Fillable Era 1 (Commonwealth of Massachusetts)

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Era 1 (Commonwealth of Massachusetts)

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The Era 1 (Commonwealth of Massachusetts) form is 2 pages long and contains:

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  • 3 check-boxes
  • 54 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth
Electronic Remittance Advice
Enrollment/Modication Form
PROVIDER INFORMATION
Provider Legal Name DBA Name
Street City State Zip Code
PROVIDER IDENTIFIERS INFORMATION
Provider TIN or EIN NPI
Other Identifier(s)
Assigning Authority Trading Partner ID
Provider Type Provider Taxonomy Code
PROVIDER CONTACT INFORMATION
Provider Contact Name Title
Telephone Number Telephone Number Extension Fax Number
E-mail Address
PROVIDER AGENT INFORMATION
Provider Agent Name
Street City State Zip Code
Provider Agent Contact Name Title
Telephone Number Telephone Number Extension
E-mail Address Fax Number
RETAIL PHARMACY INFORMATION
Pharmacy Name
Chain Number Parent Organization ID Payment Center ID
NCPDP Provider ID Number Medicaid Provider Number
ELECTRONIC REMITTANCE ADVICE INFORMATION
Provider Tax ID Provider NPI Method of Retrieval
ERA-1 (Rev. 08/1
7)
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ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
Clearinghouse Name
Clearinghouse Contact Name
Telephone number E-mail Address
ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION
Vendor Name
Vendor Contact Name
Telephone Number E-mail Address
SUBMISSION INFORMATION
Reason for Submission: New Enrollment Change Enrollment Cancel Enrollment
Written Signature of Person Submitting Enrollment
Printed Name of Person Submitting Enrollment
Printed Title of Person Submitting Enrollment
Submission Date Requested ERA Effective Date
• Instructions to complete the ERA Enrollment/Modification form can be found at www.mass.gov/eohhs/docs/masshealth/
aca/era-instructions.pdf.
You may also confirm the status of your ERA enrollment by contacting MassHealth Customer Service at 1-800-841-2900.
• The ERA Enrollment/Modification form can be completed manually or electronically via the Provider Online Service Center
(POSC). All paper forms must be mailed to the following address:
MassHealth Customer Service
Attn: Provider Enrollment and Credentialing
P.O. Box 121205
Boston, MA 02112-1205
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Era 1 (Commonwealth of Massachusetts)

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Completed 23 July 2020

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