Electronic Claims Payment For Providers 2026

1. Click ‘Get Form’ to open the Electronic Claims Payment For Providers in the editor.
2. Begin with Part I: Reason for Submission. Select one of the options: New EFT Authorization, Cancel EFT, Revision to Existing Enrollment, or Enroll in Electronic Remittance Advice (ERA).
3. In Part II: Pharmacy/Organization Information, fill in your Tax ID, Chain Code/Payment Center ID/NCPDP, Organization Name, Address, City, State, and Zip Code.
4. Proceed to Part III: Pharmacy/Organization Contact. Enter the Name, Title, Email Address, Phone Number, and Fax Number of the primary contact.
5. In Part IV: Designation of Depository, provide Bank Name, Account Name, Bank Address details including City and State. Fill in Bank Contact Name and Phone Number along with Bank Account Number and Routing Transit Number. Choose between Checking or Savings Account.
6. For Part V: Electronic Remittance Advice Information, if applicable, complete the contact information for electronic remittance setup and select your preferred delivery option.
7. Finally, sign and date the authorization section at the end of the form. Ensure all required attachments are included before submission.

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