WPS MEDICARE AUTHORIZATION FORM FOR ELECTRONIC REMITTANCE ADVICE ERA TUTORIAL

1. 03/02/09 WPS MEDICARE AUTHORIZATION FORM FOR ELECTRONIC REMITTANCE ADVICE (ERA) TUTORIAL

2. 03/02/09 Tutorial for completing a Medicare ERA Authorization Form This tutorial is designed to walk you through the process of completing the Medicare ERA Authorization Form. The form must be completed correctly and legible in order to be processed. The following presentation will assist you in completing the application correctly.

3. 03/02/09 What you need to know before you begin… You can obtain your ERA file several ways. A Clearinghouse, Billing Service, or Third Party Company can obtain the files on your behalf. You can download the file from our Bulletin Board System (BBS) using a 5 digit submitter ID number. You may also use a connectivity vendor such as Ivans or Visionshare. Connectivity vendors allow an alternative method to connect with the contractor to receive ERA files. IVANS: www.ivans.com VISIONSHARE: www.visionshareinc.com CMS offers FREE software, Medicare Remit Easy Print (MREP) for Part B providers, and PC Print for Part A providers which will convert the ERA file to a readable and printable format. Changes made to an ERA set up for Medicare Part B providers will prompt remits to be generated paper for 45 calendar days, in addition to the ERA file. Part A Providers who are a new set up only will receive paper EOB’s in the mail for 30 calendar days. The ERA Authorization form can be located at the following web address: http://www.wpsic.com/edi/pdf/edi_ernmedb.pdf The form can be completed on the website and printed out for a signature. For more information or further assistance, please contact your Helpdesk. Medicare Legacy B EDI Hotline (WI, MI, MN, and IL): (877) 567-7261 Medicare Part A & B J5 EDI Hotline (MO, IA, KS, NE): (866) 503-9670 Medicare Legacy Part A (institutional providers who joined WPS in October 2007): (866)-734-6656

4. 03/02/09 How to complete the Medicare ERA Authorization form continued… If the form is received as not legible or not completed correctly, it will be returned to the provider for correction. The request may take up to 14 business days to complete.

5. 03/02/09 How to complete the Medicare ERA Authorization form continued… New Submitter or Add Providers: The NEW SUBMITTER or ADD PROVIDERS portion of the form applies ONLY to Part A providers. Check all lines of business that apply: (based on the state where the services are being rendered) Part MAC J5 A or B (IA, KS, NE, MO) Part B Legacy (IL, MI, MN, WI) Part A Legacy (multi-states, institutional providers who joined WPS in October 2007) Please identify the company that will be retrieving the ERA files: Provider/Physician: This is when you have obtained a 5 digit Submitter ID number issued by the EDI Dept or through self registration on our website and will be downloading your ERA files through the Bulletin Board System (BBS) (this includes Providers utilizing IVANS/Visionshare) Corporate Office: This is when the Corporate Office (generally seen with large facilities) has been issued the 5 digit Submitter ID number and will be obtaining and dispersing the ERA files within their corporation. Third Party Company/Clearinghouse: This is when another party (clearinghouse, billing service) will have obtained the 5 digit Submitter ID number and will be retrieving the ERA files on your behalf. You will get your ERA files from the Third Party Company, Billing Service, or Clearinghouse.

6. 03/02/09 How to complete the Medicare ERA Authorization form continued… *** This section of the form should contain the PROVIDERS information ONLY. -Provide the name, address, city, state and zip of the billing provider. -You must provide the address that is on file with Medicare Provider Enrollment. If the address provided on the form does not match the address we have on file, the form will be returned for correction. -Provide a contact person’s name, email address, fax, and phone number. WPS SUBMITTER ID: This is the number that has assigned to whomever is sending the claims. If you are utilizing a Third Party Company, Billing Service, or Clearinghouse to send on your behalf, you may need to contact this entity and request the Submitter ID number. All WPS issued Submitter ID numbers are 5 digits. Part B Missouri East providers ONLY may also use an alpha numeric Submitter ID. (IE: MO123)

7. 03/02/09 How to complete the Medicare ERA Authorization form continued… Provider Name: This would be the provider name on file with Provider Enrollment. For Part B providers, if the individual provider is a member of a group or has more than one NPI number (Group NPI and Individual NPI), it will be the group name that needs to be provided. NPI Number and Provider Number: (AKA: Pin, Legacy, Provider Number, Oscar, and Group Number) For Part B providers, if you are enrolled as an individual within a group or have more than one PTAN/NPI number, the numbers provided on the form MUST be the Group or Clinic numbers. For Part A providers, all NPI numbers associated with the provider number must be given. Multiple Group or Facility Numbers can be listed on the form if they share the same address information.

8. 03/02/09 How to complete the Medicare ERA Authorization form continued… All providers must include both a signature and effective date for this request to be processed. Provide a signature from an authorized representative for the provider, printed name, and date you want to begin receiving ERA’s. Do not send the form with an effective date greater than two weeks from the date sent to EDI. (If the effective date is greater than two weeks from the date sent to EDI, the form may be returned to you.) Who is authorized to sign? This is a contract. As long as you are authorized to put the provider into a binding contract, you may sign the form.

9. 03/02/09 How to complete the Medicare ERA Authorization form continued… This section of the form should ONLY be completed if someone such as a Billing Service, Clearinghouse, or Third-Party Vendor will be sending claims on your behalf. Place and “X” in the box authorizing the Third Party Company, Billing Service or Clearinghouse to send on your behalf. All providers must include both a signature and effective date for this request to be processed. Provide a contact person’s name, email address, and phone number from the entity receiving ERA on your behalf. (the providers contact information would be provided in the top portion of the form)

10. 03/02/09 How to complete the Medicare ERA Authorization form continued… MREP: (Medicare Remit Easy Print) This software is specifically designed for Medicare Part B providers ONLY. The download can be found at the following web address.. http://www.cms.hhs.gov/AccesstoDataApplication/02_MedicareRemitEasyPrint.asp PC PRINT: This software is specifically designed for Medicare Part A providers ONLY. The download can be found at the following web address.. http://www.wpsmedicare.com/part_a/business/pc_print.shtml

11. 03/02/09 How to complete the Medicare ERA Authorization form continued… Once the agreement is completed, it can be returned to the appropriate Help Desk via Fax or Mail.

12. 03/02/09 This Concludes the Tutorial.