4755 S. 44
th
Place
Phoenix, AZ 85040
602-263-3000/ 1-800-624-3879
EFT Fax: 866-237-0760
Instructions for Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation
Page 1
Please use this guide to prepare/complete your
Electronic Funds Transfer (EFT) Authorization Agreement Form.
Missing, illegible
or incomplete
information within the agreement
form will delay the benefits of participating in EFT. The following is a reference guide only, do not fax
or email
the
instructions
with the completed authorization
form. Return Pages 2-3 ONLY. If you prefer to enroll/change/cancel
electronically,
please go to our website
at www.MercyCareAZ.org
for the electronic form and instructions.
If you have questions about the
authorization
agreement form or
the enrollment
process, please call Finance at 602-263-3000 or email us at MercyEFT@aetna.com.
Please note that the descriptions for the data elements contained in the Electronic Funds Transfer (EFT) Authorization Form have been placed in an
Appendix to make it easier to complete the form. Please refer to the Appendix when completing the form.
Are you using one authorization agreement form per tax id number?
• Enrollment forms containing more than one tax id will be returned.
Did you remember to put the NPI # on the authorization agreement form?
• Enrollment forms without an NPI number will be returned.
Have you attached a pre-printed voided check with the account holder imprinted on the check or bank letter for new enrollments or changes
in bank information?
• Enrollment requests cannot be processed without this information.
• A voided check/bank letter must accompany the form. Deposit Slips, starter checks, handwritten or altered checks will not be accepted. The
banking information on the voided check/bank letter must match what is listed on the form.
Need to change or cancel an existing enrollment?
• Complete a new authorization agreement form to make changes to an existing enrollment or to cancel an existing enrollment. Complete all
parts of the form and mark the appropriate choice in the Submission Information section of the form. You are responsible for notifying
Mercy Care of any changes in your information.
Has the form been signed by the appropriate individuals?
• Unsigned forms will be returned.
Have you completed all sections?
• Please type or print all requested information clearly. Incomplete and/or illegible fields will cause the form to be returned.
Have a completed form to submit? Forms can be submitted by fax or email.
• Completed new or change authorization agreement forms with voided check and/or bank letter and completed cancellation authorization
agreement forms can be submitted through one of the following
methods:
Fax
to:
Mercy Care, Finance EFT Enrollment at – 866-237-0760. Only one form per fax. Faxes containing multiple forms will be returned.
Email to: MercyEFT@aetna.com. Only one form per email. Emails containing multiple forms will be returned.
Need to check the status of your EFT enrollment?
• Please allow 10-15 business days for processing once enrollment is received. Processing times may vary depending on number of
enrollments received, accuracy of the information provided and how legible the form is.
• A confirmation letter will be sent to the Provider Address on the enrollment form once setup is complete.
• A $0.00 pre-note test transaction will be sent to your financial institution. The pre-note period can take 10-15 days from the processing date
of the approved Electronic Funds Transfer (EFT) Authorization Agreement Form.
• Changes to existing banking information will trigger a new 10 to 15 day pre-note period.
• The online instructions on our website at www.MercyCareAZ.org will instruct you to contact Finance at 602-263-3000 or email
MercyEFT@aetna.com with any questions or to check enrollment status.
Have you contacted your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements
from the NACHA ACH/EFT payment file?
• Your
financial institution must be a participating member of the Automated Clearinghouse Association (ACH) and accept the CCD+ format.
You must proactively contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements
necessary for the successful reassociation of the EFT payment with the ERA remittance advice.
Do you have a Late or Missing EFT payment or ERA remittance advice?
• If you have not received your EFT payment or the corresponding ERA remittance advice by the 4
th
business day
after you receive either the
EFT payment or ERA remittance advice, contact your Provider Relations representative at 602-263-3000 or 1-800-624-3879 Express Code
631 or email us at providerrelations@mercycareaz.org
or fax us at 860-975-3201.
AZ-07-01-18
