HUMANA 835 ERA PRE ENROLLMENT INSTRUCTIONS 61101 HOW LONG DOES PRE ENROLLMENT TAKE? Up to 21 business days WHERE SHOULD I SEND THE FORMS? Send the forms to Emdeon via fax to 615 231 4843 or email to batchenrollment@emdeon.com WHAT FORM SHOULD I DO? Emdeon ERA Provider Information Form o Section 1: Provider Organization This is the provider s information. o Section 2: Vendor This is Office Ally s Information, and is pre filled. o Section 3: Payer This is where the ID(s) for the payer(s) are entered. You may enter up to 10 payers on the same form. Prefilled for Humana ERA. Payer ID Emdeon Payer ID Group ID Would be a number assigned by Office Ally, this is not required. Individual Provider ID This would be an ID assigned by the payer. This is not required. o Section 4: Confirmations Prefilled with vendor indicating confirmations are coming to Office Ally. Humana 835 Health Care Electronic Remittance Advise New Request Form o Section A: Provider Information This is the provider s information. o Section B: Vendor Information This is Emdeon s information, and is pre filled. o Section C: Authorized Signature This is for the provider to sign. o Section D: Health Care Provider Certification This is for the provider to fill out, based on individual preference. If you want EFT: o Terms and Conditions for Electronic Funds Transfer (FT) agreement and authorization o New EFT Authorization Form HOW DO I CHECK STATUS? Call 800 845 6592, option 1, option 4, option 2 Office Ally, Inc. P.O. Box 872020 Vancouver, WA 98687 www.officeally.com Phone: 866 575 4120 Fax: 360 896 2151
PAYER ID: SUBMITTER ID: Emdeon ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name Tax ID Client ID Site ID Address City/State Zip Code Contact Name E-mail Address Telephone Fax 2 Vendor (Emdeon certified vendor used to submit files to Emdeon) Vendor Name Contact Name E-mail Address 3 Payer Vendor Submitter ID Division ID Payer ID Group ID Individual Provider ID NPI ID 4 Confirmations Send Emdeon Claim Confirmations To: Special Instructions: All Payer Registration forms must contain signatures when applicable, stamped signatures or photocopies are accepted. SUBMIT COMPLETED FORM TO: Fax: (615) 231-4843 Email: batchenrollment@emdeon.com EMDEON REVISION FORM DATE:
ERA/EFT FAQ Q. Do I qualify for ERA set up? A. Your tax ID must be loaded in the Humana systems from submitting claims and you should have only one active tax ID for a group level provider record or an individual non group level provider record in our system. Q. Do I qualify for ERA/EFT set up? A. Your tax ID must be loaded in the Humana systems from submitting claims, you must have active contracts with Humana and you should have only one active tax ID for a group level provider record or an individual non group level provider record in our system. Q Where do I send issues related to my ERA/EFT with Humana? A. Humana uses Availity as a gateway for delivery of 835 data files for all clearinghouses/billing agencies/vendors. First contact your clearinghouse to report the issue. If your clearinghouse needs assistance, they will contact Availity. If further assistance is required Availity will open a ticket with Humana. For EFT issues, send an email to providerconnect@humana.com with a description of your issue, tax ID, EFT number, amount and date of disbursement in question. Q. Why am I receiving checks when I signed up for EFT? A. If you see any ASO (administrative services only) members, members that are a part of a large group (i.e. Ford), Humana administers the benefits on behalf of the group but the group administers the payments for the benefits. You will receive an ERA, but the payment will continue to be a paper check. For private fee for service members, you will receive an ERA, but you might receive an EFT or a paper check for the payment. This is due to the provider may not be contracted to see that member which will cause a paper check to be generated. If the provider is contracted to see that member, an EFT payment will be sent to your account. Q. I received my ERA but I haven t received my EFT payment, why? A. Humana has a standard float day period of up to ten (10) days to deposit the EFT from the time the ERA has been generated. Q. How long does it take to set up my ERA or ERA/EFT request? A. Humana is attempting to target a 30-45 day completion time, if we have received all the necessary forms and there are no issues with the forms, such as missing information and the tax ID must exist on our system. If a test period is elected then the setup period will be additional 30 days. These time frames may vary depending upon the volume of requests that Humana has received.
