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Change HealthcareePayment EnrollmentAuthorization FormInstructionsProviders can receive electronic payments by enrolling in Change Healthcare ePayment in four easy steps! If you have questions about thisChange Healthcare ePayment Enrollment and Authorization Form, or if you need help accessing Change Healthcare Payment Manager, pleasecall 866.506.2830 and select option 1. Please allow for a 15 day validation period to process these EFT forms.Step 1 - Complete EFT Authorization Form and include Validation paperworkTo complete enrollment you must provide the following:All forms require an original signature (no stamps or e-signatures).Electronic copy of a government issued ID (i.e. State Driver's License, Visa, Passport, Military ID etc.) (with signature), on payee legal entity'sletter head. CDAC Providers must provide a copy of State CDAC approval in lieu of letter head.Contact name , address and phone number of Financial Institution.Bank authorization letter or voided check.Any bank account changes will require the validations set forth above for completion of changes as well as confirmation of the last EFTdeposit amount with Change Healthcare.Provider Contact Information 1 & 2 is mandatory in page# 2 (These are staff members that may be calling in for EFT/ERA information)Please check this box if you would like to enroll for all TIN & NPI (if provided) EFT Payers included on page 5 & 6All Payers that require Provider ids must indicate the payer assigned provider id (Trading Partner id) starting on page 7Otherwise, indicate the individual payer you would like to enroll on the below pages.How to Submit the Change Healthcare ePayment Enrollment and AuthorizationAuthorization Form by EmaEmaililThis Change Healthcare ePayment Enrollment and Authorization Form includes form fields enabling you to complete it using the online form.Please sign and email your completed Change Healthcare ePayment enrollment authorization form as an PDF attachment toEFTEnrollment@changehealthcare.com or fax completed enrollment forms to 615.238.9615. Please allow for a 15 day validation periodto process these EFT forms.Step 2 - Confirm Deposit to Verify AccountOnce you have completed the enrollment process, Change Healthcare will make a small deposit in your designated bankaccount with the reference note “EFT Enroll”. After this has been deposited into your designated account, please call866.506.2830 or email EFTEnrollment@changehealthcare.com for verification purposes.Step 3 - Start using Payment Manager to Search, View,View, Download and Print ERAsYou may access Change Healthcare Payment Manager https://cda.changehealthcare.com/Portal/ to search, view andprint your payment and remittance advice for participating Payers. To see a quick tour of Change Healthcare Payment Manager,visit /* Providers that utilize a software vendor for ERA delivery may need to request your vendor enroll with Change Healthcare* If you are an existing Payment Manager user, your services will be enabled under the assigned account* If you are a new Payment Manager user, you will be given a username and password for your new accountStep 4 - Contact your Financial Institution to Receive the CCD Reassociation NumberTo reassociate payments and ERAs, a CCD Reassociation Number has been created and passed to your financial institution. ToTobegin receiving this number, you must contact your financial institution and request it866.506.2830.To resolve a late or missing payment or ERA, please contact the EFT enrollment team at 866.506.2830Page 1 ofQuestions? Call 866.506.2830 for assistance.a
Attachment 1: Provider InformationCheck here if you are updating existing enrollment information.Provider Identifiers InformationProvider Federal Tax Identification Number (TIN)or Employer Identification Number (EIN)All Group and Provider National Provider Identifier (NPI)Provider InformationProvider NameDoing Business As Name (DBA)Provider AddressStreetCityState/ProvinceZip Code/Postal CodeCountry CodeLicense NumberLicense IssuerProvider TypeMedicalDentalProvider Taxonomy CodeProvider Contact Information 1 *Required*Provider Contact NameTitleTelephone NumberTelephone Number ExtensionEmail AddressFax NumberProvider Contact Information 2 *Required*Provider Contact NameTitleTelephone NumberTelephone Number ExtensionEmail AddressFax NumberProvider Agent InformationProvider Agent NameProvider Agent AddressStreetCityState/ProvinceZip Code/Postal CodeCountry CodeProvider Agent Contact NameProvider Agent Contact TitleTelephone NumberTelephone Number ExtensionEmail AddressFax NumberPage 2 ofQuestions? Call 866.506.2830 for assistance.Pharmacy
