Fillable Cigna ERA 835 Enrollment

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Cigna ERA 835 Enrollment

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Cigna Electronic Remittance Advice Enrollment
Rev. 01.21.2014.1
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 Cigna 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 Cigna. Availity
requires the provider’s tax ID to establish an ERA receiver mailbox and to parse remittance transactions from Cigna.
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 and Clearinghouses:
If you are a billing service or clearinghouse 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: 6415@availity.com
3. Send the e-mail message.
972.383.6415
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).
Cigna Electronic Remittance Advice Enrollment
Rev. 01.21.2014.1
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
Provider Addres – Street
Provider Addres – City
Provider Addres – State/Province
Provider Addres – ZIP Code/Postal
Code
PROVIDER
IDENTIFIERS
INFORMATION
Provider Federal Tax Identification
Number (TIN) or Employer Identification
Number (EIN)
National Provider Identifier (NPI)
Provider Type
PROVIDER
CONTACT
INFORMATION
Provider Contact Name
Telephone Number
E-mail Address
Fax Number
Cigna Electronic Remittance Advice Enrollment
Rev. 01.21.2014.1
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 (continued)
Section
Field
ELECTRONIC
REMITTANCE
ADVICE
INFORMATION
Preference for Aggregation of
Remittance Data (e.g., Account
Number Linkage to Provider Identifier)
SUBMISSION
INFORMATION
Reason for Submission
Authorized Signature
Printed Name of Person Submitting
Enrollment
Requested ERA Effective Date
Cigna Electronic Remittance Advice Enrollment
Rev. 01.21.2014.1
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
Payer Name: Cigna
Payer ID: 62308
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 Name:
Provider
Address
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 Type:
PROVIDER CONTACT INFORMATION
Provider Contact Name:
Telephone Number:
E-mail Address:
Fax Number:
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:
Requested ERA Effective Date:
SEND THE
FORM VIA:
E-mail:
Fax: 972.383.6415
Mail:
Avality LLC
P.O. Box 550857
Jacksonville, FL 32255-0857
E-mail Form
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Cigna ERA 835 Enrollment

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Completed 1 October 2019

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