Q. What do I need to provide for ERA or ERA/EFT set up? A. For ERA, a completed application faxed to 877.210.5422. The tax ID must be loaded in the Humana systems from submitting claims to Humana. For ERA/EFT, a completed application, EFT authorization form, a copy of a voided check or bank letter faxed to 877.210.5422. The tax ID must be loaded in the Humana systems from submitting claims to Humana and you must have active contracts with Humana. Q. Why do I receive a large volume of payments? A. For ASO Humana sends one payment per remit per group by processed date For Non ASO Humana sends one payment per product line You may be able to reach out to your Market Representative to determine if your contracts are set up to pay to the group level group roll up. Q. Why can t I match what I get from my bank on my EFT payment to my 835 data file. A. Currently, Humana sends a CTX format for EFT payments. The trace number is located in the addenda records which are not read by the bank. You may ask you bank if it is possible to receive these records, however, most banks will charge a fee. Humana will be moving toward the CCD+ format in the near future. Q. Why do I see two $.01 transactions in my bank account? A. This is a prenote transaction to test whether the payments will be deposited to your account. There are two transactions because Humana processes claims on two systems so $.01 from each system. There is no need to return these test transactions to Humana. Q. How can I pull a copy of my EOB? A. You can register on www.humana.com or www.availity.com. For further assistance on registration send an email to deployment@humana.com Q. How do I change my vendor for my 835 data file? A. Fax a 835 Vendor file delivery change form to 877.210.5422. Q. If I m set up to receive EFT payments and I close my bank account without notifying Humana of the change, before the account is closed, what will happen to the payments? A. If payments are rejected back from your bank because you closed the account, Humana will need to reprocess these claims so the payment can be redelivered. The estimated completion time for reprocessing claims is 30-45 days. If you notify Humana before the account is closed, then we can set up the new bank account information and send out a prenote to test the payment delivery to your account. You can send an email to providerconnect@humana.com when you receive your prenote and then we can release the payments. If you choose not to
835 Health Care Electronic Remittance Advice (ERA) Request Form General Completion Instructions for New Enrollment Purpose: The 835 Health Care electronic remittance advice request form is designed for providers who want to receive a HIPAA X12N 835 version 4010 A1 electronic remittance (ERA) transaction (Raw Data File) from Humana. It is recommended that an auto posting software or a translator be used to view the X12 file. Eligibility Requirements to receive 835(ERA): You must submit claims to Humana Inc Individual provider must practice under single tax id or payment to the group Group providers must practice under single tax id Eligibility Requirements to receive EFT with ERA: You must receive 835 (ERA) files. Individual provider must practice under single tax id or payment to the group Group providers must practice under single tax id You must be contracted with Humana Section A: Provider Information This section must be completed by the provider office. Please mark individual if you are a stand alone physician and submitting professional claims. Please mark group if there is the more than one physician within your practice and submitting professional claims. Please mark facility if you submit institutional claims. Note: E-mail address is not required, but highly recommended. Section B: Vendor Information This section is for the vendor that delivers the 835 Health Care Electronic Remittance Advice to you. Humana 835 files are delivered to Availity, please include the Availity Genkey of where files should be delivered. The vendor could be a clearinghouse or billing agency that will retrieve the files from Availity. Note: Providers ensure you have contacted you Vendor to inform them of your 835 Enrollment Section C: Authorization Signature The signature in this section must be from the provider s office. Section D: Health Care Provider Certification for Humana 835 Electronic Remittance Advice This section must be completed and signed by the provider s office. Completed Forms: Print and fax completed ERA forms to the following fax number: 877-210-5422 Attention: ERA/EFT Coordinator Print and fax completed ERA forms to the following fax number 877-210-5422-1 - H1
contact Humana when you receive your prenote then around 7 days later we will release the payments. Q. If I cancel ERA with my vendor before notifying Humana of the change, what will happen to my electronic remittances? A. Electronic remittances will continue to be delivered to the vendor. This could cause a delay in receiving remittances. If you wish to cancel ERA or ERA/EFT you must fax an 835 Cancellation Request form to 877.210.5422. Q. I have changed my tax id number, will I receive electronic remittances if I was enrolled for ERA for my previous tax id? A. If your tax id number has changed you should notify Humana with a new enrollment form for that tax id number. If you wish to enroll for ERA or ERA/EFT you must fax a ERA and/or EFT Request form to 877.210.5422.
