Fillable Form 835: Network Medical Management (eSolutions Payerlist)

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Form 835: Network Medical Management (eSolutions Payerlist)

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The Form 835: Network Medical Management (eSolutions Payerlist) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Payer ID: Per the payer list
www.esolutionsinc.com 2020-10-28
Network Medical Management
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 group/billing information as credentialed with the payer.
• Once completed, save for your records, print and obtain appropriate signature(s).
• EDI enrollment processing timeframe is approximately 15 business days.
837 Claim Transactions:
Enrollment applies to ERA only and is not necessary prior to sending claims.
835 Electronic Remittance Advice:
Complete the Electronic Remittance Advice (ERA) Enrollment Form
Complete all sections as appropriate.
Sign and submit direct to the payer.
Provider must Submit Completed Documents:
Email or Fax to
ProviderNetworkOperations.Dept@nmm.cc
626-943-6309
Please complete all sections. Incomplete submissions will not be processed.
ELECTRONIC REMITTANCE ADVICE (ERA) ENROLLMENT FORM
Electronic Remittance Advice (ERA/835) files are electronic transactions that contain the same
information as your paper remittances. Please complete the sections below in its entirety and send to
the following: FAX (626) 943-6309, via email, ProviderNetworkOperations.Dept@nmm.cc
Advantage Health Network (ADV)
Access Primary Care Medical Group (APCMG)
Accountable Health Care (AHCIPA)
Adventist Health Physicians Network (GAMC / WMMC)
Arroyo Vista Family Health Center (AVISTA)
Citrus Valley IPA (CVIPA)
Greater San Gabriel Valley Physicians (GSGP)
Community Family Care IPA (CFC)
LaSalle Medical Associates (LSMA)
Alpha Care Medical Group (ACMG)
Greater Orange Medical Group (GOM)
Other ___________________________
PROVIDER INFORMATION
Contracted Provider Group Name:
Provider Main Office Address:
Authorized Contact Person:
Authorized Contact Person Phone:
Authorized Contact Person Email:
PROVIDER IDENTIFICATION INFORMATION
Federal Tax ID:
Group NPI:
Individual Provider NPI(s):
ELECTRONIC REMITTANCE ADVICE INFORMATION (ONLY CHECK ONE BOX)
Preference for Aggregation of Remittance Data: (i.e., Account number linkage to Provider identifier). Please note, preference for grouping
claim payment advice, must match preference for EFT payment (i.e., Billing Provider). Please fill in only one below:
Provider Federal Tax Identification Number:
_________________________________________________
OR
National Provider Identifier (NPI):
__________________________________________________
I _____________________________________, hereby authorize Network Medical Management to
provide ____________________________________ with the Electronic Remittance Advice for our organization.
Practice/Owner Name: _________________________________________________________________
Practice/Owner Signature: _________________________________________ Date:_________________
Practice Owner/CEO
eSolutions fka ClaimRemedi
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Form 835: Network Medical Management (eSolutions Payerlist)

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Completed 23 September 2021

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