Fillable AETNA BETTER HEALTH OF VIRGINIA (128VA) ERA ENROLLMENT

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AETNA BETTER HEALTH OF VIRGINIA (128VA) ERA ENROLLMENT

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• Aetna Better Health of Virginia Electronic Remittance Advice (ERA) Enrollment Form
• Emdeon ERA Enrollment Form
o NOTE: This form is emailed to Office ally, not Emdeon.
• Fax the Aetna ERA form to (844) 230-8829 or email it to AetnaBetterHealth-VAProviderRelations@aetna.com
• Email the Emdeon ERA Enrollment Form to Support@officeally.com
• Office Ally will process your Emdeon ERA Enrollment Form within 24-48 hours.
• Aetna will process your enrollment form within 10-15 business days.
• To check the status, email AetnaBetterHealth-VAProviderRelations@aetna.com
.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
AETNA BETTER HEALTH OF VIRGINIA
(128VA) ERA ENROLLMENT INSTRUCTIONS
WHAT FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME FOR ERA ENROLLMENT?
HOW DO I CHECK STATUS?
In order to enroll to receive ERAs electronically from this payer, please fill out this form and return it via email
to Support@officeally.com
, the Email Subject should read: Emdeon ERA Enrollment.
Provider Name:
Provider Address:
Provider Federal Tax Identification Number (TIN)
OR Employer Identification Number (EIN):
National Provider Identifier (NPI):
Provider Contact Name:
Telephone Number:
Email Address:
Preference for Aggregation
Of Remittance Data:
Note: Account Number Linkage to Provider Identifier. Must match preference for EFT payments.
Reason for Submission:
Authorized Signature:
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 INFORMATION:
PROVIDER IDENTIFIER INFORMATION:
PROVIDER CONTACT INFORMATION:
ELECTRONIC REMITTANCE ADVICE INFORMATION:
SUBMISSION INFORMATION:
Aetna Better Health of Virginia (Payer ID: 128VA)
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AETNA BETTER HEALTH OF VIRGINIA (128VA) ERA ENROLLMENT

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Completed 7 April 2021

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