In order to enroll to receive ERAs electronically from this payer, please fill out this form and return it via email
, the Email Subject should read: Emdeon ERA Enrollment.
Provider Federal Tax Identification Number (TIN)
OR Employer Identification Number (EIN):
National Provider Identifier (NPI):
Provider Contact Name:
Preference for Aggregation
Of Remittance Data:
Note: Account Number Linkage to Provider Identifier. Must match preference for EFT payments.
Reason for Submission:
Note: Electronic Signature (typed name) of Person Submitting ERA Enrollment.
Oﬃce Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
EMDEON ERA ENROLLMENT FORM
PAYER NAME AND PAYER ID:
PROVIDER IDENTIFIER INFORMATION:
PROVIDER CONTACT INFORMATION:
ELECTRONIC REMITTANCE ADVICE INFORMATION:
Aetna Better Health of Virginia (Payer ID: 128VA)