI Submission information Reason for Submission New Enrollment Change Enrollment Cancel Enrollment Included Voided Check Bank Letter Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Submission Date If you are modifying or changing your bank account information, you must include your old bank account information on page 2 of this form or your request will be incomplete. Please print double-sided whenever possible. EFT-1 (Rev. 06/14) page (1/2)

Please complete page 2 in its entirety. If you are modifying your bank account information please provide the old bank account information directly below. Provider Old Bank Account Number Account Type Checking Savings CERTIFICATION I,, hereby certify that the account(s) indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the Commonwealth of Massachusetts to initiate, change, or cancel credit entries to that account/s as indicated on this form. For ACH debits consistent with the International ACH Transaction (IAT) rules check one: I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account. I affirm that payments authorized hereunder are to an account that is subject to being transferred to a foreign bank account. This authority is to remain in full force and effect until the Office of Comptroller (CTR) has received written notification from either me or an authorized officer of the organization of the account's termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it. This authorization will remain in effect until it is canceled in writing or until an updated form changing information is sent to the department you currently do business with. Signature of authorized representative Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD+(Corporate Credit or Debit entry) data elements needed for reassociation of the payment and the Electronic Remittance Advice (ERA). Instructions to complete the EFT Enrollment/Modification form can be found at www.mass.gov/eohhs/docs/masshealth/ aca/eft-instructions.pdf. You may also confirm the status of your EFT enrollment by contacting the MassHealth Customer Services Center at 1-800-841-2900. The EFT user job aid that explains how providers may match the EFT payment to the remittance advice can be found at https://massfinance.state.ma.us/vendorweb/masshealthproviderja.asp. The EFT Enrollment/Modification form can be completed manually or electronically. Electronic submissions must be printed, signed, and mailed to the address below. The Commonwealth of Massachusetts requires a "wet" signature on all EFT enrollments, modifications, and terminations. All paper forms must be mailed to the following address. MassHealth Customer Services Center Attn: Provider Enrollment and Credentialing P.O. Box 9162 Canton, MA 02021-5213 page (2/2)

Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Electronic Funds Transfer Enrollment/Modification Form Instructions These instructions should be used as a guide to complete the Electronic Funds Transfer (EFT) Enrollment/Modification Form. Data Elements Provider Name Doing Business As (DBA)Name Street City State Zip Code +4 Provider Federal Tax Identification Number (TIN) or Federal Employer Identification Number (FEIN) or SSN National Provider Identifier (NPI) Provider Contact Name Telephone Number Telephone Number Extension E-mail Address Federal Program Agency Identifier Financial Institution Name Street City State Zip Code +4 Financial Institution Routing Number Type of Account at Financial Institution Provider s Account Number with Financial Institution Definition PROVIDER INFORMATION Complete legal name of institution, corporate entity, practice, or individual provider. Trade name, or business name, under which the business or operation is conducted. The DBA must match the name on the bank account submitted for EFT. The number and street name where a person or organization can be found. City associated with provider address field. Two-character code associated with the state. System of postal-zone codes ( zip stands for "zone improvement plan") to support mail delivery and exploit electronic reading and sorting capabilities. PROVIDER IDENTIFIERS Enter the federal tax identification number or federal employer identification number, also known as an (FEIN) or (SSN), here. This is the number you provided to the Commonwealth upon enrollment in MassHealth. The 10-digit unique identifier for all Health Insurance Portability and Accountability Act (HIPAA)-covered health care. This is the number you provided to the Commonwealth upon enrollment in MassHealth. PROVIDER CONTACT INFORMATION Name of a contact person in the provider office for handling EFT issues. Telephone number of the provider contact. Extension of the provider contact. An electronic mail (e-mail) address at which the health plan might contact the provider. FEDERAL AGENCY INFORMATION MassHealth provider ID/service location. FINANCIAL INSTITUTION INFORMATION Official name of the provider s financial institution. Street address associated with the receiving depository listed in the financial institution name field. City associated with the receiving depository financial institution listed in address field. Two-character code associated with the state. System of postal-zone codes ( zip stands for "zone improvement plan") to support mail delivery and electronic reading and sorting capabilities. A nine-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. The type of account the provider will use to receive EFT payments. This must be either a Checking or Savings account. Provider s account number at the financial institution to which EFT payments are to be deposited. EFT-1 Instructions (Rev. 02/14)

Provider Federal Tax Identification Number (TIN) National Provider Identifier (NPI) New Enrollment Change Enrollment Cancel Enrollment Voided Check Bank Letter Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Provider Old Bank Account Number Account Type A federal tax identification number, also known as an employer identification number (EIN), is used to identify a business. This is the number you provided to the Commonwealth upon enrollment in MassHealth. The 10-digit unique identifier for all Health Insurance Portability and Accountability Act (HIPAA)-covered health care. This is the number you provided to the Commonwealth upon enrollment in MassHealth. SUBMISSION INFORMATION Reason for Submission: Check this box to enroll in EFT. Check this box if you want to make changes to your current EFT enrollment information. Please be sure to provide the existing account from which you are changing on page 2 of the form. This section can be found directly following the Submission Information section on the EFT Enrollment/Modification Form. Check this box if want to cancel your enrollment in EFT. Included: A voided check is attached to provide confirmation of identification/account numbers. A letter on bank letterhead that formally certifies the account owner s routing and account numbers. A wet signature is required. Manually completed forms, including a wet signature of the authorized person completing the form, must also be mailed to the address at the bottom of the EFT Enrollment/Modification form. The printed name of the authorized person signing the form; may be used with electronic and paper-based manual enrollment. Provider s old bank account number at the financial institution that is requested to be changed. The provider s old bank account type that received EFT payments. This must be either a Checking or Savings account. Complete name this is found on page 2 of the form and must be completed. Certification Affirmation Check one payments ARE NOT payments ARE subject to being transferred to a foreign bank account Signature of authorized representative * Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD+ (Cash Concentration or Disbursement) data elements needed for re-association of the payment and the Electronic Remittance Advice (ERA). * Instructions to complete the EFT Enrollment/Modification Form can be found at http://www.mass.gov/eohhs/docs/masshealth/ aca/eft-instructions.pdf. You may also confirm the status of your EFT enrollment by contacting MassHealth Customer Service at 1-800-841-2900. * The EFT User job aid that explains how providers may match the EFT payment to the remittance advice can be found at https:// massfinance.state.ma.us/vendorweb/masshealthproviderja.asp. * The EFT Enrollment/Modification Form can be completed manually or electronically. Electronic submissions must also be printed, signed, and mailed to the address below. The Commonwealth of Massachusetts requires a wet signature on all EFT enrollments, modifications, and terminations. All paper forms must be mailed to the following address: MassHealth Customer Service Attn: Provider Enrollment and Credentialing P.O. Box 9162 Canton, MA 02021