Carefirst Eft Form PDF Details

Financial planning is an important part of everyone's life. For some, it is more important than others. Whether you are young and starting out on your own or you are closer to retirement age, there are steps that everyone can take to make sure their finances are in order. CareFirst offers a variety of financial tools and services to help its members get the most from their money. One such tool is the CareFirst Eft Form. This form allows members to make automatic payments from their bank account directly to CareFirst, making it easy to pay your premiums on time every month. Using the CareFirst Eft Form is a convenient way to ensure that your insurance premiums are always paid on time, without having to worry about missed payments or late fees.

QuestionAnswer
Form NameCarefirst Eft Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescarefirst eft enrollment, carefirst deposit eft ach, carefirst eft change, automatic deposit eft ach carefirst

Form Preview Example

REV 2013.10.09.1

Automatic Deposit (EFT/ACH Credits)

Authorization Agreement and Contact Information

*All fields are required. See instructions on next page.

PROVIDER INFORMATION

Provider Name:

Street:

City:

State/Province:

ZIP Code/Postal Code:

PROVIDER IDENTIFIERS

Provider Federal Tax Identification Number (TIN) National Provider Identifier (NPI): Assigning Authority: or Employer Identification Number (EIN):

PROVIDER CONTACT INFORMATION

Provider Contact Name:

Telephone Number:

Email Address:

Fax Number:

FINANCIAL INSTITUTION INFORMATION

Financial Institution Name:

Street:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province:

ZIP Code/Postal Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Financial Institution Routing Number:

Type of Account at Financial Institution:

Provider’s

Account Number

with Financial Institution:

 

 

 

 

 

 

Checking

 

 

Savings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number Linkage

 

 

 

 

Provider Tax Identification Number (TIN):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to Provider Identifier (select one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Provider Identifier (NPI):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMISSION INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Submission (select one):

 

 

New Enrollment

 

Change Enrollment

 

Cancel Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Include with Enrollment Submission (select one):

 

Voided Check

 

 

 

 

Bank Letter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach a voided check to this space.

OR

Attach a copy of a bank letter after this form.

The name, address, account and routing numbers must be viewable.

Bank deposit tickets, bank statements, and other items will not be accepted in lieu of a voided check or bank letter.

*Notify the bank to arrange for the delivery of the CORE-required minimum CCD+ data elements necessary

for successful EFT payment and re-association with the electronic remittance advice (ERA).

I (we) understand that by using CareFirst BlueCross BlueShield Electronic Funds Transfer, we will no longer receive printed voucher summaries.

I (we) certify that I am a duly authorized signer of the above designated bank account and as such hereby authorize CareFirst, and Independent Licensee of the Blue Cross and Blue Shield Association, to initiate credit entries and, if and only to the degree necessary for any credit entries initiated in, debit entries to my (our) account indicated above and authorize the depository indicated above, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. This authorization is to remain in full force and effective until CareFirst has received written notification from me (or either of us) of its termination in such time and in such manner as to afford CareFirst and DEPOSITORY a reasonable opportunity to act on it. In the

event CareFirst finds it necessary to initiate a correcting debit or credit entry, the account holder will be notified in advance. Modifications to this agreement will result in an automatic denial of your request to establish automatic deposit. “CareFirst” refers to CareFirst BlueCross BlueShield or

CareFirst BlueChoice, Inc.

Authorized Signature:

Submission Date:

Requested EFT Start/Change/Cancel Date:

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services. Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ® Registered trademark of CareFirst of Maryland, Inc.

REV 2013.10.09.1

Automatic Deposit (EFT/ACH Credits)

Authorization Agreement and Contact Information

Instructions

1.Complete the form (type all responses). For information about a field on the form, refer to the field descriptions below.

2.Attach a voided check in the space provided on the form or attach a copy of a bank letter after the form.

3.Send the completed form via e-mail to EFTenrollment@availity.com or via fax to 904-470-4781.

What information do I need to provide to the bank?

You must contact your financial institution to arrange for the delivery of the CORE-required minimum CCD+ data elements needed for re-association of the EFT payment and the ERA. When you contact the bank, you must provide the bank with the following CCD+ data elements:

∙Effective Entry Date

∙Amount

∙Payment-Related Information

Who do I contact if I have questions?

If you have questions regarding the EFT enrollment process, contact Availity Client Services at 1.800.AVAILITY (282.4548).

Field

Description

PROVIDER INFORMATION

 

Provider Name

Complete legal name of institution, corporate entity, practice or individual provider.

 

 

Street

The number and street name where a person or organization can be found.

 

 

City

City associated with provider address field.

 

 

State/Province

ISO 3166-2 Two Character Code associated with the State/Province/Region of the

 

applicable Country.

 

 

ZIP Code/Postal Code

System of postal-zone codes (zip stands for "zone improvement plan") introduced in the

 

U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting

 

capabilities.

