Fillable multipayer_era_835_enrollment

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multipayer_era_835_enrollment

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Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
Overview
Availity
®
supports the exchange of electronic remittance advice (ERA) files for various payers in the ASC X12 835 format.
Complete this enrollment form to receive 835 ERA files from payers through the Availity Web Portal. All information on
the form is required unless noted otherwise.
The enrollment process establishes an electronic mailbox where Availity places ERA files received from payers. Availity
requires the provider’s tax ID to establish an ERA receiver mailbox and to parse remittance transactions from the various
payers. Availity will process your enrollment within three to five business days of receipt and will send you a confirmation
e-mail once enrollment is complete.
Note for Billing Services:
If you are a billing service that wants to receive ERAs on behalf of one or more providers, you must have each provider
complete and sign an enrollment form authorizing you to retrieve its remittance files, or you must submit a copy of your
power of attorney for the provider with the enrollment form.
Instructions
1. Complete the form (type all responses). For information about a field on the form, refer to the field descriptions below.
Note: If you are returning the form via e-mail, type the name of the person who would normally sign the form in the
Authorized Signature field.
2. Return the completed, signed form to Availity via:
E-mail
Fax
Mail
1. Click the Send Form button at the bottom of the form.
2. In the Send Email dialog box, click Default email application,
and then click Continue.
The form will be attached to an e-mail message that is
automatically addressed to: Autoreg835@availity.com
3. Send the e-mail message.
904.470.4773
Availity, LLC
P.O. Box 550857
Jacksonville, FL 32255-0857
Who do I contact if I have questions?
If you have questions about your enrollment, contact Availity Client Services at 1.800.AVAILITY (282.4548).
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
Field Descriptions
Section
Field
PAYER
INFORMATION
Payer Name
Payer ID
RECEIVER
INFORMATION
Who will receive your ERA files?
Receiver Name
Availity Customer ID
Contact Name
Telephone Number/Ext
E-mail Address
PROVIDER
INFORMATION
Provider Name
Street
City
State/Province
ZIP Code/Postal Code
PROVIDER
IDENTIFIERS
INFORMATION
Provider Federal Tax Identification
Number (TIN) or Employer Identification
Number (EIN)
National Provider Identifier (NPI)
PROVIDER
CONTACT
INFORMATION
Provider Contact Name
Telephone Number
E-mail Address
ELECTRONIC
REMITTANCE
ADVICE
INFORMATION
Preference for Aggregation of
Remittance Data (e.g., Account
Number Linkage to Provider Identifier)
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
Field Descriptions (cont.)
Section
Field
SUBMISSION
INFORMATION
Reason for Submission
Authorized Signature
Printed Name of Person Submitting
Enrollment
Submission Date
Multi-Payer
Electronic Remittance Advice Enrollment
Rev. 03.04.2014.1
THIS TRANSMISSION IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this transmission may contain confidential health
information that is legally privileged. This information is intended only for the use of the individuals or entities listed above. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in
error, please notify the sender immediately and arrange for the return or destruction of these documents.
PAYER INFORMATION
Refer to the Availity Health Plan Partner List for payer IDs.
Payer Name:
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
Payer Name:
Payer ID:
RECEIVER INFORMATION
* If different than provider contact information.
Who will receive your ERA files?
Provider
Clearinghouse
Vendor
Receiver Name:
Availity Customer ID:
Contact Name*:
Telephone Number*:
Ext:
PROVIDER INFORMATION
PROVIDER IDENTIFIERS INFORMATION
Provider Name:
Provider Federal Tax Identification Number
(TIN) or Employer Identification Number (EIN):
Street:
City:
State/Province:
ZIP Code/Postal Code:
National Provider Identifier (NPI):
Provider Name:
Provider Federal Tax Identification Number
(TIN) or Employer Identification Number (EIN):
Street:
City:
State/Province:
ZIP Code/Postal Code:
National Provider Identifier (NPI):
PROVIDER CONTACT INFORMATION
Provider Contact Name:
Telephone Number:
E-mail Address:
ELECTRONIC REMITTANCE ADVICE INFORMATION
Preference for Aggregation
of Remittance Data
Provider Tax Identification Number (TIN):
National Provider Identifier (NPI):
SUBMISSION INFORMATION
Reason for Submission:
New Enrollment
Change Enrollment
Cancel Enrollment
Authorized Signature:
Important: By typing or signing a name in this field, you acknowledge and agree that you have been authorized by the provider or its agent to initiate,
modify, or terminate an enrollment. You further acknowledge and agree that you have the legal authority to perform such action on behalf of your
organization. In no event will Availity be liable for any losses or damages including without limitation, indirect or consequential losses or damages, or
any loss or damage whatsoever arising from loss of data or profits arising out of, or in connection with this submission.
Printed Name of Person Submitting Enrollment:
Submission Date:
SEND THE
FORM VIA:
E-mail:
Fax: 904.470.4773
Mail:
Avality LLC
P.O. Box 550857
Jacksonville, FL 32255-0857
E-mail Form
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multipayer_era_835_enrollment

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Completed 1 October 2019

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