Fillable form for each.: Electronic Remittance Advice (ERA) enrollment (Moda Health)

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  • 87 other fields

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28697918 (10/17)
General instructions:
1. Moda requires both the EFT and ERA forms to be completed.
2. Once we receive the completed forms and/or confirmation from the clearinghouse to set up the provider
(if applicable), allow 2-3 weeks for the enrollment process. The enrollment process includes pre-note
verification, provider/clinic/facility name and TIN confirmation with IRS and verifying NPIs.
NOTE: Each clearinghouse may require providers to complete a separate enrollment forms.
3. If there are multiple NPIs under one TIN, complete one ERA/EFT enrollment form and complete the List of
NPI page included with this form. If there are different bank account for each NPIs, complete one ERA/EFT
form for each.
4. For questions regarding the forms, please send an email to edigroup@modahealth.com.
Completing the ERA Form
1. Provider information
a. Provider name — - provider/clinic/facility name as
listed in the W9 or IRS EIN Assignment letter.
b. Doing business as name — DBA name if applicable.
c. Provider address — this can be the billing address or
physical location.
2. Provider identifiers information
a. Provider TIN or EIN — provider/clinic/facility TIN or EIN.
b. National Provider Identifier — provide Type II NPI if
enrolling a clinic, provider group or facility. If enrolling
an individual provider or sole proprietor, provide
Type II NPI if you have one, otherwise provide Type I.
c. Other identifier/taxonomy code — provide if known
but this is not a requirement.
3. Provider contact information
a. Provider contact name — name of contact person for
the provider/clinic/facility.
b. Telephone number and extension — provider
telephone and extension for the contact person.
c. Email address — email address of the provider
contact person.
4. Electronic Remittance Advice information
a. Preference for aggregation of remittance data
(e.g account number linkage to provider identifier:
• Provider Federal Tax Identification Number —
provide provider/clinic/facility TIN.
• National Provider Identifier — provide Type II NPI
if enrolling a clinic, provider group or facility. If
enrolling an individual provider or sole proprietor,
provide Type II NPI, if you have one, otherwise
provide Type I.
b. Method of retrieval — generally this should be
“Clearinghouse.”
5. Electronic Remittance Advice
clearinghouse information
a. Clearinghouse name — provide clearinghouse name.
See the clearinghouse list below.
6. Submission information
a. Reason for submission — check if enrollment is new,
change or cancel.
b. Authorized signature — written and printed name of
the authorized personnel.
c. Submission date — date form is submitted to Moda.
Changes to an existing 835 setup
Bank account update
Complete new EFT enrollment form and fax to Moda Health.
Allow 10 business days for bank account update as this
requires pre-note verification.
Clearinghouse update
Complete new ERA enrollment form. Providers must contact
their clearinghouses for specific instructions on their
enrollment process. See the clearinghouse list.
Other updates
Change in Tax Identification Number (TIN), Employer
Identification Number (EIN) and/or National Provider
Identification (NPI)
a. Providers are required to contact Moda Health
Professional Relations department to update the TIN,
EIN or NPI in our provider records.
Providerupdates@modahealth.com
Fax 503-243-3964
Phone 800-420-7758
b. Contact Clearinghouse for their specific instructions
on their enrollment process.
c. Providers will need to complete and submit new ERA
and EFT forms.
Change in billing or physical address
a. Providers are required to contact Moda Health
Professional Relations department to update
the address in our provider records. See above
contact information.
b. New forms are not necessary as this does not affect
the delivery of payment or ERA.
Cancellation of 835 setup
To cancel 835 setup, send an email request to
edigroup@modahealth.com.
Electronic Remittance Advice (ERA)
enrollment form instructions
2/4/2020
28697918 (10/17)
Moda Health ERA Clearinghouse Connection for
ERA/EFT initial enrollment
Clearinghouse name Contact and general enrollment information
Ability/MD Online
Complete the Moda Health ERA and EFT enrollment form and fax to Moda.
If you have any questions regarding Ability (MD Online) see below contact information:
https://abilitynetwork.com
To contact Sales, please call: 888 858-0506
Availity
Availity requires providers to enroll with them first in order to receive ERA from Moda.
To enroll with Availity connect to Availity Portal and follow the instructions listed on the
Availity Payer List.
• Complete Moda Health ERA form and EFT form and fax to Moda Health.
Availity sends a report to Moda (on Mondays) with the list of providers that completed the enrollment
