Please carefully read all instructions before beginning ... - MD On-Line

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Please carefully read all instructions before beginning ... - MD On-Line

MASSACHUSETTS MEDICAID EDI CONTRACT INSTRUCTIONS (SKMA0)FAX or EMAIL the completed setup form and signed EDI Enrollment request to:MD On-LineATTN: Enrollment888-837-2232setup@mdol.comPRINT these instructions. Refer to them as you complete the registration process.The MassHealth 837/835 EDI enrollment request template following these instructions must be printedon 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 onfile. MD On-Line cannot complete this step for you.• OPTIONAL: If you want to receive ERA from this payer, MassHealth now requires that all providersenroll 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 beforerequesting ERA enrollment.• Providers should contact MassHealth to confirm pre-notification status before requesting ERAenrollment.• EFT and ERA enrollment do not affect 837 claims enrollment; providers can enroll in 837 claimswith 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 signatureNone 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 EDIEnrollment request to MD On-Line Enrollment only.Do not submit the setup form or the MassHealth 837/835 EDI Enrollmentrequest 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-LineATTN: Enrollment888-837-2232setup@mdol.comHave questions or need assistance? Contact the MD On-Line EnrollmentDepartment at 888-499-5465 x3506 or setup@mdol.com082014


SUBMIT COMPLETED FORMS TO ENROLLMENT BY FAXAT 888-837-2232 OR EMAIL AT SETUP@MDOL.COMPlease complete one Contract Setup Form per Tax ID. Return the form to MD On-Line’s Enrollment Department with yourEDI 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 InstructionsPlease type or copy & paste the following letter onto your provider letterhead. Thisletter is necessary for us to begin sending claims to Massachusetts Medicaid on yourbehalf: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) underMedical Claim Corp., submitter number 110076480A.Provider name Provider Number NPI(Please list all provider names and their corresponding Medicaid provider number andNPI. 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 MassachusettsExecutive Office of Health and Human Serviceswww.mass.gov/masshealthElectronic Funds Transfer (EFT)Enrollment/Modification FormComplete this form to enroll in electronic funds transfer (EFT) with MassHealth or to terminate or modify an existing electronicfunds agreement. Additional terms of agreement on page 2 of this form must be completed.Provider InformationProvider Legal NameDBA NameStreet City State Zip CodeProvider Identifiers InformationProvider TIN or EINNPIProvider contact InformationProvider Contact NameTelephone NumberTelephone Number ExtensionE-mail AddressFederal agency informationFederal Program Agency IdentifierFinancial Institution informationFinancial Institution NameStreet City State Zip CodeFinancial Institution Routing NumberType of Account at Financial InstitutionProvider’s Account Number with Financial InstitutionProvider TINNPISubmission informationReason for Submission New Enrollment Change Enrollment Cancel Enrollment Included Voided Check Bank LetterWritten Signature of Person Submitting EnrollmentPrinted Name of Person Submitting EnrollmentSubmission DateIf you are modifying or changing your bank account information, you must include your old bank account informationon 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 SavingsCERTIFICATIONI, , hereby certify that the account(s) indicated on this formis under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the Commonwealthof Massachusetts to initiate, change, or cancel credit entries to that account/s as indicated on this form. For ACH debitsconsistent 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 aforeign bank account.I affirm that payments authorized hereunder are to an account that is subject to being transferred to aforeign bank account.This authority is to remain in full force and effect until the Office of Comptroller (CTR) has received written notificationfrom either me or an authorized officer of the organization of the account's termination in such time and in such a manneras 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 sentto 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 forInformation Exchange)-required Minimum CCD+(Corporate Credit or Debit entry) data elements needed for reassociationof 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 CustomerServices 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 athttps://massfinance.state.ma.us/VendorWeb/MassHealthProviderJA.asp.• The EFT Enrollment/Modification form can be completed manually or electronically. Electronic submissions must beprinted, signed, and mailed to the address below. The Commonwealth of Massachusetts requires a "wet" signature on allEFT enrollments, modifications, and terminations. All paper forms must be mailed to the following address.MassHealth Customer Services CenterAttn: Provider Enrollment and CredentialingP.O. Box 9162Canton, MA 02021-5213page (2/2)


Commonwealth of MassachusettsExecutive Office of Health and Human Serviceswww.mass.gov/masshealthElectronic Funds Transfer Enrollment/Modification FormInstructionsThese instructions should be used as a guide to complete the Electronic Funds Transfer (EFT) Enrollment/Modification Form.Data ElementsProvider NameDoing Business As (DBA)NameStreetCityStateZip Code +4Provider Federal Tax IdentificationNumber (TIN) or FederalEmployer Identification Number(FEIN) or SSNNational Provider Identifier (NPI)Provider Contact NameTelephone NumberTelephone Number ExtensionE-mail AddressFederal Program Agency IdentifierFinancial Institution NameStreetCityStateZip Code +4Financial Institution RoutingNumberType of Account at FinancialInstitutionProvider’s Account Number withFinancial InstitutionDefinitionPROVIDER INFORMATIONComplete legal name of institution, corporate entity, practice, or individual provider.Trade name, or business name, under which the business or operation is conducted. TheDBA 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 maildelivery and exploit electronic reading and sorting capabilities.PROVIDER IDENTIFIERSEnter the federal tax identification number or federal employer identification number, alsoknown as an (FEIN) or (SSN), here. This is the number you provided to the Commonwealthupon 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 uponenrollment in MassHealth.PROVIDER CONTACT INFORMATIONName 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 INFORMATIONMassHealth provider ID/service location.FINANCIAL INSTITUTION INFORMATIONOfficial name of the provider’s financial institution.Street address associated with the receiving depository listed in the financial institutionname 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 maildelivery and electronic reading and sorting capabilities.A nine-digit identifier of the financial institution where the provider maintains an accountto which payments are to be deposited.The type of account the provider will use to receive EFT payments. This must be either aChecking or Savings account.Provider’s account number at the financial institution to which EFT payments are to bedeposited.EFT-1 Instructions (Rev. 02/14)


Provider Federal Tax IdentificationNumber (TIN)National Provider Identifier (NPI)New EnrollmentChange EnrollmentCancel EnrollmentVoided CheckBank LetterWritten Signature of PersonSubmitting EnrollmentPrinted Name of PersonSubmitting EnrollmentProvider Old Bank Account NumberAccount TypeA 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 Commonwealthupon 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 uponenrollment in MassHealth.SUBMISSION INFORMATIONReason 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 ofthe form. This section can be found directly following the Submission Information sectionon 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 accountnumbers.A “wet” signature is required. Manually completed forms, including a wet signature of theauthorized person completing the form, must also be mailed to the address at the bottom ofthe EFT Enrollment/Modification form.The printed name of the authorized person signing the form; may be used with electronicand paper-based manual enrollment.Provider’s old bank account number at the financial institution that is requested to bechanged.The provider’s old bank account type that received EFT payments. This must be either aChecking or Savings account.Complete name – this is found on page 2 of the form and must be completed.CertificationAffirmation Check one –payments ARE NOTpayments AREsubject to being transferred to a foreign bank accountSignature of authorizedrepresentative* Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for InformationExchange)-required Minimum CCD+ (Cash Concentration or Disbursement) data elements needed for re-association of thepayment 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 at1-800-841-2900.* 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 ServiceAttn: Provider Enrollment and CredentialingP.O. Box 9162Canton, MA 02021

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