Retail Pharmacy InformationPharmacy NameChain NumberParent Organization IDPayment Center IDNCPDP Provider ID NumberMedicaid Provider NumberFinancial Institution InformationNew EnrollmentChange to Existing EnrollmentDeactivate Existing Bank Account*Please complete if you are a new customer. If you are an existing customer needing to change bank information, pleaseenter current (old) bank information here and complete the Bank Account Change EFT Validation Form on page 4.Financial Institution Account #1Financial Institution NameFinancial Institution AddressStreetCityState/ProvinceZip Code/Postal CodeFinancial Institution Telephone Number/ExtFinancial Institution Contact NameFinancial Institution Routing NumberType of Account at Financial InstitutionProvider’s Account Numberwith Financial InstitutionAccount Number Linkage to ProviderIdentifierCheckingProvider Tax IdentificationNumber (TIN)National Provider Identifier(NPI)Page 3 ofQuestions? Call 866.506.2830 for assistance.Savings
Bank Account Change EFT Validation FormDate of ĞƉŽƐŝƚLast EFT ĞƉŽƐŝƚLast Four Ěigits of Account WĂLJĞƌ / EƵŵďĞƌ ŵŽƵŶƚAny bank account changes will require the validations set forth above for completion of changes as well as confirmation ofthe last EFT deposit amount with Change Healthcare.*Only use the following section if you are an existing customer needing to change banking information.Please Complete new banking information belowFinancial Institution Account #2Financial Institution NameFinancial Institution AddressStreetCityState/ProvinceZip Code/Postal CodeFinancial Institution Telephone Number/ExtFinancial Institution Contact NameFinancial Institution Routing NumberType of Account at Financial InstitutionProvider’s Account Numberwith Financial InstitutionAccount Number Linkage to ProviderIndentifierCheckingProvider Tax IdentificationNumber (TIN)National Provider Identifier(NPI)Page 4 ofQuestions? Call 866.506.2830 for assistance.Savings
CheckBoxPayerIDAssigning AuthorityCX097Access DentalBOONG43168Advantica Administrative Service71057Cannon Cochran Management Services95340Adventist Health System/Westcm001CaremoreAetna - Aetna Life Insurance Company64073223845937462118Aetna - Allianz Life Insurance Company62118Aetna - American General Life Insurance62118Aetna - Continental Life Insurance621186211862118621186211813333Boon Admin Services Inc (ERA req to rece EFT)Cigna-HealthSpringCeltic Insurance23626Central Pennsylvania Teamsters Fund36222Chicago Regional Council of Carpenters Welfare84129Colorado Access37227Aetna - Combined Insurance CompanyAetna - Union Fidelity Life InsuranceCareFirst Administrators/NCAS6806337214Aetna - American Continental Insurance62118Assigning Authority75190Advantica and Delta VisionAetna - Aetna Health and Life InsurancePayerID52192Administrative Concepts, Inc6211862118CheckBoxCenteneCentral StatesCNIC (EFT required to receive ERA)42723Community First Health Plans58231Core Administrative Services39113Dean Health Plan (DHP)CX093Dental Select35199Aetna - Virginia Surety Company, IncAetna - Washington National InsuranceAetna/Genworth - Genworth Life InsCooperative Managed CareCTI Administrators42141Affinity Health Plan95241AGIACX03552193AllegeantMWELTDistrict 9 Machinists Welfare Trust48055American Progressive Life and Health52611Electrical Workers Welfare Trust26202Auxiant62045Farm Bureau Health Plans26119751371378848055AIAAssociated AdministratorsFAMR1AveraAdvantage77054AvMed (EFT Req for ERA)SX145Banner Health AZ12X4277078Banner Health AZ (Medisun)Benefits Administration CorpSB790Blue Cross Blue Shield of New Mexico773073200261124ElderPlan, Inc.FAIFidelis Secure Care of Michigan85362Foundation for Med Care of Tulare & Kings64246Guardian Life Insurance Company86066Hawaii Mainland Administrators77023Health (CarePoint Health Plans)15064Health First Health Plans (EFT req to rec ERA)46051Banner Health AZ443572048831625AmeriBen59274Dental Care PlusGenerations - HillcrestHarken10152Better HealthHCH Administration (IL)37111Blue Cross Blue Shield of Vermont77950Blue Cross Complete of MichiganBluegrass Family HealthPage 5 ofQuestions? Call 866.506.2830 for assistance.Health Alliance Medical Plans