835 Health Care Electronic Remittance Advice New Request Form Section A. Provider Information Please indicate your classification(check all applicable): Individual Provider Group/Practice Facility Both Group & Facility Provider/Group Name: Provider TAX ID: Multiple TAX ID s (see Attachment 1) NPI: Provider Contact Name: Provider Billing Address: Provider City, State, and Zip: Provider Contact Phone Number: Provider E-mail Address: Section B. Vendor Information Please indicate the vendor/clearinghouse/billing agency that will deliver the electronic transactions (835): Vendor Name: Availity Genkey (optional): Contact Name: Contact Phone Number: Contact E-Mail Address: Section C. Authorization Signature Provider, hereby appoints (Provider Name/Provider Representative Name (please print)) to act as the authorized agent for the (Vendor (please print)) purpose of retrieving the 835 electronically from Humana Inc. Provider/Provider Representative name (Printed) Date Provider/Provider Representative Signature Print and fax completed ERA forms to the following fax number 877-210-5422-2 - H1
Section D. Health Care Provider Certification The undersigned Health Care Provider hereby certifies to Humana the following with respect to the 835 Electronic Remittance Advice: OPTION#1: I would like to test my ERA file for 30 days. Note: After 30 days of testing, paper EOR s will no longer be received. Health Care Provider will coordinate receipt of remittance test file(s) from the designated clearinghouse/vendor. Health Care Provider acknowledges that they complete the test file(s) and use the 835 Remit data for posting to their accounting systems. Health Care Provider will notify their EDI Clearinghouse of their intention to begin ERA testing. OPTION#2: I would like to start receiving my ERA file upon setup without testing. Note: Paper EOR s will no longer be received. Health Care Provider has notified their EDI Clearinghouse of their intention to start their ERA processing upon setup. Health Care Provider will start receiving and processing Humana s Electronic Remittance Advice (ERA) information. Health Care Provider agrees that upon approval of this Certification and the initiation of routine ERA processing, Health Care Organization will no longer receive hard copy EOR (Explanation of Remittance). Health Care Provider, or an authorized representative of the Health Care Organization, will notify Humana in writing of any changes or corrections required in the ERA process. Approved By: Signature (Authorized Representative) Printed Name of Authorized Representative Print Title Date Print and fax completed ERA forms to the following fax number 877-210-5422-3 - H1
Attachment 1: Multiple Tax IDs If you receive reimbursement for multiple Tax IDs, please list them below. If you prefer to receive the 835 health care electronic remittance advice (ERA) for one Tax ID, please ensure that Tax ID is placed in Section A. Note: I want to receive the 835 File with ALL Tax ID s in one file I want to receive the 835 File for each INDIVIDUAL Tax ID Facility Name / Group Name / Practice Name / Provider Name Tax ID NPI Billing Address Print and fax completed ERA forms to the following fax number 877-210-5422-4 - H1
Electronic Funds Transfer (EFT) General Completion Instructions for New Enrollment Requirements to receive EFT with ERA: You must receive 835 (ERA) files. Individual provider must practice under single tax id or payment to the group Group providers must practice under single tax id You must be contracted with Humana TERMS AND CONDITIONS FOR ELECTRONIC FUNDS TRANSFER (EFT) The signature in this section must be from the provider s office. AGREEMENT AND AUTHORIZATION Provider Information & Financial Information This section must be completed by the provider office. Note: E-mail address is not required, but highly recommended. Please include voided check or bank letter and send to fax: 877-210-5422. Note: Two 1 cent deposits will be made to account for verification. No other deposits will be made while in testing status. Completed Forms: Print and fax completed EFT forms to the following fax number: 877-210-5422 Attention: ERA/EFT Coordinator Print and fax completed EFT forms to the following fax number 877-210-5422 1
TERMS AND CONDITIONS FOR ELECTRONIC FUNDS TRANSFER (EFT) AGREEMENT AND AUTHORIZATION T he undersigned parties ( (Provider) and HUMANA) hereby agree to the following terms and conditions with respect to Electronic Funds Transfer: 1. Payment for all claims submitted to HUMANA and its affiliates will be made through Electronic Funds Transfer (EFT), based on the information provided by the Provider in the attached, executed, Authorization. 2. HUMANA will rely exclusively on information supplied by the Provider, in the attached Authorization for payment of claims through EFT. 3. The Provider, or an authorized representative of the Provider, will notify HUMANA in writing of any changes or corrections to information contained in the Authorization at the time this Agreement is executed and any future changes in this information. Notification will be made in a timely manner to allow HUMANA to respond to any corrections or changes. Provider hereby releases HUMANA from any liability, which may arise solely by reason of error, mistake or fraud, relating to the information provided on the Authorization by the Provider. 