2020-04-21 —
ERA Setup Form We received your request stating that you want to receive electronic remittances. See the list below of payers you can receive ERAs from and follow the instructions below. 1. Review the list below 2. Check the box next to the payer(s) you want to be set up for 3. Complete the requested information on the form below 4. Send this completed form back to us via e-mail to paperwork@icssoftware.net, or send via fax to 516-632-7078 Practice Name Provider Name Tax ID Billing NPI Address: City, State, Zip code: Contact person for this request: Phone#: Email: Select the companies you would like to receive ERAs from. Enter the appropriate PTAN# if applicable. Carrier 1199 National Benefit Fund AARP United Healthcare Advocate Physician Partners Aetna* a login for the CAQH EnrollHUB website is needed. Instructions for EFT & ERA enrollment will be emailed to you. Once you receive the instructions, if you need assistance, please email paperwork@icssoftware.net to arrange an appointment. Aetna Senior (SSI) Affinity Health Plan Agewell Altius Health American Family PPO Americhoice APIPA Payer ID 13162 36273 36320 60054 62118 13334 AWNY6 25133 56071 03432 Last updated: 04/21/2020 1 | P a g e Americhoice by United Healthcare/Community Plan NY Americhoice of MD/UHC Community Plan (DE, LA, MD, OH, PA) Americhoice of NE Americhoice of NJ Americhoice of WI Amerigroup Blue Cross Blue Shield Bravo Health and Spring Health ChampVA Cigna Clover Community Plan of Pennsylvania Connecticare Coventry/MHBP Federal Employees Elder Plan Fidelis Care* this payer requires EFT enrollment before they will provide ERA. If you'd like ERA for this payer, please visit https://www.fideliscare.org/Apps/eft/Default.aspx to request EFT enrollment first. Gateway Medicare Assured Gateway Healthplan Medicaid PA GEHA Geisinger* this payer requires EFT & ERA enrollment with InstaMed. Instructions will be sent to you. Do you already have an InstaMed account? Y / N GHI-Group Health Incorporated Golden Rule & American Medical Security Harvard Pilgrim* a login for the Payspan website is needed. Instructions for EFT & ERA enrollment will be emailed to you. Once you receive the instructions, if you need assistance, please email paperwork@icssoftware.net to arrange an appointment. HealthCare Partners Healthfirst* This payer requires EFT enrollment-please include a void check with this form. Health Net Federal Svs Health Springs HIP NYU01 04567 UFNEP 86047 WID01 27514 52192 84146 62308 77023 04567 06105 & 78375 25133 31625 11315 60550 25169 44054 75273 13551 81400 & 37602 04271 11328 80141 68021 63092 55247 Last updated: 04/21/2020 2 | P a g e Humana* a login for the Availity website is needed. Instructions for EFT & ERA enrollment will be emailed to you. Once you receive the instructions, if you need assistance, please email paperwork@icssoftware.net to arrange an appointment. Johns Hopkins 61101 52123 Martins Point 53275 MED3000 CMS Title 21 EM205 Medica 94265 Medicaid PTAN: Medical Mutual of OH 29076 Medicare PTAN: Medicare DMERC PTAN: Medicare Railroad PTAN: Metro Plus Health Plan 13265 Montefiore 13174 Mutual Health Service 34192 Mutual of Omaha 71412 MVP 14165 Pacificare of CA 95959 Peach State Health Plans 68069 Pomco 16111 Pruitt Health PH001 Qualcare 23342 Sanford Health 91184 SIHO 77153 Simply Health 27094 State Farm 31053 Time Ins. Co 39065 Today's Options 48055 Tribute SelectCare OK 73117 Tricare East* a login for the CAQH EnrollHUB website is needed. Instructions for EFT & ERA TREST enrollment will be emailed to you. Once you receive the instructions, if you need Tricare for Life* assistance, please email paperwork@icssoftware.net to arrange an appointment. TDDIR Trihealth Physician Solutions 31144 Tufts Health Plan* a login for the Payspan website is needed. Instructions for EFT & ERA enrollment will be emailed to you. Once you receive the instructions, if you need assistance, please email paperwork@icssoftware.net to arrange an appointment. 04298 Last updated: 04/21/2020 3 | P a g e UMR Wausau/UHIS Union Security United Healthcare United Healthcare Community NJ UPMC VNS Choice Medicare Wellcare* a login for the Payspan website is needed. Instructions for EFT & ERA enrollment will be emailed to you. Once you receive the instructions, if you need assistance, please email paperwork@icssoftware.net to arrange an appointment. 39026 70408 87726 86047 23281 77073 14163 Authorized By: ______________________________________ Date: ________________ By signing above, you are authorizing us to complete all of the necessary paperwork to set you up to receive Electronic Remittance Advices through Sammy Systems for the specified carriers. You are also granting us permission to sign such documents on your behalf, i.e. signing your name, in order to expedite the process. If you do not allow this option please cross out this paragraph and initial here. Send this completed form back to us via e-mail to paperwork@icssoftware.net or send via fax to 516-632-7078. Last updated: 04/21/2020 4 | P a g eAdobe PDF Library 20.6.74