PAYER ENROLLMENT INSTRUCTIONS FOR MC030
Medicaid,
Oklahoma - ERA
ERABefore enrolling please be sure your Capario contract includes the transactions you will be using. Transactions are available as an additional Capario contracted service. Please ensure you are contracted
with Capario
to request Electronic Remittance BEFORE requesting ERAs through Capario for this payer. If you
Complete the payer enrollment process BEFORE submitting claims to Capario for this payer. If you are unsure
about
your current status please contact Capario sales at: [email protected] or 800-586-6870.
are unsure about your contract status please contact Capario Support team at: [email protected] or EFT 800‐792‐5256. enrollment and transmission is an arrangement between the provider and the Payer. If the Payer offers EFT
transactions contact them to determine if they:
We recommend enrolling using our Portal enrollment tool. This free Portal tool allows you to enter • Require
you to receive EFTs in order to receive their ERAs
• Charge
an
additional fee for EFTs/ERAs
Providers and select the payers and transactions for your enrollment as it prefills the agreement • Require you to enroll for EFTs on this ERA enrollment form.
forms for you. Another advantage of the enrollment tool is the ability to follow the progress of enrollments from initial generation through to payer approval. Our team will set you up and provide We recommend
enrolling using the convenience of our enrollment tool located on the Capario portal. This tool
allows
you
to
enter
providers, select the payers and transactions for which you want to enroll, and produces
a quick tutorial. Contact us at [email protected] pre-filled forms for processing. If you are not currently using the Capario portal, you can contact us at
[email protected]
and our team will ensure that you are set up and will provide a quick tutorial on using the
enrollment tool.
If you are not enrolling with the free portal Enrollment tool, please following these instructions: Enrollment can be completed without the enrollment tool by following the specific instructions for this payer shown
If this payer does not require an agreement, go to Step 2. below.
STEP 1: COMPLETE AGREEMENT 

Complete all required fields on agreement and verify that information entered is correct. If an agreement requires signatures, we recommend signing in blue ink. Do not use signature stamps. STEP 2: PROCESS **NOTE** This agreement requires signature
Mail, Fax or Email the completed Oklahoma Medicaid EDI/ERA Application to:
EHP Enterprise Services
Attn: EDI Department
2401 NW 23rd St., Ste. 11
Oklahoma
City, OK 73107
Fax: (405) 416-1426
Email:
[email protected]
STEP 3: COMPLETE CAPARIO ENROLLMENT SPREADSHEETS 

Capario Provider Spreadsheet – This is completed for each new provider. http://www.capario.com/downloads/xls/provider_bulk_spreadsheet.xlsx Capario Payer Enrollment Spreadsheet – This is completed when requesting enrollment with a payer for providers previously added to the Capario system. Please refer to the instruction tab on each spreadsheet form for details about the information to enter in each column. **PLEASE NOTE** The fields for tracking information are key for both your record keeping of enrollments and for Capario following up with payers for approvals. Be sure to enter all tracking for each enrollment. http://www.capario.com/downloads/xls/enrollment_bulk_spreadsheet.xlsx Email the completed spreadsheet(s) to: [email protected] Questions? Contact us: Phone: (800) 792‐5256 Option 1 Fax: (404) 877‐ 3324 Email: [email protected]
Oklahoma SoonerCare EDI/ERA Application for Providers
New Application
Amended Application
Vendor Change
X
Section I – Provider Information
Business Name: _______________________________________________
Address: ________________________________________
Provider ID or NPI: ___________________
City ________________
State _______
Zip ______
1st Contact Name: _____________________ Phone: ______________ Fax: _______________Email: ____________________________
2nd Contact Name:_____________________ Phone: ______________ Fax: _______________Email: ____________________________
Capario
EDI Vendor: ____________________________________________________________________
Vendor Type (check one):
Software Product
Billing Agent
1901 E. Alton Ave. Suite 100
Address: ________________________________________
EDI Team
Contact Name: ___________________________
X
Clearinghouse
Santa Ana
City ________________
(800) 792-5256 Opt. 1
CA
State _______
92705
Zip ______
[email protected]
Phone: ______________________ Email: ______________________
Please indicate the EDI transactions being requested to send/receive:
X
837 Professional Claim
837 Institutional Claim
837 Dental Claim
270/271 Eligibility Request/Response
835 Remittance Advice * * (fill out section below)
278 Prior Authorization Request
820 Capitation Payments
834 PMP Roster
276/277 Claim Status Request/Response
Section II – complete only if requesting the Electronic Remittance Advice (ERA)
This request is to (check one):
X
Enable 835 Remittance Advice and cease paper RA after two week overlap
Disable 835 and resume paper RA effective immediately .
SoonerCare Provider ID/NPI Numbers(s) to be Enabled/Disabled:
1. ID _____________________ Name ________________________________ 3. ID _________________________ Name _________________________
2. ID _____________________ Name ________________________________ 4. ID _________________________ Name _________________________
Please use an attachment for additional providers as needed.
X
Elect a Designated Receiver for All ERA(s):
500000009
Receiver’s ID ___________________
Capario
Name __________________________________________
EDI Team
Contact Person _______________________
Phone __________________ Email _____________________________
(800) 792-5256 Opt. 1
[email protected]
The 835 Electronic Remittance Advice (ERA) is an X12 transaction that may require special software to process. Paper remittances will cease once the 835 has been enabled. The 835 ERA may be
switched back to paper with written notice, and paper copies of your remit may be requested at any time by submitting form HCA-18. As a courtesy, your paper remittances will continue for two weeks
after the 835 is enabled. By signing this form you acknowledge that you have read and agree to these terms.
Section III – Signature and date
Authorized Signature: ________________________________
Date: __________________
Please submit form by mail, fax or email to HP Enterprise Services Attn: EDI Department / 2401 NW 23rd Street, Ste .11 /Oklahoma City, OK 73107
Fax: (405) 416-1426/ email to [email protected]
Questions about this form or EDI procedures call the EDI Helpdesk at (800)522-0114 option 2, 2 or email at [email protected]