CheckBoxPayerIDAssigning Authority68035CheckBoxPayer IDAssigning AuthorityHealth Plan of San Joaquin87020Sentinel Security Life Ins Company37290HealthServices for Children with Special2709466003Johns Hopkins Advantage MD76342Sierra Health Services (EFT req to rec ERA)HealthyCT IncSX142South Indiana Health Operations - HMO40523Kaiser Foundation Health Plan67829Sterling LifeLMCHPLeon Medical Centers Health Plans411787718035316HealthEZ (formerly America’s TPA)Key Benefit AdministratorsSynermed (Angeless IPA)43619Teamsters Medicare Trust for Retired Emp75228Texas Children’s Health Plan - STARMessaDSHOPTML Intergovernmental Employee BenefitsMunicipal Health Benefit Fund74214The Dental Shop48055TRLTCToday's Options powered by CCRX TMGTRP1ETransamericaTransamericaMarquette Life Insurance Company12422MedicaMedPartners Administrative Services27401Michigan UFCW Unions & 77076Network Health Insurance Corp-Medicare91068Northwest AdministratorsR0755Southern Benefit Aministrators.INC75299480557432338242Simply Health CareNetwork Health Plan of WisconsinTRP1POhio Benefit AdministratorsTLINSTeacher’s Health TrustTexas Children’s Health Plan - CHIPTexasFirst Health Plan (NTX)TransamericaTransamericaLIFE1Optumcare (EFT required to rec ERA)TRCLFSX158Paramount Health37284TransChoice – Key Benefit Administrators73117Tribute /SelectCare of Oklahoma7611247027Oxford Life Insurance Company39181Physicians Mutual91171Physicians of Southwest Washington65088Preferred Care Partners33081TRSEL77022Pinnacle21524Preferred Medical Claim Solutions (PMCS)48055Pyramid Life Insurance Company28530S & S Healthcare6505445281Premier Eye CareRiversideUltimate Health Plans, Inc94174United Administrative Service74227United Healthcare Student Resources59189United Group Programs45282University of Maryland Health Advantage59266Volusia Health Network38337Upper Peninsula Health PlanSanta Clara Family Health Plan (SCFHP)TH023WellmedSelectCare of Texas (HPN) Heritage68039240777604583035Triad Healthcare (CBHNP Amerihealth)Web-TPA Employer Services, LLCS & S Healthcare ricaSanfordScott & White Health Plan911363727231048Senior Whole Health (SWH)26335Page 6 ofQuestions? Call 866.506.2830 for assistance.Welfare and PensionWells Fargo TPAWestern Health AdvantageWestern Southern Financial Group (WSFG)Zepherella
ning AuthorityA&I Benefit Plan Administrator, Inc.Advocate Health PartnersAdvocate HPOAFTRA Health FundAmeriHealth Caritas DelawareAmeriHealth Caritas District of ColumbiaAmeriHealth Caritas IowaAmeriHealth Caritas LouisianaAmeriHealth Caritas NortheastAmeriHealth Caritas PennsylvaniaAmeriHealth Caritas VIP Care PlusAmeriHealth Caritas VIP Arbor Health PlanArise Health PlanCBHNP- AmerihealthEmployee Plans LLCFirst Choice VIP Care Plus - SCFirstCare HealthFlorida True Health, IncGEHAHawaii Medical Assurance AssociationHealth PlusHealthcare Partners IPAHealthLinkHealthy PAHealthy PAHorizon NJ HealthHudson Health PlanHudson Health PlanIndependent HealthIPMGJohns Hopkins Healthcare (EHP/PP)Johns Hopkins Healthcare (USFHP)Keystone FirstKeystone First VIP ChoiceMDwise Excel NetworkMed3000 CMS Safety NetMed3000 CMS Title 19 ReformMed3000 CMS Title 21Med3000 Pedicare Title 19Med3000 Pedicare Title 21MedCost BenefitsMedical Associates Health PlanPremier DentalPrestige Health ChoiceProfessional Benefit Services, IncQualcareQualCare, IncSCAN Health PlanSEIUSelect Health of South CarolinaTufts Health PlanUniversity of Utah Health PlansViva HealthWindsor Medicare ExtraProvider Id /Legacy IDProvider ID- (R)Legacy ID- (R)Provider ID- (R)Provider ID- (O)Provider ID- (R)Legacy ID- (R)Payee ID- (R)Legacy ID- (R)Legacy ID- (R)Payee ID- (R)Provider ID- (R)Provider ID- (R)Provider ID- (R)Legacy ID- (R)Provider ID- (O)Legacy ID- (O)Legacy ID- (R)Provider ID- (R)Provider ID- (O)Legacy ID- (R)Provider ID- (R)Legacy ID- (O)Legacy ID- (R)Vendor ID- (R)Vendor ID- (R)Provider ID- (R)Provider ID- (R)Legacy ID- (R)Legacy ID- (O)Trading Partner ID-(O)Tax ID & Pharmacy Payee IDTrading Partner ID-(O)Provider ID- (O)Provider ID- (O)Legacy ID- (R)Provider ID- (R)Payee ID- (R)Provider ID- (R)Provider ID- (R)Provider ID- (R)Provider ID- (R)Provider ID- (R)Legacy ID- (O)Provider ID- (O)NPI-R; Brokers Agency - RLegacy ID- (R)Provider ID- (O)Vendor ID- (R)Vendor ID- (R)Vendor ID- (R)Provider ID- (O)Legacy ID- (R)Provider ID- (R)Vendor NPI- (R); Tax ID- (R)Vendor ID- (R)Vendor ID- (R)Page 7 ofQuestions? Call 866.506.2830 for assistance.Trading Partner Id
