Fillable Form 835: AARP Dental Please save this document (eSolutions Payerlist)

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Form 835: AARP Dental Please save this document (eSolutions Payerlist)

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Payer ID: AARP1
www.esolutionsinc.com 2020-01-31
ESH
AARP Dental
835
EDI Enrollment Instructions:
• Please save this document to your computer. Open the file in the Adobe Reader program and type
directly onto the form.
• Complete the form using the provider’s billing/group information as credentialed with this payer.
• EDI enrollment processing timeframe is approximately 30 business days.
• To check enrollment status, contact your clearinghouse at 866-633-4726.
837 Claim Transactions:
EDI enrollment applies to ERA only and is not necessary prior to sending claims.
835 Electronic Remittance Advice:
Electronic Remittance Advice (ERA) Authorization Agreement
Complete all applicable fields.
Submit Completed Document:
E-mail to eSolutions with this cover sheet.
The enrollment specialist will complete the setup with the payer.
ESH@claimremedi.com
Electronic Remittance Advice (ERA)
Authorization Agreement
17701 Cowan Suite250 Irvine, CA 92614
I
01/20/14
Page 1/2
To start receiving your ERAs from the payer through DentalXChange you will need to follow the
instructions below. (* indicates required field)
*
Payer Name
A. Provider Information
*
Provider Name
*
Provider Address
Street:
State/Province:
Zip Code/Postal Code:
B. Provider Identifiers Information
Provider Federal Tax Identification Number (TIN) or
Employer Identification Number (EIN)
National Provider Identifier (NPI)
C. Provider Contact Name
*Contact
*Telephone Number
*Email Address
D. 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)
D. Submission Information
*
Reason for Submission
New Enrollment Change Enrollment Cancel Enrollment
Authorized Signature
Electronic or Printed Signature of Person Submitting Enrollment
Title of Person Submitting Enrollment
AARP
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Form 835: AARP Dental Please save this document (eSolutions Payerlist)

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Completed 23 September 2021

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