and registration process with them. Availity sends an email to the providers with confirmation of
enrollment. Then, Moda starts the enrollment process.
If you have any questions regarding Availity, see below contact information:
1.800.282.4548
www.availity.com
Trizetto/Gateway EDI
Trizetto/ Gateway EDI requires provider to enroll with them first in order to receive ERA
from Moda.
• Complete the Moda Health ERA form and EFT form and fax to Gateway EDI
Provider Enrollment 314-898-1932
When Trizetto/Gateway EDI completes processing the provider enrollment forms, these are
forwarded to Moda for processing.
For any question regarding this process, please contact Trizetto/Gateway EDI Provider Enrollment:
800-969-3666
www.gateway.edi.com
MCPS — Medical Claims
Processing Solutions
Complete the Moda Health ERA form and EFT form and fax to Moda Health.
If you have any questions regarding MCPS, see below contact information:
800-879-7534
Office Ally
Complete the Moda Health ERA form and EFT form and fax to Moda Health.
If you have any questions regarding Office Ally, see below contact information:
866-575-4120
www.officeally.com
Payer Connection
Complete the Moda Health ERA form and EFT form and fax to Moda Health.
If you have any questions regarding Payer Connection, see below contact information:
503-419-6208
ChangeHealthcare
Providers are required to enroll thru Relay Health Collaboration Compass in order to receive ERAs
from Moda Health.
• Complete the Moda Health ERA form and EFT form and send or fax to Relay Health.
When Relay Health completes processing the provider enrollment forms, these are forwarded to
Moda for processing.
If you have any questions regarding Relay Health, see below contact information:
800-527-8133 (option 1)
Fax 916-267-2963
www.changehealthcare.com
2/4/2020
28697918 (10/17)
Section 1 Provider information
Provider name: Doing business as name (DBA):
Street:
City: State/Province: ZIP code/Postal code:
Section 2 Provider identifiers information
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):
National Provider Identifier (NPI):
Other identifier(s); provider taxonomy code:
Section 3 Provider contact information
Provider contact name: Telephone number: Telephone extension:
Email address:
Section 4 Electronic Remittance Advice information
Preference for Aggregation of Remittance Data (e.g. account number linkage to provider identifier)
Provider Tax Identification (TIN): National Provider Identifier (NPI): Method of retrieval:
Section 6 Submission information
Reason for submission
� New enrollment � Change enrollment � Cancel enrollment
Written signature:
X
Printed name: Printed title: Submission date (ccyymmdd):
Confidential when completed. Please mail or fax to:
Moda Health
ATTN: EDI Department
601 SW 2nd Ave
Portland, OR 97204
Fax number: 503-412-4068
NOTE: Do not send completed form via email.
Section 5 Electronic Remittance Advice Clearinghouse information
Clearinghouse name:
Moda Health Electronic Remittance Advice (ERA)
enrollment form
2/4/2020
click to sign
signature
click to edit
28697918 (10/17)
List of NPI under same TIN/EIN and same bank account:
NPI Physical Address if clinic has multiple locations
2/4/2020
28697918 (10/17)
modahealth.com
Moda Health nondiscrimination notice
ATENCIÓN: Si habla español,
hay disponibles servicios de
ayuda con el idioma sin costo
alguno para usted. Llame al
1-877-605-3229 (TTY: 711).
注意：如果您說中文，可得到免費語言
幫助服務。請致電
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서비스를 이용하시려면 다음
연락처로 연락해주시기 바랍니다.
전화
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PAUNAWA: Kung nagsasalita
ka ng Tagalog, ang mga
serbisyong tulong sa wika, ay
walang bayad, at magagamit
mo. Tumawag sa numerong
1-877-605-3229 (TTY: 711)
ВНИМАНИЕ! Если Вы говорите
по-русски, воспользуйтесь
бесплатной языковой
поддержкой. Позвоните
по тел. 1-877-605-3229
(текстовый телефон: 711).
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)711  1-877-605-3229
ATANSYON: Si ou pale Kreyòl
Ayisyen, nou ofri sèvis gratis pou
ede w nan lang ou pale a. Rele
nan 1-877-605-3229 (moun ki
itilize sistèm TTY rele : 711)
ATTENTION : si vous êtes
locuteurs francophones, le
service d’assistance linguistique
gratuit est disponible. Appelez
au 1-877-605-3229 (TTY : 711)
UWAGA: Dla osób mówiących
po polsku dostępna jest
bezpłatna pomoc językowa.
Zadzwoń: 1-877-605-3229
(obsługa TTY: 711)
ATENÇÃO: Caso fale português,
estão disponíveis serviços
gratuitos de ajuda linguística.
Telefone para 1-877-605-3229
(TERMINAL: 711)
ATTENZIONE: Se parla
italiano, sono disponibili per
lei servizi gratuiti di assistenza
linguistica. Chiamare il numero
1-877-605-3229 (TTY: 711)
注意：日本語をご希望の方には、
日本語サービスを無料で提供してお
ります。
1-877-605-3229（TTY、
テレタイプライターをご利用の方
は
711）までお電話ください。
Achtung: Falls Sie Deutsch
sprechen, stehen Ihnen kostenlos
Sprachassistenzdienste
zur Verfügung. Rufen sie
1-877-605-3229 (TTY: 711)
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
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
1-877-605-3229


