MEDICAID LOUISIANA (MCDLA) ERA ENROLLMENT INSTRUCTIONS

Transcription

1 MEDICAID LOUISIANA (MCDLA) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Luisiana Medicaid Electrnic Remittance Advice (ERA) Authrizatin Agreement WHERE SHOULD I SEND THE FORM(S)? Mail the frm t: Mlina EDI Department PO Bx Batn Ruge, LA WHAT IS THE TURNAROUND TIME? Standard prcessing time is 3 weeks. HOW DO I CHECK STATUS? Call Medicaid LA at (225) and ask if yu have been linked t Office Ally s Submitter ID fr ERA s. Office Ally P.O. Bx Vancuver, WA Phne: Fax:

2 Luisiana Medicaid Prgram LOUISIANA MEDICAID ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENT (Frm is subject t change withut ntice) Revised 03/14

3 GENERAL INFORMATION FOR THE ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENT Cmplete this frm if yu are requesting receipt f the Electrnic Remittance Advice (HIPAA v A1 835 transactin) fr the first time r wish t change the submitter r clearinghuse authrized t receive the 835 n yur behalf. Individual prviders: Individual prviders must sign their wn frms. Original signatures nly; n stamps r cpied signatures will be accepted. (Blue r clred ink preferred nt black ink). If the individual prvider is ding grup billing nly, then an ERA frm shuld nt be cmpleted fr the individual. Instead, an ERA frm shuld be submitted (r already n file) nly fr the business r entity which the individual is linked t. Business/Entity prviders: Only an authrized representative may sign this frm. This authrized representative must be smene designated t enter int a legal and binding cntract with Luisiana Medicaid. This persn must be smene currently listed n the Disclsure f Ownership as either an wner r manager. Any ther signature will be grunds fr rejecting this frm. Original signatures nly; n stamps r cpied signatures will be accepted. (Blue r clred ink preferred nt black ink). The prvider name n this frm must match the prvider name assciated with the Luisiana Medicaid number, the NPI, r bth. If the entity/business is ding grup billing, then an ERA frm is required fr the grup nly, and nt the individual prviders. Send yur cmpleted ERA Frm t: Mlina EDI Department P.O. Bx Batn Ruge, LA Call Mlina EDI Department at (225) if yu have questins regarding the cmpletin f this frm r the status f yur request. Yu may als g t lamedicaid.cm under the HIPAA Infrmatin link fr the 5010 EDI General Cmpain Guide fr cntact infrmatin. Once yu are enrlled fr ERA and yur electrnic remittance is missing r late, call the Mlina EDI Department at (225) and reprt the late and/r missing 835 transactin. After yu are enrlled fr ERA cntact yur financial institutin if yu wish t arrange fr delivery f the CORE-required Minimum CCD+ data elements needed fr re-assciatin f yur Medicaid payments via electrnic funds transfer and the v5010 X Electrnic Remittance Advice. Revised 03/14

4 (Revised 01/14) LOUISIANA MEDICAID ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENT INSTRUCTIONS 1. Prvider Name Cmplete legal name f institutin, crprate entity, practice r individual prvider. 2. Prvider Federal Tax Identificatin Number (TIN) r Emplyer Identificatin Number (EIN) A Federal Tax Identificatin Number, als knwn as an Emplyer Identificatin Number (EIN) is used t identify a business entity (9 digits). 3. Natinal Prvider Identifier (NPI) A Health Insurance Prtability and Accuntability Act (HIPAA) identificatin number Administrative Simplificatin Standard. The NPI is a unique identificatin number fr cvered healthcare prviders. Cvered healthcare prviders and all health plans and healthcare clearinghuses must use the NPIs in the administrative and financial transactins adpted under HIPAA. The NPI is a 10-psitin, intelligence-free numeric identifier (10-digit number). This means that the numbers d nt carry ther infrmatin abut healthcare prviders, such as the state in which they live r their medical specialty. The NPI must be used in lieu f legacy prvider identifiers in the HIPAA standards transactins. 4. Mlina Medicaid Trading Partner ID (7 digits) The 7-digit Luisiana Medicaid identificatin number assigned t the submitter authrized t receive the 835. (This number always begins with 450.) 5. Prvider Cntact Name Name f a cntact in prvider ffice fr handling EFT issues. 6. Prvider Cntact Telephne Number Assciated with cntact persn. 7. Prvider Cntact Address An electrnic mail address at which the health plan might cntact the prvider. 8. Accunt Number Linkage t Prvider Identifier Check ne: Prvider Tax Identificatin Number (TIN), r Natinal Prvider Identifier (NPI). 9. Methd f Retrieval Check ne: Dwnlad 835 Frm BBS, r Dwnlad 835 Using CAQH CORE Web Service 10. Reasn fr submissin Check ne: New Enrllment, Change Enrllment, r Cancel Enrllment 11. Written Signature f Persn Submitting Enrllment (Authrized Signature) 12. Printed Name f Persn Submitting Enrllment 13. Printed Title f Persn Submitting Enrllment A (usually cursive) rendering f a name unique t a particular persn used as cnfirmatin f authrizatin and identity. The printed name f the persn signing the frm; may be used with electrnic and paperbased manual enrllment. The printed title f the persn signing the frm. 14. Submissin Date CCYYMMDD

5 (Revised 03/14) DEPARTMENT OF HEALTH AND HOSPITALS LOUISIANA MEDICAID ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENT 1. Prvider Name 2. Prvider TIN r EIN (9 digits) 3. Natinal Prvider Identifier (NPI) (10 digits) 4. Mlina Medicaid Trading Partner ID (7 digits) Prvider Cntact Name 6. Prvider Cntact Telephne Number 7. Prvider Cntact Address 8. Accunt Number Linkage t Prvider Identifier (check ne) Prvider Tax Identficatin Number (TIN) Natinal Prvider Identifier (NPI) 9. Methd f Retrieval (check ne) Dwnlad 835 Frm BBS Dwnlad 835 Using CAQH CORE Web Service 10. Reasn fr Submissin (check ne) New Enrllment Change Enrllment Cancel Enrllment I authrize the Medicaid Fiscal Intermediary t send all HIPAA required data in the 835 transactin which includes claims infrmatin, payment infrmatin, and bank accunt infrmatin, prvided by me and currently n file if enrlled in Electrnic Funds Transfer, t the submitter identified in item #4 in the Electrnic Remittance Advice Authrizatin (ERA) Agreement Frm. This authrizatin will remain in effect until discntinued by written request r changed by a future request. I attest that all infrmatin supplied in this authrizatin agreement is true, accurate and cmplete. Only an authrized representative may sign this frm. This authrized representative must be smene designated t enter int a legal and binding cntract with Luisiana Medicaid n behalf f the prvider. I understand this electrnic 835 transactin cntains Prtected Health Infrmatin (PHI) and have taken the necessary steps with my submitter t maintain the cnfidentiality f all PHI data. 11. Written Signature f Persn Submitting Enrllment (Authrized Signature) 12. Printed Name f Persn Submitting Enrllment 13. Printed Title f Persn Submitting Enrllment 14. Submissin Date