Electronic Funds Transfer Form – Fill Out and Use This PDF

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

INSTRUCTIONS FOR COMPLETING THIS FORM FOLLOW ON PAGES 3-5

PROVIDER INFORMATION

Provider Name

Provider Address

Street

City ____________________________ State/Province ________ ZIP Code/Postal Code __________________

PROVIDER IDENTIFIERS INFORMATION

Provider Identifiers

Provider Federal Tax Identification Number (TIN) or Employer Identification Number:  TIN  EIN ___________________

National Provider Identifier (NPI) (Required, unless exempt): ____________________

Other Identifiers – Assigning Authority – New York Medicaid

Trading Partner ID: MMIS Provider ID # (Required, if NPI exempt): ___________________

PROVIDER CONTACT INFORMATION

Provider Contact Name			__ Telephone Number________________ Extension____
Contact
Email Address				_______ Fax Number_______________

FINANCIAL INSTITUTION INFORMATION

Financial Institution Name

Financial Institution Address

Street

City ____________________________ State/Province ________ ZIP Code/Postal Code __________________

		Financial Institution Routing Number
		Type of Account at Financial Institution (Check one)		 CHECKING	OR	 SAVINGS
		Provider's Account Number with Financial Institution
		Account Number Linkage to Provider Identifier			LEAVE THIS SECTION BLANK
		Provider Tax Identification Number (TIN) OR National Provider Identifier (NPI)
		SUBMISSION INFORMATION
		Reason for Submission	 New Enrollment		OR	 Change Enrollment
		Include with Enrollment Submission	 Original Voided Check		OR	 Original Bank Letter

Authorized Signature: If submitting the form for a practitioner, the practitioner must sign below.

If submitting this form for a group, business or institution, the authorized representative must sign below.

____________________________________________________	___________________________________
Written Signature of Person Submitting Enrollment	Submission Date
____________________________________________________	___________________________________
Printed Name of Person Submitting	Printed Title of Person Submitting Enrollment

CSC as the eMedNY Fiscal Agent contractor for the New York State Department of Health will have the right to recover any amount that has been credited to your account incorrectly.

FOR CSC USE ONLY – DO NOT WRITE

Date Received:

	Pick Up Indicator: No:			 Yes:  Facility Location:
	Processed by:					Date:
	Authorized by:					Date:
	Effective Start Date:					Cycle #:
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ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

1.To successfully authorize the use of Electronic Funds Transfer for the depositing of New York Medicaid funds, providers and group practices must perform all steps listed below.

**All Sections of the EFT form must be complete and legible; otherwise the request will not be processed and returned to the provider. **

Provider Information

Step 1. Enter the providers’/organizations’ name and address exactly as it was filed with Medicaid. This is the address as it appears on your current checks and remittance statements, if any. If you are unsure of the name and address on file with Medicaid, contact the eMedNY Call Center at 1-800-343-9000.

Provider Identifiers Information

Step 2. Enter the providers’/organizations’ Social Security Number or Tax ID supplied to Medicaid at the time of enrollment. For established providers/organizations, the Tax ID can be found on the 1099 tax form.

Step 3. Complete one of the following based on your provider type.

•For Individual Providers: Enter the MMIS Provider ID or NPI in the applicable section. Enter only one provider number per application form.

•For Multiple Providers: Providers with multiple provider numbers (Medicaid number or NPI) must submit a signed attachment on original letter head listing all MMIS ID’s and NPIs to be placed on EFT.

•For Group Practices: Enter the group NPI if payment is made to a group practice. Enter only one provider number per application form. Provider Groups that receive payments under the Group number need only complete a single enrollment form for the Group NPI. However, members of Provider Groups who also bill individually may enroll by submitting a separate enrollment form using their individual Provider number.

Provider Contact Information

Step 4. Provide a contact name, telephone number, and email (if available) should additional information be required.

Financial Institution Information

Step 5. Enter the name and address of the banking institution to which funds are to be transferred.

Step 6. Enter the routing number and account number for the checking or savings account to which funds are to be

transferred. Both numbers can be found at the bottom of your check or letter from a banking officer.

Submission Information

Step 7. Be sure to include the required documents. Check the appropriate box for the document included with this form.

Step 8. Indicate if this is a new or change in EFT enrollment.

a.For providers already enrolled in Medicaid, check CHANGE IN ENROLLMENT. Please see page 5 for further instructions on changing banking information.

b.Enrolling providers must choose NEW ENROLLMENT.

Step 9. The form must be completed with an original signature of the provider or designated practice or business representative and date signed. Requests from individual practitioners must be signed by the practitioner. Requests from groups, business, or institutions must be signed by an authorized representative. The Title of provider or practice or business representative must be indicated.

EMEDNY-701101 (03/14)

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ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

2.Attach one of the following banking documents to the first page of EFT Authorization Form packet:

a.For Checking Accounts: An original blank check from the checking account to which the funds are to be transferred. The word “VOID” must be written across the face of the check. The check must contain the name and address of the provider or provider organization.

b.For deposit-only checking accounts (and you do not have checks) or a savings account: Submit an original letter from a bank officer. The letter must be on bank letterhead, signed by a bank officer, notarized by a notary public, and include the following information:

1.the bank’s name and address

2.routing number

3.the type of account

4.account number

5.the account owner’s name

6.owner's address

7.owner's tax id

3.Mail the form (pages 1 and 2) and all attachments to:

Attention: EFT Processing

Computer Sciences Corporation

P.O. Box 4616

Rensselaer, NY 12144-4616

EFT Authorization Forms that do not comply with these instructions will be rejected.

Questions about form completion should be directed to the eMedNY Call Center.

Providers who have not received their EFT or Remittance Statement within 4 business days of each other should

contact the eMedNY Call Center.

1-800-343-9000

In addition to the above, if the provider needs the CCD+ reassociation data elements to link the ERA to the payment, the provider must contact their financial institution, not eMedNY, to arrange for the delivery of the CORE required minimum CCD+ data elements. See Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule, for more details.

http://www.caqh.org/CORE_phase3.php

What to Expect

Allow a minimum of 6-8 weeks for your request to be processed. During the process period a test transaction for one cent will be transferred to your account.

For providers who have claims paid within a particular payment cycle, Medicaid funds are normally scheduled to be transferred on Wednesday afternoons. Due to normal banking procedures, the funds may not become available in the provider’s chosen account for up to 48 hours from the initial transfer. Contact your banking institution with questions about the availability of funds.

EFT does not waive the two week lag for release of Medicaid payments.

EMEDNY-701101 (03/14)

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