(
TTY: 711
)
УВАГА! Якщо ви говорите
українською, для вас доступні
безкоштовні консультації
рідною мовою. Зателефонуйте
1-877-605-3229 (TTY: 711)
ATENȚIE: Dacă vorbiți limba
română, vă punem la dispoziție
serviciul de asistență lingvistică
în mod gratuit. Sunați la
1-877-605-3229 (TTY 711)
THOV CEEB TOOM: Yog hais
tias koj hais lus Hmoob, muaj
cov kev pab cuam txhais lus,
pub dawb rau koj. Hu rau
1-877-605-3229 (TTY: 711)
โปรดทราบ: หากคุณพูดภาษา
ไทย คุณสามารถใช้บริการ
ช่วยเหลือด้านภาษาได้ฟรี
โทร
1-877-605-3229 (TTY: 711)




1-877-605-3229 (TTY: 711)
HUBACHIISA: Yoo afaan
Kshtik kan dubbattan ta’e
tajaajiloonni gargaarsaa
isiniif jira 1-877-605-3229
(TTY:711) tiin bilbilaa.
Moda, Inc. complies with applicable
federal civil rights laws. We do not
discriminate on the basis of race, color,
national origin, age, disability or sex.
Moda provides free, timely aids and
services to people with disabilities
to help them communicate with us
effectively. These accommodations
include sign language interpreters and
written information in other formats.
If your primary language is not
English, Moda also provides free,
timely interpretation services and/or
materials written in other languages.
If you need any of the services
listed above, contact:
Customer Service,
503-243-2987 or 800-342-0526
(TDD/TTY 711)
If you believe that Moda has failed to
provide these services or discriminated
in another way on the basis of race,
color, national origin, age, disability
or sex, you can file a written grievance
by mailing or faxing it to:
Moda, Inc.
Attention: Appeal Unit
601 SW Second Ave.
Portland, OR 97204
Fax: 503-412-4003
If you need assistance filing
a grievance, please call the
applicable Customer Service
department listed to the left.
You can also file a civil rights complaint
with the U.S. Department of Health and
Human Services Office for Civil Rights at
ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone to:
U.S. Department of Health
and Human Services
200 Independence Ave. SW, Room 509F
HHH Building, Washington, DC 20201
800-368-1019, 800-537-7697 (TDD).
Office for Civil Rights complaint
forms are available at
hhs.gov/ocr/office/file/index.html.
Moda’s efforts to assure
nondiscrimination are coordinated by:
Tom Bikales, VP Legal Affairs
601 SW Second Ave.
Portland, OR 97204
855-232-9111
compliance@modahealth.com
2/4/2020
62776562 (11/19)
General instructions:
1. Moda Health requires both the EFT and ERA forms to be completed.
2. Once we receive the completed forms and/or confirmation from the clearinghouse to set up the provider
(if applicable), allow 2–3 weeks for the enrollment process. The enrollment process includes pre-note
verification, provider/clinic/facility name and TIN confirmation with IRS and verifying NPIs.
NOTE: Each clearinghouse may require providers to complete a separate enrollment forms.
3. If there are multiple NPIs under one TIN, complete one ERA/EFT enrollment form and complete the List of
NPI page included with this form. If there are different bank account for each NPIs, complete one ERA/EFT
form for each.
4. For questions regarding the forms, please send an email to edigroup@modahealth.com.
Electronic Fund Transfer enrollment form instructions
Completing the EFT Form
1. Provider information
a. Provider name — provider/clinic/facility name as listed
in the W9 or IRS EIN assignment letter.
b. Doing business as name — DBA name if applicable.
c. Provider address — this can be the billing address or
physical location.
2. Provider identifiers information
a. Provider TIN or EIN — provider/clinic/facility TIN or EIN.
b. National provider identifier — provide Type II NPI if
enrolling a clinic, provider group or facility. If enrolling
an individual provider or sole proprietor, provide Type
II NPI if you have one, otherwise provide Type I.
c. Other identifier/Taxonomy code — provide if known
but this is not a requirement.
3. Provider contact information
a. Provider contact name — name of contact person for
the provider/clinic/facility.
b. Telephone number and extension — provider
telephone and extension for the contact person.