Table 1: Direct Payment PayersThe payers listed below are offering to distribute EFT payments directly to you and not through Change Healthcare. If you select a payerbelow, that payer will pay you directly and Change Healthcare shall not be involved in any of their payment transactions. As such,Change Healthcare makes no representations or warranties regarding the payment services provided by the payers set forth below.Check Belowto EnrollPayer ID Payer Name27514AmerigroupAdditional Provider IDRequired/Optional (R/O)Legacy PIN – (R)Additional RequirementsTrading Partner idProviders must enroll using Amerigroupassigned Provider Identification Number. ERAis only available with EFT enrollment.Providers must enroll or be enrolled for ElectronicRemittance Advice (ERA) when selecting CareFirstEFT. Are you currently setup for ERAs withCareFirst?SB580CareFirstNPI – (R) Yes NoIf you are not yet enrolled and want to enroll forboth ERA and EFT fromCareFirst please check the following box. You will receive CareFirst ERAs through Emdeon ifthis box is checked.)Check ListAll forms require an Original signature (no stamps or e-signatures).Electronic copy of a government issued ID (i.e. State Driver's License, Visa, Passport, Military ID etc.)(with signature), on payee's (group/facility) legal entity's letter head / Company letter headCDAC Providers must provide a copy of State CDAC approval in lieu of letter head."Contact name, address and phone number of financial Institution.Bank authorization letter or voided check attached.Provider Contact Information 1 & 2 is mandatory in page # 2To view the CORE required Maximum EFT Enrollment Data Set, please follow this ptions.pdf?sfvrsn 2Page 8 ofQuestions? Call 866.506.2830 for assistance.
Change Healthcare ePayment Enrollmentand Authorization Form AcknowledgementBy signing below, Provider acknowledges that the Provider has read, agrees that it is subject to and agrees to comply with the ChangeHealthcareGeneral Terms and Conditions, the Business Associate Terms, the ePayment Services Addendum and the Privacy Policy forchangehealthcare.com. To view the Change HealthcareGeneral Terms and Conditions, the Business Associate Terms and the ePaymentServices Addendum please visit: www.changehealthcare.com/epayment/terms. To view the Privacy Policy for changehealthcare.com,please visit www.changehealthcare.com/privacy. In addition, by signing below, Provider represents and warrants that all of the informationthat it is providing to Change Healthcareis accurate and complete. In furtherance of the ePayment Services, Provider authorizes ChangeHealthcare Solutions LLC or one of its Affiliates to initiate ACH debit and credit entries to the above account(s) at the above depositoryfinancial institution(s). Provider acknowledges that the origination of ACH transactions to the above account(s) must comply with theprovisions of U.S. law. Provider also acknowledges that in the provision of the ePayment Services, the Provider’s enrollment information maybe made available to the Payers making payment to the Provider through the ePayment Services.Provider desires to revoke or modify the authority of any Authorized Representative or add additional Authorized Representatives, Providermust execute and deliver to Change Healthcare a new ePayment enrollment authorization form. Letters or other forms of communicationswill not be accepted. Any subsequent ePaymen t enrollment authorization form supersedes any previously submitted ePayment enrollmentauthorization form. CURRENT AUTHORIZED REPRESENTATIVES NOT ON THE ePayment enrollment authorization form WILL NOT BERECOGNIZED.Please check the box below if you have elected to receive payments from Direct Payment Payers selected on Page 8I hereby authorize Direct Payment Payer(s) to initiate ACH credit and debit entries to the account(s) listed in Table 1 for all benefitspayments. Provider acknowledges that the origination of ACH transactions to the above accounts must comply with the provisions of U.S.law. This agreement will remain in effect until I notify the Direct Payment Payer(s) of the desire to cancel or change this service or until I amnotified by Direct Payment Payer(s) that this service has been terminated. I understand I must allow reasonable time for my instructions tobe executed.As required by 42 C.F.R. 455.18 and 455.19, I understand in accepting electronic payment that such payment may be from Federal and StateFunds and any falsification or concealment of a material fact may be prosecuted under Federal law.IN WITNESS WHEREOF, the parties have caused this Change Healthcare ePayment Enrollment and Authorization Form to be executed bytheir respective duly authorized representatives.Submission InformationReasons for submissionNew EnrollmentChange EnrollmentAuthorized SignaturePrinted Title of Person Submitting EnrollmentSubmission DateRequested EFT Start / Change / Cancel DatePage 9 ofQuestions? Call 866.506.2830 for assistance.Cancel Enrollment
Advanticaand Delta Vision 71057 95340 Cannon Cochran Management Services AdventistHealth System/West 75190 62118 CareFirst Administrators/NCAS Aetna -AetnaHealth and Life Insurance cm001 62118 Caremore Aetna -Aetna Life Insurance Company 68063 62118 Celtic Insurance . Washington National Insurance 58231 Core A 62118 Aetna/Genworth - Genworth .
