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BCBS OF LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• BCBS LA Business Associate Profile
• Electronic Remittance Advice (ERA) Enrollment – If you would like to receive ERAs through Office Ally
• Email the form(s) to ediservices@bcbsla.com; OR
• Fax to (225) 298-2945
• Standard processing time is 3 business days
• To check the status of your enrollment, call (225) 291-4334 and ask if you have been linked to Office Ally’s
Submitter ID P0010990
• Once you receive confirmation that you have been linked to Office Ally you MUST email
Support@officeally.com
with the below information PRIOR to submitting claims electronically
Email Subject: BCBS Louisiana (53120) – EDI Approval
Body of Email:
Please log my EDI approval for BCBS Louisiana.
o Provider Name
o NPI
o Tax ID
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
BCBS OF LOUISIANA (53120)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
® ®
An independent licensee of the Blue Cross and Blue Shield Association.
Business Associate Profile
The Business Associate Profile form must be completed to
r
eflec
t
each
provider/location
that
has
authorized
the
Trading Partner
to submit and receive BCBSLA electronic
trans
a
ctions.
o
Add
new
Provider
Location
S
ubmitter
ID
For
Existing
Submitters:
_______________
Provider/Clinic/Location
Name Date Completed By
Phone Number Email Address
Complete this form if you wish to enroll for claim submission only.
835/ ERA enrollments will only be processed by completing the new ERA Enrollment form found at
www.bcbsla.com >I’m a Provider >Electronic Services >Clearinghouse
Please allow 3-5 business days for set up.
BCBSLA
does not set up out of state providers.
Provider’s NPI must already be registered with BCBSLA Provider File area. You may contact the
Provider
File Department at
800-716-2299 option 3 for further information.
Completed forms can be faxed: 225-298-2945 or emailed: edich@bcbsla.com. For questions
regarding this form, please contact the EDI department: 225-291-4334.
Print the provider name as it appears on
each BCBSLA Payment Register.
Provider Name:
Print the provider’s
Federal Tax ID #:
Print NPI Number:
P0010990
18NW2095 R08/15 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and
incorporated as Louisiana Health Service & Indemnity Company.
The ERA service enables Blue Cross and Blue Shield of Louisiana to provide you with an electronic remittance advice,
which is a statement of your claims payments in an electronic format. A copy of this form is available online at
www.bcbsla.com/providers >Electronic Services >Clearinghouse.
PROVIDER INFORMATION
Provider Name – Complete legal name of institution, corporate entity, practice or individual provider
Street Address – The number and street name where a person or organization can be found
City – City associated with provider address field
State/Province – The two character code associated with the State/Province/Region of the applicable country
ZIP Code/Postal Code – System of postal-zone codes (zip stands for “zone improvement plan”) introduced in the
U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities
PROVIDER IDENTIFIERS INFORMATION
Provider Federal Tax Identification Number (TIN) / Employer Identification Number (EIN) – A Federal Tax
Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity
National Provider Identifier (NPI) – A Health Insurance Portability and Accountability Act (HIPAA) Administrative
Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered
healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative
and financial transactions adopted by HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit
number). This means that the numbers do not carry other information about healthcare providers, such as the state
in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA
standards transactions.
Trading Partner ID – The provider’s submitter ID assigned by health plan, the provider’s clearinghouse or vendor.
PROVIDER CONTACT INFORMATION
Contact Name – Name of a contact in provider office for handling ERA issues
Title – Title of the contact person
Telephone Number – Associated with the contact person
Email Address – An electronic mail address at which the health plan might contact the provider
Fax Number – A number at which the provider can be sent facsimiles
ELECTRONIC REMITTANCE ADVICE INFORMATION – Provider preference for grouping (bulking) claim payment
remittance advice – must match preference for EFT payment.
Provider Tax Identification Number (TIN) – see explanation under Section 2 above.
National Provider Identifier (NPI) – see explanation under Section 2 above.
Method of Retrieval – The method in which the provider will receive the ERA from the health plan (e.g., download
from health plan website, clearinghouse, etc.)
Note: BCBSLA groups all Electronic Remittance Advices by NPI, if available. When NPI is not available, ERAs are
grouped by TIN.
Guide to Completing the
Electronic Remittance Advice
(ERA) Enrollment Form
18NW2095 R08/15 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and
incorporated as Louisiana Health Service & Indemnity Company.
ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
Clearinghouse Name – Official name of the provider’s clearinghouse
Clearinghouse Contact Name – Name of a contact in clearinghouse office for handling ERA issues
Telephone Number – Telephone number of contact
Email Address – An electronic mail address at which the health plan might contact the provider’s clearinghouse
ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION
Vendor Name – Official name of the provider’s vendor
Vendor Contact Name – Name of a contact in vendor office for handling ERA issues
Telephone Number – Telephone number of contact
Email Address – An electronic mail address at which the health plan might contact the provider’s vendor
SUBMISSION INFORMATION
Reason for Submission
New Enrollment – Select this option when not already enrolled for ERA (835)
Change Enrollment – Select this option when changing from an existing Trading Partner to a new Trading
Partner. Blue Cross allows set-up of ERA (835) for only one Trading Partner ID (i.e. PXXXXXXX) at a time.
The existing Trading Partner will be terminated 30 days from the enrollment date of your new Trading Partner.
