Electronic Remittance Advice Enrollment Form

Required Fields

PAYOR INFORMATION

Indicate the payor (one or both below) for this Electronic Remittance Advice (ERA) submission:

Horizon BCBSNJ (payor ID 22099)

Braven Health (payor ID 84367)

PROVIDER INFORMATION

Provider Name

Provider Address: Street

City

State/Province

ZIP Code/Postal Code

PROVIDER IDENTIFIERS INFORMATION

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

National Provider Identifier (NPI)

Other Identifier(s)

Assigning Authority

PROVIDER CONTACT INFORMATION

Provider Contact Name

Title

Telephone Number

Email Address

ELECTRONIC REMITTANCE ADVICE INFORMATION

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)

Provider Tax Identification Number (TIN)

Method of Retrieval

Clearinghouse/Vendor

Clearinghouse Only

SUBMISSION INFORMATION

Reason for Submission

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature

Authorized Electronic Signature of Person Submitting Enrollment

(enter your name here)

Submission Date

I hereby authorize Horizon BCBSNJ, on behalf of itself, its subsidiaries, and its affiliates, including but not limited to, Braven Health (“Company”), to process this request for participation in Company’s Electronic Remittance Advice (ERA/835) program. This authorization will remain in effect until Company receives and has a reasonable opportunity to process a revocation request. Revocation shall not apply to transactions initiated prior to the effectiveness of such revocation. By entering my name above and checking this box, I certify that the information submitted is true and accurate in all respects, and the individual executing and delivering this information is authorized to do so. The recipient will promptly notify Company of any changes to the information submitted and hold Company harmless from any liability resulting from Company’s reliance on the information provided.