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): (must be 9 digits)
National Provider Identifier (NPI): (Billing/Type 2 NPI – must be 10 digits)
PROVIDER CONTACT INFORMATION
Provider Contact Name: Title:
Telephone Number: Telephone Number Extension:
Email Address: Fax Number:
ELECTRONIC REMITTANCE ADVICE INFORMATION
Preference for Aggregation of Remittance Data: (e.g., account number linkage to Provider Identifier)
c Provider Tax Identification Number (TIN) c National Provider Identifier (NPI)
SUBMISSION INFORMATION
Reason for Submission:
c New Enrollment c Change Enrollment c Cancel Enrollment
Authorized Signature:
Printed Name of Person Submitting Enrollment:
Printed Title of Person Submitting Enrollment: Submission Date:
SUBMISSION INFORMATION
This ERA Enrollment Form must be fully completed, signed, and returned via fax to Blue Cross
and Blue Shield of New Mexico (BCBSNM) Electronic Commerce Services at 312-946-3500.
Prior to enrolling for ERA you or your preferred clearinghouse must be registered with Availity
®
.
The ERA enrollment process establishes an electronic mailbox where Availity will place the
electronic remittance file(s) received from payer(s). There is no charge to register with Availity.
Visit availity.com for details.
Out-of-state providers need to specifically contact their local Blue Plan
for enrollment to receive ERAs for BlueCard
®
and Medicare Secondary
Crossover claims.
ERA enrollment processes for Federal DentalBlue
SM
Supplemental policies are
administered by Dental Network of America (DNoA).
Upon completion and approval this ERA Authorization Agreement will be used to activate
ERA delivery for all claims submitted by/on behalf of the enrolling provider, once claims are
finalized. The paper Provider Claim Summary (PCS) currently provided by BCBSNM will be
discontinued 31 days after your ERA enrollment is effective.
If you have questions regarding the ERA enrollment process, contact BCBSNM Electronic Commerce
Services at ecommerceservices@bcbsnm.com or 800-746-4614. To obtain the status of your
enrollment refer to the Electronic Commerce section on our website at bcbsnm.com/provider.
Electronic Remittance Advice (ERA)
Authorization Agreement
RECEIVER INFORMATION (Not required for cancellation requests)
Availity Customer ID: (must be 4-6 numeric digits)
If a separate mailbox is needed for Electronic Payment
Summary (EPS)* delivery, provide the Availity Customer ID:
Receiver Name:
Select Yes or No to enroll in ERA for Medicare Secondary
Crossover claims from other Blue Plan(s):
c Yes c No
OTHER INFORMATION
Indicate which provider file(s) associated with the NPI/
Tax ID combination should be updated:
c Institutional c Professional c Both
*EPS delivery is unavailable for Medicare Advantage claims.
Availity is a trademark of Availity, LLC., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides
administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any
questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
DNoA is a separate company that is the administrator for BCBSNM dental plans.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross
®
, Blue Shield
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
June 2019 03537.0519
