magnacare - Availity

11303
MAGNACARE
PAYER ENROLLMENT INSTRUCTIONS
Professional
Institutional
Claims
✔ ERAs
Important - HeW provides the EDI paperwork pre-populated with our submitter information as a courtesy to our clients.
Please note that even though we make all attempts to have the most current form available, we are not always notified
by the carriers when their EDI forms are updated.
FORM INSTRUCTIONS
The paperwork is designed for you to type into while opened in Adobe Reader. Please use your Tab key on your
keyboard to move to the next field.
*****BILLING AGENTS - MagnaCare requires a copy of the Business Associate Agreement (BAA) you have signed
with your provider to be sent with this completed ERA request form.*****
*****PROVIDERS NOT USING A BILLING AGENCY - MagnaCare will require a copy of the Business Associate
Agreement (BAA) in place between yourself and us (HeW). You will need to forward the MagnaCare ERA form to the
HeW Enrollment Department for processing.*****
This carrier requires EFT enrollment before they will approve an ERA enrollment.
PAPERWORK SUBMISSION
RCM Clients: Please submit paperwork directly to HeW at hewrcmsupport@availity.com.
HeW Clients: Please submit paperwork directly to HeW at hewenrollment@availity.com.
Updated: 08/29/2014
Electronic Remittance Advice (ERA) Authorization Agreement
This ERA Authorization Agreement must be fully
completed, signed and returned via fax or email
Email: edienrollment@magnacare.com
Fax: 516.723.7397
Basic Requirements
 A bank account in which to deposit the electronic
funds.
 Your clearinghouse/software vendor must be able to
accept the ERA file in the 835 HIPAA standard format.
Provider Information:
Provider Name:
Provider Type:
Physician
Physician Group
Ancillary
Hospital
Provider Street Address:
City:
State:
Zip Code:
Provider Identifiers Information:
Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN):
National Provider
Identifier (NPI):
Provider Contact Information:
Provider Contact Name:
Phone Number:
Email Address:
Fax:
Provider Agent Information (if applicable):
Agent Contact Name:
Phone Number:
Email Address:
Fax:
If you are operating as Agent to receive the ERA/EFT on behalf of a provider, the provider must complete the enrollment documents
authorizing you to retrieve their remittance files, or a copy of the business associate agreement between you and the provider must
be submitted along with this form.
Electronic Remittance Advice Information:
Preference for aggregation of remittance data is Federal Tax Identification Number (TIN) provided above.
Method of Retrieval:
FTP setup, connectivity and file transmission protocol.
FTP Host
FTP Server
Inbound
itbbs.magnacare.com
MagnaCare
to MagnaCare
Outbound
itbbs.magnacare.com
MagnaCare
to Provider
MagnaCare Administrative Services, LLC
EDI Implementations
User ID
Password
Transfer Protocol
SSL FTP+PGP
SSL FTP+PGP
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Electronic Remittance Advice (ERA) Authorization Agreement
Clearinghouse Information (if applicable):
Clearinghouse Name: HeW
Contact Name: Enrollment Team
Phone Number: 877-565-5457
Email Address: hewenrollment@availity.com
Fax: 406-449-0190
If you are operating as clearinghouse to receive the ERA/EFT on behalf of a provider, the provider must complete the enrollment
documents authorizing you to retrieve their remittance files, or a copy of the business associate agreement between you and the
provider must be submitted along with this form.
Vendor Information (if applicable):
Vendor Name: N/A
Contact Name:
Phone Number:
Email Address:
Fax:
If you are operating as Vendor to receive the ERA/EFT on behalf of a provider, the provider must complete the enrollment documents
authorizing you to retrieve their remittance files, or a copy of the business associate agreement between you and the provider must
be submitted along with this form.
ERA Trading Partner/Receiver (if applicable):
If you as provider are authorizing an Agent, Clearinghouse or Vendor to conduct the 835 transaction, select only one of the following.
MagnaCare will utilize this designation for purposes of contacting the correct entity to initiate these transactions.
