Provider ERA Enrollment Page

You use the Electronic Remittance Advice (ERA) page to enroll for electronic remittance advice notices. The ERA 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.

ERA Enrollment Fields

Field	Description
Electronic Remittance Advice Enrollment Fields These fields are displayed if the provider selects Electronic (835) options.
Provider Information
Provider Name	Complete legal name of institution, corporate entity, practice or individual provider.
Doing Business As Name(DBA)	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 ERA with specific provider type description included by the health plan in its instruction and guidance for ERA 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 the provider office for handling ERA issues.
Title	The provider's title.
Telephone Number	The telephone number associated with the 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.
Electronic Remittance Advice Information
Preference for Aggregation of Remittance Data (eg. Account Number Linkage to Provider Identifier)	Provider preference for grouping (bulking) claim payment remittance advice – must match preference for EFT payment.
Submission Information
Reason for Submission	The reason for submitting the ERA 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.