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EFT/ERA Enrollment Guidelines

Please use the following guidelines when completing the EFT and ERA Enrollment Form above. The form can be used to initiate, change or terminate Electronic Funds Transfer (EFT) and/or Electronic Remittance Advice (ERA/835) enrollment for medical claims.

A separate form is required for each Tax Identification Number and entity in your organization that is authorized as the payee for medical claim payments.

If you enroll in both EFT and ERA, you will need to contact your financial institution to arrange for them to deliver the CORE required minimum CCD+ data elements to you. These elements are needed to help you associate the EFT payment with the ERA.

If you are enrolling in ERA and you are not already set up to retrieve ERA from an Electronic Data Interchange (EDI) vendor, you are required to contact one of our EDI partners to establish an account with them.

Allow approximately three weeks for enrollment processing to begin. We may contact you with questions regarding the information you provide. If you have questions about completing the form, or if you do not start receiving the EFT or ERA within 3 weeks of submitting the form, please contact Samaritan Health Plans’ Provider Service at 541-768-5207 or 1-888-435-2396, Mon.-Fri., 8 a.m. to 6 p.m.

Once the EFT and ERA enrollment is in effect, you can expect to receive an EFT file within 4 business days of receipt of the corresponding ERA. For assistance in researching late or missing files, contact Samaritan Health Plans’ Claims Accounting at 541-768-6481.

Reason for Submission

Select the reason for the EFT and/or ERA enrollment submission:  

  • New Enrollment
  • Change Enrollment
  • Cancel Enrollment

Provider Name

Enter the complete legal name of institution, corporate entity, practice or individual practitioner currently authorized as the remittent (payee) for medical claim payments. For individual practitioners, please enter the name in the format:  LAST, FIRST MI.

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. This is a 9-digit number.

  • Select the type of Tax ID Number: EIN or SSN.

National Provider Identifier (NPI)

The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. Covered healthcare providers and all health plans and healthcare clearinghouses must use NPIs in the administrative and financial transactions adopted under HIPAA. This is a 10-digit number.

Provider Contact Name

Name of a contact in the provider office for handling EFT or ERA issues.

Telephone Number

Telephone number for the provider contact.

Email Address

Electronic mail address for the provider contact. (optional)

Financial Institution Name

Official name of the provider’s financial institution where the provider maintains an account to which payments are to be deposited. 

Financial Institution Routing Number

A 9-digit identifier of the financial institution. 

Type of Account at Financial Institution

Select the type of account to receive EFT payments. 

Provider’s Account Number at Financial Institution

Account number at the financial institution to which EFT payments are to be deposited. Include applicable leading zeros. 

Account Number Linkage to Provider Identifier

Provider preference for grouping (bulking) claim payments – must match preference for remittance advice. This should be the identifier associated with the provider’s Receiving Depository Financial Institution (RDFI) account. Select one of the following: 

  • Provider Federal Tax Identification Number (TIN)
  • National Provider Identifier (NPI)

Preference for Aggregation of Remittance Data

Provider preference for grouping (bulking) claim payments must match preference for payment. This should be the identifier associated with the provider’s Receiving Depository Financial Institution (RDFI) account. Select one of the following: 

  • Provider Federal Tax Identification Number (TIN)
  • National Provider Identifier (NPI)
Clearinghouse Name is the official name of the provider’s clearinghouse. Select one of the EDI vendors listed. 

Electronic Signature of Person Submitting Enrollment is an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment.

Printed Title of Person Submitting Enrollment is the printed title of the person submitting the form.

 

Talk with our Provider Services representatives 

call us at 541-768-5207">541-768-52071-888-435-2396">1-888-435-23968 a.m. to 5 p.m.
Mon. - Fri.