Cancel Enrollment – Select this option when altogether terminating enrollment from the ERA (835) process
Authorized Signature – The signature of an individual authorized by the provider or its agent to initiate, modify or
terminate an enrollment. May be used with electronic and paper-based manual enrollment.
Electronic Signature of Person Submitting Enrollment – a typed rendering of a name unique to a
particular person used as confirmation of authorization and identity
Written Signature of Person Submitting Enrollment – a (usually cursive) rendering of a name unique to a
particular person used as confirmation of authorization and identity
Printed Name of Person Submitting Enrollment – The printed name of the person signing the form; may
be used with electronic and paper-based manual enrollment
Printed Title of Person Submitting Enrollment – The printed title of the person signing the form; may be
used with electronic and paper-based manual enrollment
Submission Date – The date on which the enrollment is submitted
RETURN INFORMATION
The form lists the mailing address, fax number and email address of BCBSLA’s EDI Department as three options
for returning the ERA (835) Enrollment Form.
Mail to: Attn: EDI / BCBSLA
P.O. Box 98029
Baton Rouge, LA 70898-9029
Fax: 1.225.298.2945
Email: EDICH@bcbsla.com
18NW2095 R08/15 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and
incorporated as Louisiana Health Service & Indemnity Company.
Providers should contact their financial institution to arrange for the delivery of the CORE required minimum CCD+ Data
Elements necessary for successful re-association of the electronic funds transfer (EFT) payment with the ERA (835)
remittance advice. Shown below are the Data Elements that are necessary for re-association:
CCD
Record #
Field # Field Name
5 9 Effective Entry Date
6 6 Amount
7 3 Payment Related Information
Late/Missing EFT and ERA Transactions Resolution Procedures:
ERA (835) files are available weekly in Trading Partner mailboxes on Mondays, and no later than Wednesday, except
during holidays or unexpected office closures. If you do not receive your ERA by close of business on Wednesday, you
may contact EDI Services at 225.291.4334 or email EDICH@bcbsla.com. Please include the Trading Partner ID, check
number, check amount, check date and NPI.
EFT transactions are typically available at the provider’s bank on Wednesday. If you have not received your deposit by
close of business on Wednesday, you may contact EDI Services by calling the LINKLine at 225.293.5465 or
1.800.216.2583.
For questions about the ERA Form, please contact EDI Services at 225.291.4334. Also visit www.bcbsla.com/providers
>Electronic Services >Clearinghouse.
To check the status of your ERA Form, you may submit your request via email to EDICH@bcbsla.com. Please include
the provider or group name, NPI, TIN or EIN and Trading Partner ID. Please allow three to five business days for setup.
To check the status of your EFT Form, you may submit your request via email to network.administration@bcbsla.com.
Please include the provider or group name, NPI and TIN or EIN. Please allow up to 15 business days for setup.
Provider’s NPI must already be on file with Blue Cross. For more information on reporting your NPI to Blue Cross, visit
www.bcbsla.com/providers >NPI or you may contact Network Operations at 1.800.716.2299, option 3.
Blue Cross does not set up ERAs for out-of-state providers.
18NW2094 R08/15
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and
incor
p
orated as Louisiana Health Service & Indemnit
y
Com
p
an
y
.
Electronic Remittance Advice
(ERA) Enrollment Form
By completing this form, you are enrolling for the receipt of an ERA (835), to be delivered to the Trading Partner ID you
are specifying in this enrollment. All fields must be completed in order for us to complete processing of the enrollment.
PROVIDER INFORMATION
Provider Name
Provider Address: Street
City State/Province Zip Code/Postal Code
PROVIDER IDENTIFIERS INFORMATION
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
National Provider Identifier (NPI) Trading Partner ID
PROVIDER CONTACT INFORMATION
Contact Name Title
Telephone Number Email Address Fax Number
ELECTRONIC REMITTANCE ADVICE INFORMATION
Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)
Provider Tax Identification Number (TIN):
National Provider Identifier (NPI):
Method of Retrieval
From Health Plan Secure FTP
From Clearinghouse SOAP/MIME
ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
Clearinghouse Name
Clearinghouse Contact Name Telephone Number Email Address
ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION
Vendor Name
Vendor Contact Name Telephone Number Email Address
~Over~
P0010990
Office Ally (Submitter ID: P0010990)
Customer Service
360-975-7000
support@officeally.com
18NW2094 R08/15
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and
incor
p
orated as Louisiana Health Service & Indemnit
y
Com
p
an
y
.
SUBMISSION INFORMATION
Reason for Submission
New Enrollment
Change Enrollment
Cancel Enrollment
Authorized Signature
This information is to remain in full force and effect until Blue Cross and Blue Shield of Louisiana has received written
notification from me of its change or cancellation in such time and in such manner as to afford Blue Cross a
reasonable opportunity to act on it.
Electronic Signature of Person Submitting Enrollment
Written Signature of Person Submitting Enrollment
Printed Name of Person Submitting Enrollment
Printed Title of Person Submitting Enrollment
Submission Date
RETURN INFORMATION
Please return your completed ERA Enrollment Form in one of the following ways:
Mail to: Attn: EDI/BCBSLA Email: edich@bcbsla.com
P.O. BOX 98029
Baton Rouge, LA 70898-9029 Fax: (225) 298-2945
If you have any questions about this form or your ERA enrollment status, please contact EDI at:
Phone: (225) 291-4334 Email: edich@bcbsla.com
Internal Use Only
TPM set-up completed on:
Employee ID No.:
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BCBS OF LOUISIANA (53120) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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