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.
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.