- Please allow 7 to 10 business days for your enrollment to be completed. If you don’t start receiving ERAs after 10 days, contact the EDI Helpdesk.
- Researching Missing / Late Files: If you don’t receive ERA after 4 banking days from receiving receipt of the corresponding EFT file, call the EDI Helpdesk.
- For questions about the ERA (835) enrollment process, please call the EDI Helpdesk at 1-800-777-3622 or 1-801-578-5600 in the Salt Lake City area.
-- Please fill out completely
– Complete legal name of institution, corporate entity, practice or individual provider.
Doing Business As Name (DBA)
– Legal term meaning that the trade name, or fictitious business name, under which the business is conducted is not the legal name of the person who actually own it and are responsible for it.
– The number and street name where a person or organization can be found.
– City associated with provider address field.
– ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country.
Zip Code/Postal Code
– System of postal-zone codes (zip stands for “zone improvement plan”) introduced in the U.S. in 1963 to improve delivery and exploit electronic reading and sorting capabilities.
– Both are required
Provider Federal Tax Identification Number (TIN)
– A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity.
National Provider Identifier (NPI)
– A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
– Organization that issues and assigns the additional identifier requested on the form. If submitting transactions through UTransend or UHINet II, the Utah Health Information Network is the assigning authority for Trading Partner ID’s.
Trading Partner ID
– The provider’s submitter ID assigned by the health plan or the provider’s clearinghouse or vendor.
Provider Contact Information
Provider Contact Name
– Name of a contact in the provider office for handling EFT issues.
– Associated with contact person.
– An electronic mail address at which the health plan might contact the provider.
Note: Confirmation of enrollment for EFT will be sent to this email address.
Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)
– Provider preference for grouping (bulking) claim payments – must match the preference for EFT payment.
Provider Tax Identification Number (TIN)
– 9 digit. System will default to the TIN entered above.
National Provider Identifier (NPI)
– 10 digit. System will default to the NPI entered above.
Electronic Remittance Advice Clearinghouse Information
– Official name of the provider’s clearinghouse
Clearinghouse Contact Name
– Name of a contact in clearinghouse office handling ERA issues
– Telephone number of contact
– An electronic mail address at which the health plan might contact the provider’s clearinghouse
Reason for Submission
– provider is not currently enrolled to receive electronic remittance advice (ERA).
– provider is enrolled to receive ERA but requires a change to previously submitted enrollment information.
– provider wishes to discontinue receiving ERA and will revert to paper remittance advice.
– The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment.
Written Signature of Person Submitting Enrollment
– A rendering of a name unique to a particular person used as confirmation of authorization and identity.
Printed Title of Person Submitting Enrollment
– The printed title of the person signing the form.
Requested ERA Start/Change/Cancel Date
– The date on which the requested action is to begin.