CENTENE ERA CONTRACT INSTRUCTIONS
Submit the completed Contract Setup Form to:
ABILITY Network, ATTN: Enrollment
FAX: 888.837.2232 | EMAIL: [email protected]
INSTRUCTIONS
• Please carefully read all instructions before beginning.
• Please do not submit your forms directly to the payer. Submit your forms to ABILITY Network only.
• Print these instructions. Refer to them as you complete the registration process.
• Please type provider information for ease of processing at ABILITY Network.
• Page 1: Centene Electronic Remittance Advice Request
- Enter the Payee (Provider who receives payment) Name and Phone number on file with Centene.
- Enter the Tax ID and NPI on file with Centene.
- Do not alter any of the pre-completed submitter information.
- Enter the name and payer ID of the Centene plan you want to receive ERA from.
- Choose whether you would like to continue receiving a paper EOB. This is completely your choice.
• Page 2:
- Enter your contact Email address.
- Do not enter any data in the box below the Email address field.
- After printing, sign and date the form.
• Please do not submit your forms directly to the payer. Submit your forms to ABILITY Network only.
Questions or need assistance?
Contact ABILITY Network Enrollment Department at 888.499.5465 or [email protected].
CENTENE ERA CONTRACT INSTRUCTIONS
Submit the completed Contract Setup Form to:
ABILITY Network, ATTN: Enrollment
FAX: 888.837.2232 | EMAIL: [email protected]
INSTRUCTIONS
Please complete one Contract Setup Form per Tax ID. Return the form to ABILITY Network’s Enrollment Department with
your EDI documentation. All information is required.
BILLING INFORMATION
If you use a third-party billing service to prepare your claims, complete this section (if not, skip to the provider info
section):
Please type your responses directly into the form.
Billing Service Name
TIN or ABILITY ID:
Contact Name:
Phone:(
)
Group/Provider Name:
Billing Tax ID:
Indicate
Tax ID
SSN
Address on file with Payer(s):
City:
State:
Zip+4:
Zip+4:
Street Address/Practice Location on file with Payer(s):
City:
State:
PRINT Authorized signature name, title (CEO, etc):
Contact Full Name:
Contact Fax: (
Phone:(
)
)
Email:
PROVIDER INFORMATION
List carriers/providers with which you wish to enroll below. Please refer to the ABILITY Network Payer List for enrollment requirements.
Payer ID
Payer Name
PTAN
Rendering NPI
BIlling NPI
Claims
Questions or need assistance?
Contact ABILITY Network Enrollment Department at 888.499.5465 or [email protected].
ERA
Electronic Remittance Advice Request
Providers who receive payment of claims by Centene Health Plans can request
electronic remittance advices for their respective health plan. Please list the health plan
name on the line below for the health plan you currently bill claims to for payment.
By signing the form below you are authorizing Centene Corporation to send your
electronic remittance via the following clearinghouse:
Payee Name:
Payee Phone Number:
IRS#:
if more than one list all
NPI#: *
*List all that apply.
835
Yes, Please send electronic explanation of payment
Clearinghouse Name:
MD ON-LINE INC
Clearinghouse ID#:
223389595
Sender/Receiver ID:
421406317
Technical Contact Name:
ENROLLMENT
Technical Contact Phone:
888-499-5465 x3506
Health Plan name:
Health Plan Payer ID:
Remit
Yes, please send a paper copy of the explanation of payment
No, please do not send a paper copy of the explanation of payment
If you answer YES to both the ‘835’ and ‘Remit’, the paper copy will discontinue after 60
days.
Please note if you would like EFT’s (Electronic Funds Transfers) set up you will need to
contact PaySpan Health at: (877) 331-7154. Visit their website at: www.payspanhealth.com
Signature of Provider or Administrator:
Date:
Contact email address:
For internal use only:
Received date:
By:
Provider or group id:
Please send completed form to: [email protected]
or fax to 866-266-6985