EFT Enrollment Form

This e-form may be used to initiate, modify or terminate EFT enrollment. Please complete a separate form for each TIN/EIN your request pertains to and include all applicable billing NPIs. (NOTE: NPIs can only be edited in the Provider Identifiers section of this e-form.) This Plan does not require submission of hand-written signatures; typed entries in this e-form will be considered sufficient authorization to comply with your request. Please allow two weeks for the EFT process to complete. If you do not begin receiving payments after two weeks, or if you have any questions about the EFT enrollment process, please call Provider Network Services at 1-800-432-3587 or (785) 291-4135, option 1.

Provider Information - Please fill out completely

 

Provider Name – Complete legal name of institution, corporate entity, practice or individual provider.

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 Address

Provider Identifiers

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 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 Contact Information

Provider Contact Name – Name of a contact in provider office for handling EFT issues.

Telephone Number – Associated with contact person.

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.

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.

Provider's Account Number with Financial Institution – Provider’s account number at the financial institution to which EFT payments are to be deposited.

Type of Account at Financial Institution

Account Number Linkage to Provider Identifier (Must match ERA Preference)

Account Number Linkage to Provider Identifier: Provider preference for grouping, (bulking) claim payments – must match preference for V5010 X12 835 remittance advice (Electronic Remittance Advice/ERA).

Reason for Submission

Authorized Signature

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 or paper-based manual enrollment.

Printed Name of Person Submitting Enrollment – The printed name of the person signing the form; may be used with electronic and paper-based manual enrollment.

Printed Title of Person Submitting Enrollment – The title of the person signing the form.

The provider must contact their financial institution to arrange for the delivery of the required minimum CCD+ data elements needed for association of the payment and the ERA (Electronic Remittance Advice), if applicable.

Researching Missing/Late Files

EFT files that have not been received after 4 business days of receipt of the corresponding ERA file can be researched by calling the ACH department at your bank.