4. HUMANA will make payment in accordance with and be governed by the National Automated Clearinghouse Association s Corporation Trade Payment Rules, which are incorporated herein by reference and made a part hereof. HUMANA s EFT process is governed by and in accordance with the laws, other than choice of law provision of any particular contract, of New York, including Article 4A of the Uniform Commercial Code as enacted by the State of New York and amended from time to time. 5. Payment is initiated in accordance with the terms of the agreement. Except as provided for herein, the terms and conditions of this agreement neither enlarges or diminishes the respective rights and obligations of the parties within (with respect to any other agreement between the parties) any applicable commercial agreement. Provider acknowledges that payment of claims have been made when the financial institution designated by the Provider has received or has control of the payment transaction. This will generally occur within two (2) calendar days following initiation by HUMANA. 6. If HUMANA initiates payment on a non-banking day at HUMANA s originating bank, the funds transfer will occur the following day. In all cases, Banking Day is defined as the day on which both trading partners banks will be available to transmit and receive these fund transfers. 7. HUMANA has the right to adjust future payments should any payments previously made by Humana be determined to be a duplicate payment, in excess of requirements, is fraudulent or made in error. 8. HUMANA is responsible for payments under the terms of this agreement up to the point at which the Provider s financial institution receives the payment from HUMANA or otherwise has control of the transaction. Responsibility for any loss after such time will be the Provider s unless the loss is due to the negligence of HUMANA or HUMANA s originating bank. Page 2 of 3 Attachment 2 Policy 702-010-00 9. Provider shall notify HUMANA immediately if payment is not received as described in item 8 above. HUMANA shall have a reasonable time (not to exceed ten (10) business days) to make such payment. Print and fax completed EFT forms to the following fax number 877-210-5422 2
10. Provider agrees to submit all claims for payment electronically to HUMANA and accept remittance detail via the ANSI X.12-835 format from HUMANA in order to receive payment of such claims by HUMANA electronically. 11. Either party may terminate this agreement upon 30 (thirty) days written notice to the other party. This Agreement may also be terminated upon mutual written agreement of the parties. Humana may terminate this agreement upon 30 (thirty) days notice to Provider in the event that the Provider fails to submit claims electronically to HUMANA or is unable to accept remittance detail via the ANSI X.12-835 format from HUMANA according to this agreement. Notice may be made as follows: HUMANA will notify the Provider in writing at the address provided on the attached authorization. The Provider, or an authorized representative, must notify HUMANA as follows: Humana Inc, EFT/EDI Coordinator, 101 East Main Street, Louisville, KY 40201-1438, or fax to: 877-210-5422. AGREED TO BY: Print Name of Provider By: Signature (Authorized Representative) Print Name Print Name Print Title Date Print and fax completed EFT forms to the following fax number 877-210-5422 3
Humana Inc. New EFT AUTHORIZATION The information concerning your organization s financial institution will be used to make Electronic Funds Transfer payments on all claims that are due and approved for payment to the legal business name listed below: Provider Legal Business Name: Federal Tax ID # NPI: Address: City: State: Zip Code: Name of contact person for billings and payments: (Please print) Telephone: E-Mail Address: FINANCIAL INSTITUTION INFORMATION Name of Financial Institution: Telephone: Address: City: State: Zip Code: Nine (9) Digit American Banker s Association (ABA) Identifying Number for Routing the Transfer of Funds: ABA (transit routing) number: Account Name and Number at the Financial Institution to be Credited with Invoice Payments. Please attach a voided check or bank letter. Provider must notify Humana in writing of any changes to the above information. PROVIDER S AUTHORIZING OFFICIAL: By Signing this document, you authorize HUMANA to send EFT payments to the above company account and your company agrees to the terms and conditions for EFT. Signature Printed Name Date Telephone Title Note: Funds availability for Electronic Funds Transfer payments will depend on your financial institution s federal reserve clearinghouse receipt schedule. Please include voided check or bank letter and send to fax: 877-210-5422. Print and fax completed EFT forms to the following fax number 877-210-5422 4