FLORIDA MEDICAID ERA CONTRACT ... - MD On-Line

FLORIDA MEDICAID ERA CONTRACT INSTRUCTIONS (SKFL0)
Please FAX or EMAIL completed and signed forms to:
MD On-Line
ATTN: Enrollment
888-837-2232
setup@mdol.com
Please do not submit forms directly to Medicaid.
Refer to these instructions while completing enrollment forms.
Online enrollment is required with this enrollment form.
Instructions follow after the form completion information.
Please type provider information on the form for ease of processing at MDOL.
Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement:
Provider Information*
Complete the provider name/dba name if applicable, and street address on file with Medicaid.
Contact the payer to confirm provider information; MDOL cannot obtain this information.
Provider Identifiers Information*
Complete billing TIN/EIN and billing NPI.
Other Identifiers*
Complete the FL Medicaid Provider ID Number listed on file with Medicaid.
Contact the payer to confirm provider information; MDOL cannot obtain this information.
Provider Contact Information*
Complete with contact information for the provider.
Electronic Remittance Advice Information/ERA Clearinghouse Information^
Do not alter the pre-filled information in these sections.
Submission Information*
Enter the name and title of the authorized signee. Enter the signature date. After printing, sign the form.
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Complete the online remittance advice set up per the following instructions:
Create and log into your FL MMIS account at http://home.flmmis.com.
On the Account Management screen, click the Add Agent button.
Search for Medical Claim Corp and browse to page 2.
Near the bottom of the page, choose the username flmcad08.
Press the Select button at the right. Then you will be able to add or remove roles.
-Step 1 will search for the provider or billing agent
-Step 2 will select “Florida Web Portal”
-Step 3 will choose what permissions you permit MD On-Line to have access to.
Choose Download 835 and Trade Files.
*Note: do not “ADD NEW AGENT” – your enrollment request will not process correctly.
Please FAX or EMAIL completed and signed forms to:
MD On-Line
ATTN: Enrollment
888-837-2232
setup@mdol.com
Please do not submit forms directly to Medicaid.
Have questions or need assistance Contact the MDOL Enrollment
Department at 888-499-5465 x3506 or setup@mdol.com
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For Fiscal Agent Use: ____________________
Florida Medicaid Electronic Remittance Advice (ERA) Authorization Agreement
Provider Information*
Provider Name*
Doing Business As Name (D/B/A)
Provider Address Street * (Street Name and Number – NOT a P.O. Box)
Provider Address (Suite, Room, etc.)
City* State* ZIP*
Provider Identifiers Information*
Provider Federal Tax Identification Number (TIN) or
Employer Identification Number (EIN)*
National Provider Identifier (NPI)^
Other Identifiers*
Assigning Authority – Florida Medicaid Provider
Identification Number*
Trading Partner ID^
Provider Contact Information – for ERA Issues*
Provider Contact Name*
Telephone Number* E-mail Address^ Fax Number
Electronic Remittance Advice Information*
Preference for Aggregation of Remittance Data* (Must match preference submitted on EFT)
Provider Tax Identification Number (TIN) National Provider Identifier (NPI)
NOTE: This information is being collected in the event Florida Medicaid changes ERA aggregation (which is currently done by Medicaid Provider
Identification Number).
Electronic Remittance Advice Clearinghouse Information^
Clearinghouse Name
Telephone Number
E-mail Address
Submission Information*
Authorized Signature*
Printed Name of Person Submitting Enrollment*
Printed Title of Person Submitting Enrollment*
Submission Date*
Instructions for completing the ERA Authorization Agreement
• The online registration form may be accessed via the secure web portal (http://home.flmmis.com) under the Provider
Demographic heading.
• Please type or print legibly in black or blue ink.
• Fields marked with an asterisk (*) are required.
• Fields marked with a carat (^) are required if the information is available.
• Please allow 3 weeks for processing. If after 3 weeks you do not receive ERA files, contact the EDI Operations team at
(866) 586-0961 to inquire.
AHCA Form 2200-0003 (November 2013) Page 1 of 1