Electronic Payment/Remittance Authorization Agreement

Save time by enrolling in electronic funds transfer (EFT) and electronic remittance advice (ERA). You can use our secure online form or a PDF form to sign up for EFT, ERA, or both.

Once submitted it may take up to 30 days to set up delivery of the EFT/ERA.

How to Enroll

You can choose to enroll in EFT/ACH and ERA using one of these methods.

Download PDF

Complete and submit this PDF through the Message Center, by mail, or by fax. Additional instructions can be found on the PDF.

Download PDF

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
If you are requesting EFT/ACH…

Fill in the Financial Institution Information. Both the NPI and the TIN associated with the provider’s account are required.

If you are not requesting EFT/ACH…

Registration for 835 Electronic Remittance Advice is temporarily unavailable. We apologize for this inconvenience. 

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EFT/ACH
  • 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.

EFT/ACH: Electronic Funds Transfer, which transfers payment funds directly into your account through an Automated Clearinghouse, in this case the Change HealthCare Clearinghouse.

ERA: Electronic Remittance Advice or 835 ERA, which provides claims payment explanations in HIPAA-compliant files

  • Provider Information

    • Provider Name

      Complete legal name of institution, corporate entity, practice or individual provider.

    • Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

      The Federal Tax Identification Number, also known as an Employer Identification Number (EIN), used to identify the business entity.

    • National Provider Identifier (NPI)

      Covered healthcare providers must use an NPI in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position numeric identifier (a 10-digit number).

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    Provider Contact Information

    • Provider Contact Name

      The primary telephone number associated with contact the person identified above.

    • Telephone Number

      The primary telephone number associated with the contact person identified above.

    • Email Address

      An electronic mail address at which the health plan might contact the person identified above. This does not have to be a personal address but should be an address regularly monitored by the primary contact.

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    Financial Institution Information

    Financial Institution Information must only be completed if the provider requests EFT.

    • Financial Institution Name

      The official name of the provider’s financial institution.

    • Financial Institution Routing Number

      The 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited.

    • Type of Account at Financial Institution

      The type of account the provider will use to receive EFT payments

    • Provider's Account Number with Financial Institution

      Provider's account number at the financial institution to which EFT payments are to be deposited.

    • Account Number Linkage to Provider Identifier

      The provider preference for grouping (bulking) claim payments – must match preference for v5010 X12 835 remittance advice if selected.

    • Provider Tax Identification Number (TIN)

      The TIN associated with the provider's account - required.

    • National Provider Identifier (NPI)

      The NPI associated with the provider’s account - required.

    • Reason for Submission

      State whether this is a New Enrollment or whether the provider is cancelling or changing an existing enrollment.

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    EFT/ACH/835 Remittance Advice Options

    • Change HealthCare Clearinghouse Account Number

      This account number is required if the provider has elected to receive an 835 remittance advice.

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    Signature

    • Written signature of person submitting enrollment

      The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. This must be a rendering of the name unique to the particular person used as confirmation of authorization and identity if the provider is enrolling with a paper-based manual enrollment. If the provider is enrolling online through the completion of the electronic PDF form, the enrollment form must be signed with a digital signature through the HelloSign digital signature process.

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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).

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