c. Email address — email address of the provider
contact person.
4. Financial institution information
a. Financial institution name — provide name of
financial institution.
b. Financial institution routing number — provide the
ACH Transit Routing Number.
c. Type of account at financial institution — ‘Checking’
or ‘Savings’.
d. Provider’s account number with Financial Institution —
provide the checking or savings account number.
e. Account number linkage to provider identifier:
Tax Identification Number (TIN) — provider/clinic/
facility TIN linked to the checking account.
National Provider Identifier (NPI) — provider/clinic/
facility NPI linked to the checking account.
5. Submission information
a. Reason for submission — check if enrollment is new
or change.
b. Authorized signature — written and printed name of
the authorized personnel.
c. Submission date — date form is submitted to Moda.
Changes to an existing 835 setup
Bank account update
Complete new EFT enrollment form and fax to Moda Health.
Allow 10 business days for bank account update as this
requires pre-note verification.
Clearinghouse update
Complete new ERA enrollment form. Providers must contact
their clearinghouses for specific instructions on their
enrollment process.
Other updates
Change in Tax Identification Number (TIN), Employer
Identification Number (EIN) and/or National Provider
Identification (NPI)
a. Providers are required to contact Moda Health
Professional Relations department to update the TIN,
EIN or NPI in our provider records.
providerupdates@modahealth.com
Fax 503-243-3964
Phone 800-420-7758
b. Contact clearinghouse for their specific instructions
on their enrollment process.
c. Providers will need to complete and submit new ERA
and EFT forms.
Change in billing or physical address
a. Providers are required to contact Moda Health
Professional Relations department to update
the address in our provider records. See above
contact information.
b. New forms are not necessary as this does not affect
the delivery of payment or ERA.
Cancellation of 835 setup
To cancel 835 setup, send an email request to
edigroup@modahealth.com.
2/4/2020
62776562 (11/19)
Moda Health Electronic Fund Transfer (EFT) enrollment form
Section 1 Provider information
Provider name: Doing business as name (DBA):
Street:
City: State/Province: ZIP code/Postal code:
Section 2 Provider identifiers information
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):
National Provider Identifier (NPI):
Other identifier(s); provider taxonomy code:
Section 3 Provider contact information
Provider contact name: Telephone number: Telephone extension:
Email address:
Section 4 Financial institution information
Financial institution name: Financial institution routing number:
Type of account at financial institution:
� Checking � Savings
Provider’s account number with financial institution:
Provider Tax Identification Number (TIN): National Provider Identifier (NPI):
Section 5 Submission information
Reason for submission
� New enrollment � Change enrollment � Cancel enrollment
Written signature:
X
Printed name: Printed title: Submission date (ccyymmdd):
Confidential when completed. Please mail or fax to:
Moda Health
ATTN: EDI Department
601 SW 2nd Ave
Portland, OR 97204
Fax number: 503-412-4068
NOTE: Do not send completed form via email.
2/4/2020
62776562 (11/19)
modahealth.com
Moda Health nondiscrimination notice
ATENCIÓN: Si habla español,
hay disponibles servicios de
ayuda con el idioma sin costo
alguno para usted. Llame al
1-877-605-3229 (TTY: 711).
注意：如果您說中文，可得到免費語言
幫助服務。請致電
1-877-605-3229
(聾啞人專用：711）
CHÚ Ý: Nếu bạn nói tiếng
Việt, có dịch vụ hổ trợ ngôn
ngữ miễn phí cho bạn. Gọi
1-877-605-3229 (TTY:711)
주의: 한국어로 무료 언어 지원
서비스를 이용하시려면 다음
연락처로 연락해주시기 바랍니다.
전화
1-877-605-3229 (TTY: 711)
PAUNAWA: Kung nagsasalita
ka ng Tagalog, ang mga
serbisyong tulong sa wika, ay
walang bayad, at magagamit
mo. Tumawag sa numerong
1-877-605-3229 (TTY: 711)
ВНИМАНИЕ! Если Вы говорите
по-русски, воспользуйтесь
бесплатной языковой
поддержкой. Позвоните
по тел. 1-877-605-3229
(текстовый телефон: 711).