 

 

PROVIDER IDENTIFIERS

 

Provider Federal Tax Identification Number

A Federal Tax Identification Number, also known as an Employer Identification Number

(TIN) or Employer Identification Number

(EIN), is used to identify a business entity.

(EIN)

 

 

 

National Provider Identifier (NPI)

A Health Insurance Portability and Accountability Act (HIPAA) Administrative

 

Simplification Standard. The NPI is a unique identification number for covered healthcare

 

providers. Covered healthcare providers and all health plans and healthcare

 

clearinghouses must use the NPIs in the administrative and financial transactions

 

adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-

 

digit number). This means that the numbers do not carry other information about

 

healthcare providers, such as the state in which they live or their medical specialty. The

 

NPI must be used in lieu of legacy provider identifiers in the HIPAA standards

 

transactions.

 

 

Assigning Authority

Organization that issues and assigns the additional identifier requested on the form, e.g.,

 

Medicare, Medicaid.

 

 

PROVIDER CONTACT INFORMATION

 

Provider Contact Name

Name of a contact in provider office for handling EFT issues.

 

 

Telephone Number

Associated with contact person.

 

 

Email Address

An electronic mail address at which the health plan might contact the provider.

 

 

Fax Number

A number at which the provider can be sent facsimiles.

 

 

 

 

REV 2013.10.09.1

 

 

Automatic Deposit (EFT/ACH Credits)

 

 

Authorization Agreement and Contact Information

Instructions (continued)

 

 

 

 

Field

Description

FINANCIAL INSTITUTION INFORMATION

 

 

Financial Institution Name

Official name of the provider’s financial institution.

Street

Street address associated with receiving depository financial institution name field.

 

 

City

City associated with receiving depository financial institution address field.

 

 

State/Province

ISO 3166-2 Two Character Code associated with the State/Province/Region of the

 

applicable Country.

 

 

ZIP Code/Postal Code

System of postal-zone codes (zip stands for "zone improvement plan") introduced in the

 

U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting

 

capabilities.

 

 

Financial Institution Routing Number

A 9-digit identifier of the financial institution where the provider maintains an account to

 

which payments are to be deposited.

 

 

Type of Account at Financial Institution

The type of account the provider will use to receive EFT payments, e.g., Checking,

 

Saving.

 

 

Provider’s Account Number with Financial

Provider’s account number at the financial institution to which EFT payments are to be

Institution

deposited.

 

 

Account Number Linkage to Provider

Provider preference for grouping (bulking) claim payments—must match preference for

Identifier

v5010 X12 835 remittance advice. Select one of the following options:

 

∙ Provider Tax Identification Number (TIN) – Enter a TIN in the field provided if you

 

 

select this option.

 

∙ National Provider Identifier (NPI) – Enter an NPI in the field provided if you select

 

 

this option.

 

 

 

SUBMISSION INFORMATION

 

 

Reason for Submission

Select one of the following options:

 

∙

New Enrollment

 

∙

Change Enrollment

 

∙

Cancel Enrollment

 

 

Include with Enrollment Submission

Select one of the following options:

 

∙ Voided Check – A voided check is attached to provide confirmation of

 

 

Identification/Account Numbers.

 

∙ Bank Letter – A letter on bank letterhead that formally certifies the account owners

 

 

routing and account numbers.

 

 

Authorized Signature

The signature of an individual authorized by the provider or its agent to initiate, modify or

 

terminate an enrollment. May be used with electronic and paper-based manual

 

enrollment.

 

 

Submission Date

The date on which the enrollment is submitted.

 

 

Requested EFT Start/Change/Cancel Date

The date on which the requested action is to begin.

 

 

 

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carefirst deposit eft ach completion process clarified (step 1)

2. Your next step would be to submit all of the following blank fields: Account Number Linkage to Provider, SUBMISSION INFORMATION, Checking, Savings, Provider Tax Identification Number, National Provider Identifier NPI, Reason for Submission select one, New Enrollment, Change Enrollment, Cancel Enrollment, Include with Enrollment Submission, Voided Check, Bank Letter, Attach a voided check to this space, and Attach a copy of a bank letter.

Stage # 2 for filling out carefirst deposit eft ach

3. The following portion is about I we certify that I am a duly, Authorized Signature, Submission Date, Requested EFT StartChangeCancel, and CareFirst BlueCross BlueShield is - type in these fields.

I we certify that I am a duly, CareFirst BlueCross BlueShield is, and Requested EFT StartChangeCancel of carefirst deposit eft ach

4. The fourth subsection arrives with the following form blanks to type in your specifics in: Complete the form type all, What information do I need to, You must contact your financial, Effective Entry Date Amount, Who do I contact if I have, If you have questions regarding, Field, PROVIDER INFORMATION, Description, Provider Name, Complete legal name of institution, Street, City, StateProvince, and The number and street name where a.

Filling in segment 4 of carefirst deposit eft ach

Be very mindful when completing Provider Name and Street, since this is the section where many people make a few mistakes.

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