Electronic Remittance Advice / Electronic Funds Transfer (ERA/EFT)
MCC supports our Providers, and as such would like to highlight the many benefits ERA/EFT:
- Providers get faster payment (processing can take as little as 3 days from the day the claim was submitted)
- Providers can search for a historical Explanation of Payment-EOP (aka Remittance Advice) by claim number, member name, etc.
- Providers can view, print, download and save a PDF version of the Explanation of Payment for easy reference with no paperwork to store.
- Providers can have files routed to their ftp and/or their associated clearinghouse.
MCC encourages electronic payment of your claims remittance. In order to get your claims payment direct deposited into your bank account, please complete and return this enrollment form, along with all requested documentation within the form. Return the documentation to MCCVA-Provider@MolinaHealthcare.com.
Instructions for Completing the Electronic Funds Transfer form:
All EFT requests are subject to a 15-day pre-certification period in which all accounts are verified by the qualifying financial institution before any Molina Healthcare of Virginia, LLC (dba Molina Complete Care) direct deposits are made.
PART I: REASON FOR SUBMISSION
Indicate your reason for completing this form by checking the appropriate box: New, Change or Cancel EFT enrollment account information.
PART II: ACCOUNT HOLDER INFORMATION
- Enter the provider’s/supplier’s legal business name, or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which EFT payments made must bear the name of the physician or individual practitioner, or the legal business name of the person or entity.
- Enter the account holder’s street address.
- Enter the account holder’s city, state, and zip code.
- Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation, provide the Federal employer identification number. If enrolling as an individual, provide your Social Security Number.
- Enter the 10-digit NPI number. The NPI is required to process this form.
- If issued, enter the Medicare identification number assigned by a Medicare Administrative Contractor (MAC). If you are not enrolled in Medicare, leave this field blank.
PART III: FINANCIAL INSTITUTION INFORMATION
PART IV: AUTHORIZATION
- Enter the name and title of the authorized contact person who can answer questions about the information supplied on this form.
- Enter the authorized contact person’s telephone number.
- Enter the authorized contact person’s e-mail address.
- By your signature on this form, you are certifying that the account is drawn in the Name of the Physician or Individual Practitioner, or the Legal Business Name of the person or entity. The person or entity has sole control of the account to which EFT deposits are made.
The EFT authorization form must be signed and dated by the Account Holder, an Authorized Representative or Delegate to include a telephone number to be contacted.
Submit this completed form via secure email or secure fax transmittal as instructed on the form. Missing elements such a signature, date, voided check or official bank letter will result in a delay in processing or rejection of this form.
Electronic Funds Transfer Agreement Form