)711  1-877-605-3229
ATANSYON: Si ou pale Kreyòl
Ayisyen, nou ofri sèvis gratis pou
ede w nan lang ou pale a. Rele
nan 1-877-605-3229 (moun ki
itilize sistèm TTY rele : 711)
ATTENTION : si vous êtes
locuteurs francophones, le
service d’assistance linguistique
gratuit est disponible. Appelez
au 1-877-605-3229 (TTY : 711)
UWAGA: Dla osób mówiących
po polsku dostępna jest
bezpłatna pomoc językowa.
Zadzwoń: 1-877-605-3229
(obsługa TTY: 711)
ATENÇÃO: Caso fale português,
estão disponíveis serviços
gratuitos de ajuda linguística.
Telefone para 1-877-605-3229
(TERMINAL: 711)
ATTENZIONE: Se parla
italiano, sono disponibili per
lei servizi gratuiti di assistenza
linguistica. Chiamare il numero
1-877-605-3229 (TTY: 711)
注意：日本語をご希望の方には、
日本語サービスを無料で提供してお
ります。
1-877-605-3229（TTY、
テレタイプライターをご利用の方
は
711）までお電話ください。
Achtung: Falls Sie Deutsch
sprechen, stehen Ihnen kostenlos
Sprachassistenzdienste
zur Verfügung. Rufen sie
1-877-605-3229 (TTY: 711)

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
1-877-605-3229


(
TTY: 711
)
УВАГА! Якщо ви говорите
українською, для вас доступні
безкоштовні консультації
рідною мовою. Зателефонуйте
1-877-605-3229 (TTY: 711)
ATENȚIE: Dacă vorbiți limba
română, vă punem la dispoziție
serviciul de asistență lingvistică
în mod gratuit. Sunați la
1-877-605-3229 (TTY 711)
THOV CEEB TOOM: Yog hais
tias koj hais lus Hmoob, muaj
cov kev pab cuam txhais lus,
pub dawb rau koj. Hu rau
1-877-605-3229 (TTY: 711)
โปรดทราบ: หากคุณพูดภาษา
ไทย คุณสามารถใช้บริการ
ช่วยเหลือด้านภาษาได้ฟรี
โทร
1-877-605-3229 (TTY: 711)




1-877-605-3229 (TTY: 711)
HUBACHIISA: Yoo afaan
Kshtik kan dubbattan ta’e
tajaajiloonni gargaarsaa
isiniif jira 1-877-605-3229
(TTY:711) tiin bilbilaa.
Moda, Inc. complies with applicable
federal civil rights laws. We do not
discriminate on the basis of race, color,
national origin, age, disability or sex.
Moda provides free, timely aids and
services to people with disabilities
to help them communicate with us
effectively. These accommodations
include sign language interpreters and
written information in other formats.
If your primary language is not
English, Moda also provides free,
timely interpretation services and/or
materials written in other languages.
If you need any of the services
listed above, contact:
Customer Service,
503-243-2987 or 800-342-0526
(TDD/TTY 711)
If you believe that Moda has failed to
provide these services or discriminated
in another way on the basis of race,
color, national origin, age, disability
or sex, you can file a written grievance
by mailing or faxing it to:
Moda, Inc.
Attention: Appeal Unit
601 SW Second Ave.
Portland, OR 97204
Fax: 503-412-4003
If you need assistance filing
a grievance, please call the
applicable Customer Service
department listed to the left.
You can also file a civil rights complaint
with the U.S. Department of Health and
Human Services Office for Civil Rights at
ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone to:
U.S. Department of Health
and Human Services
200 Independence Ave. SW, Room 509F
HHH Building, Washington, DC 20201
800-368-1019, 800-537-7697 (TDD).
Office for Civil Rights complaint
forms are available at
hhs.gov/ocr/office/file/index.html.
Moda’s efforts to assure
nondiscrimination are coordinated by:
Tom Bikales, VP Legal Affairs
601 SW Second Ave.
Portland, OR 97204
855-232-9111
compliance@modahealth.com
2/4/2020
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Completed 7 August 2021

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