EDI ERA Enrollment Form

Provider Name – Name of individual or billing provider organization receiving remittance advice.

Provider Address – Mailing address of the provider or billing provider organization, including Street, City, State and ZIP Code.

Provider Identifiers – Tax ID (EIN or SSN) and corresponding NPI (10 digits) of the billing provider. (Remittance Advice will be returned based on Billing NPI.)

Note:  The Billing NPI can only be loaded under one Trading Partner ID for the ERA.

Other Identifier(s) – Assigning Authority – Administrative Services of Kansas (ASK)

Trading Partner ID – Enter your 7 digit trading partner number (will begin with either 0 or 6) assigned by ASK. This determines the Trading Partner Mailbox where the remittance advice will be delivered.

Provider Contact Name – Provider office contact name.
 

Contact Telephone Number – Phone number of the contact name, including extension if available.



 

Email Address – Provider contact email address used to confirm ERA Enrollment to the provider.

Fax Number – Fax number of the contact name.

Preference for Aggregation of Remittance Data – TIN and Billing NPI should match the information provided in Provider Identifiers Information. (Remittance Advice will be returned based on Billing NPI.)

This information can only be edited in the Provider Identifiers section.

Vendor Name – Name of the software company that supports your practice management software.

Vendor Contact Name – Name of contact at the software company.
 

Telephone Number – Telephone number for the contact at the software company.
 

Email Address – Email address for the contact at the software company.

Reason for Submission – Check one box to indicate New Enrollment, Change Enrollment, or Cancel Enrollment.

Authorized Signature – The name and title of the individual within the provider office authorized by the provider to initiate, modify or terminate an enrollment.