Provider EFT Enrollment Page
You use the Electronic Funds Transfer (EFT) page to enroll in receiving electronic payments. The EFT Enrollment page for the Individual and Group Provider contains the fields shown below.
This page is accessed from the Service page during enrollment. You may also enroll at a later date.
Electronic Funds Transfer (EFT) Enrollment Fields
| Field | Description |
|---|---|
| If the provider selects Yes to enroll in EFT, the fields below are displayed. | |
| Provider Information | |
| Provider Name | Complete legal name of institution, corporate entity, practice or individual provider. |
| Doing Business As (DBA) Name | A legal term used in the United States meaning that the trade name, or fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it. |
| Provider Address | |
| Street | The number and street name where a person or organization can be found. |
| City | City associated with provider address field. |
| State/Province | 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 mail delivery and exploit electronic reading and sorting capabilities. |
| Provider Identifiers Information | |
| Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) | 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. |
| Provider License Number | The provider's license number. |
| License Issuer | The issuer of provider's license. |
| Provider Type | A proprietary health plan-specific indication of the type of provider being enrolled for EFT with specific provider type description included by the health plan in its instruction and guidance for EFT enrollment (e.g., hospital, laboratory, physician, pharmacy, pharmacist, etc.) |
| Provider Taxonomy Code | A unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification and Area of Specialization. |
| Provider Contact Information | |
| Provider Contact Name | Name of a contact in provider office for handling EFT issues. |
| Title | The provider's title. |
| Telephone Number | The telephone number associated with contact person. |
| Telephone Number Extension | The provider's telephone number extension, if applicable. |
| Email Address | An electronic mail address at which the health plan might contact the provider. |
| Fax Number | A number at which the provider can be sent facsimiles. |
| Financial Institution Information | |
| Financial Institution Name | Official name of the provider's financial institution. |
| Street | Street address associated with receiving depository financial institution name field. |
| City | City associated with receiving depository financial institution address field. |
| State/Province | 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 mail delivery and exploit electronic reading and sorting capabilities. |
| Financial Institution Telephone Number | A contact telephone number at the provider's bank. |
| Financial Institution Routing Number | A 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. Examples: Checking, Saving |
| 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 | Provider preference for grouping (bulking) claim payments – must match preference for v5010 X12 835 remittance advice. |
| Submission Information | |
| Reason for Submission | The reason for submitting the EFT enrollment. |
| Authorized Signature | The signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment. May be used with electronic and paper-based manual enrollment. |