ERA Trading Partner/Receiver:
Agent
Clearinghouse
Vendor
New Enrollment
Change Enrollment
Cancel Enrollment
Submission Information:
Reason for Submission:
Authorized Signature:
Signature of the Person Submitting Enrollment:
(Print & Sign Here)
Printed Name of the Person Submitting Enrollment:
Printed Title of the Person Submitting Enrollment:
Requested ERA Effective Date:
Submission Date:
The authorization is to remain in effect until written notice in the form of an ERA Authorization Agreement form marked as a
cancellation or change form is submitted to MagnaCare. Any changes to the provider’s agent, clearinghouse or vendor must be
submitted on an ERA Authorization Agreement form as a change. The termination or change shall be effective 20 days subsequent
to MagnaCare’s receipt of the updated form.
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Electronic Remittance Advice (ERA) Authorization Agreement
Instructions for Completing MagnaCare Electronic Remittance Advice (ERA) Enrollment Form
Complete all fields on pages 1 and 2 of this form. Once completed, print, sign and fax or email, as noted above.
Please Fax or Email only one TIN per form. A separate form for each TIN/EIN must be used. Please allow 3 weeks for
registration process to be completed. If after 4 weeks you do not start receiving ERA's then you may contact the EDI
Team.
For questions about this form or the electronic enrollment process, please contact the EDI Team.
The EDI support team will contact you upon receipt of the completed ERA Enrollment Form.
Form Submission Fields
Provider Information - please fill out completely
Provider name - Legal name of institution, corporate entity, practice or individual provider.
Provider Type – Office Type of provider.
Provider address Street - The number and street where individual/organization is located.
City - City associated with street address field.
State/Province - Two character code associated with the State/Province/Region of the applicable Country.
ZIP code/Postal code - Postal-zone code
Provider Identifier Information
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). 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 Federal Tax Identification Number (TIN) - A Federal Tax Identification Number, also known as an Employer
Identification Number (EIN), used to identify a business entity.
Provider Contact Information
Provider contact name - Name of a contact in a provider office for handling ERA issues.
Telephone number - Associated with provider contact name.
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
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Electronic Remittance Advice (ERA) Authorization Agreement
Provider Agent Information
Provider Agent Name- Name of provider's authorized agent.
Telephone Number- Telephone number for Agent contact.
Email Address - Email address for agent contact.
Electronic Remittance Advice Information:
Preference for Aggregation of Remittance Data is Federal Tax Identification Number (TIN).
Method of Retrieval- Method in which provider will receive the ERA from the health plan (e.g., download from
health plan website, clearinghouse, etc.)
Clearinghouse Information
Clearinghouse Name- Official Name of the provider's clearinghouse.
Telephone Number- Telephone number for clearinghouse contact.
Email Address - Email address for clearinghouse contact.
Vendor Information
Vendor Name - Official name of the provider's vendor.
Telephone Number- Telephone number for vendor contact.
Email Address - Email address for vendor contact.
ERA Trading Partner/Receiver
Please select the entity with whom MagnaCare will be implementing ERA (835) transactions. If you as provider
are authorizing an Agent, Clearinghouse or Vendor to conduct the 835 transaction, select only one of those
entities. MagnaCare will utilize this designation for purposes of contacting the correct entity to initiate these
transactions.
Submission Information
Reason for submission (must select one from below)
New Enrollment – Enrollment of new ERA Account.
Change Enrollment – This information facilitates the registration transition from the old to the new
clearinghouse/vendor/agent.
Cancel Enrollment – Use to terminate receipt of ERA data.
Authorized Signature
Signature of person submitting enrollment - Signature of an individual authorized by the provider or its
agent/clearinghouse/vendor to initiate, modify, or terminate an enrollment.
Printed Name of person submitting enrollment – Printed Name of an individual authorized by the provider or its
agent/clearinghouse/vendor to initiate, modify, or terminate an enrollment.
Printed title of person submitting enrollment - Printed title of the person signing the form.
ERA Enrollment Form submission date - Date on which the enrollment form is submitted.
Requested ERA effective date - Date the provider wishes to begin ERA. Per Phase III CORE Health Care Claim.
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