Electronic Remittance Advice (ERA) Enrollment Form

30.4 - Electronic Remittance Advice (ERA) Enrollment Form (Rev. 3404, Issued: 11-13-15, Effective: 12-14-15, Implementation: 12-14-15) The Medicare Electronic Remittance Advice (ERA) Enrollment process provides for collection of the information needed to successfully receive ERA transactions from Medicare and EDI trading partners. This agreement must be executed by each provider that receives ERA either directly to or from Medicare or through a third party. Each provider that will use ERA either directly or through a billing agent or clearinghouse with Medicare must sign the ERA Enrollment Form and submit it to the A/B MAC or CEDI with which ERA transactions will be received before the A/B MAC or CEDI will transmit ERA. A/B MACs or CEDI may accept a signed ERA Enrollment Form for providers via fax, email, internet portal, or hard copy and may accept electronic signature formats, “wet”, or a combination of the two. The ERA Enrollment Form is effective as specified in the terms of the agreement. In accord with a particular MAC’s business processes, providers who have a signed ERA Enrollment Form on file with a particular A/B MAC, or CEDI may or may not be required to submit a new signed ERA Enrollment Form to the same A/B MAC, or CEDI each time they change their method of electronic billing or begin to use another type of EDI transaction, e.g., changing from direct submission to submission through a clearinghouse or changing from one billing agent to another. Additionally, providers may or may not be required to notify their A/B MAC, or CEDI if their existing clearinghouse begins to use alternate software; the clearinghouse is responsible for notification in that instance. A/B MACs and CEDI must inform providers that providers are obligated to notify their A/B MAC or CEDI in writing in advance of a change that involves a change in the billing agent(s) or clearinghouse(s) used by the provider, the effective date on which the provider will discontinue using a specific billing agent and/or clearinghouse, if the provider wants to begin to use additional types of EDI transactions, or of other changes that might impact their use of ERA. A/B MAC, or CEDI receives a signed request from a provider or supplier to accept ERA transactions from or send ERA transactions to a third party, the A/B MAC, or CEDI must verify that an ERA Enrollment Form is already on file for that provider or supplier. The binding information in an ERA Enrollment Form does not expire if the person who signed that form for a provider is no longer employed by the provider, or that A/B MAC, or CEDI is no longer associated with the Medicare program. Medicare responsibility for ERA oversight and administration is simply transferred in that case to that entity that CMS chooses to replace that A/B MAC, or CEDI, and the provider as an entity retains responsibility for those requirements mentioned in the form regardless of any change in personnel on staff. The note at the end of the enrollment agreement language indicates that either party can terminate that agreement by providing 30 days advance notice. There is an exception to that requirement. In the event an A/B MAC, DME MAC or CEDI detects abuse of use of an ERA system, or discovers potential fraud or abuse, that A/B MAC, DME MAC or CEDI is to immediately terminate system access for receipt of ERA transactions by that individual or entity. A decision by an A/B MAC, DME MAC or CEDI to terminate or suspend ERA access in such a situation is not subject to appeal by the individual or entity that loses ERA access. NOTE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by CMS under this document. This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to the A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS. Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal. Signature I certify that I have been appointed an authorized individual to whom the provider has granted the legal authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the Medicare Program (e.g., new practice locations, change of address, etc.) and to commit the provider to abide by the laws, regulations and the program instructions of Medicare. I authorize the above listed entities to communicate electronically with (MAC name) on my behalf. Provider’s Name Title Address City/State/Zip By __________________________ ________________________ (Signature) (Printed Name) Date