Electronic Payment/Remittance Authorization Agreement
How to Enroll
You can choose to enroll in EFT/ACH and ERA using one of these methods.
Instructions
Start by filling out the Provider Information and Provider Contact Information sections. Provider Information will cover the provider or facility’s name and identification numbers. The Provider Contact Information section should be completed with the information for the person in the provider’s office or facility who handles EFT issues. Please attach your W-9 tax form to your submission. If applicable, additional documents can be faxed to the provider maintenance number, 1-224-387-2540. Only PDF, JPG, PNG, BMP, and GIF attachments may be added. File size limit is 20 MB.
Financial Institution Information
Fill in the Financial Institution Information. Both the NPI and the TIN associated with the provider’s account are required.
Registration for 835 Electronic Remittance Advice is temporarily unavailable. We apologize for this inconvenience.
EFT/ACH
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If you are enrolling in EFT/ACH with paper EOBs, select EFT/ACH Only (Paper EOB)This option is for providers who are enrolling in EFT and would like to receive a paper EOB. Only EFT is electronic for this option.
If you have questions, please send a secure message through the Message Center or call a Benefits Specialist at 1-800-TEAMCARE (1-800-832-6227).