Provider Pharmacy Electronic Payment And Remittance Enrollment Form
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2PROVIDER PHARMACY ELECTRONIC PAYMENT and
REMITTANCE ENROLLMENT FORM
To enroll in electronic payment of claims for Medicare Part D PDP and MA-PD sponsors and electronic remittance
advice, complete and sign this double sided form in two places. Incomplete forms will be returned.
Mail original signed form to:
Medco Health Solutions, Inc.
Attn: Pharmacy Administration and Contracting Unit
100 Parsons Pond Drive (MS-1-EFT-D-1)
Franklin Lakes, NJ 07417
Important Information:
Once this form has been completed and returned to Medco, Medco will implement the setup process. This will require
approximately 45 days for the setting up and testing of accounts. The first electronic payment for clean claims submitted
electronically by retail Provider pharmacy will be made no later than the first cycle after the setup period is successfully
completed. Electronic payment is contingent on the accuracy of all information provided by Provider pharmacy to Medco.
It is the Provider pharmacy’s responsibility to notify Medco immediately if any of this information changes.
Provider pharmacy must submit a voided check if the electronic fund transfer is going to a checking account. If a voided
check does not accompany the form, enrollment could be delayed.
A prenote will be sent to the account name indicated on this form to test its validity. If the prenote is rejected for reasons
including but not limited to incorrect account number or routing number, and Provider pharmacy does not receive
electronic payment after the approximate 45 day set-up period, it is the Provider pharmacy's responsibility to contact
Medco as soon as possible and to provide accurate account information.
Electronic reimbursement will only be available to retail network pharmacies that provide Covered Services to member
enrolled in a Medicare Part D plan. For Covered Services provided to members who are not covered under a Medicare
Part D plan, pharmacy will continue to receive paper checks.
Provider pharmacy agrees to hold Medco and Sponsors harmless for any claims where Medco has remitted payment
electronically to Provider pharmacy in accordance with account information provided by Provider pharmacy to Medco.
Provider pharmacy agrees to hold Medco and Sponsors harmless for any payments made by Medco or Sponsors to a
third party if Provider pharmacy designates such third party to receive payments and/or remittance on behalf of
Pharmacy.
Provider pharmacy agrees to accept the 835 electronic remittance format via File Transfer Protocol (FTP) as the only
format for remittance advice when electronic payment is requested for Medicare Part D.
The following information is needed to set up electronic payments for your pharmacy (Please print clearly):
Account name: _________________________________ Account type: ______________________________________
*
*
Account #
: ______________________________________ Bank routing #
: ______________________________________
+
+
Pharmacy corporate name: ________________________________ NCPDP #
: _____________ NPI#
: ________________
Pharmacy address (city, state, zip): _________________________________________________________________________
Pharmacy fax #: _____________________________________ Pharmacy phone #: ________________________________
Contact last name: _______________________________ Contact first name: __________________________________
□
□
Pharmacy Type:(check one):
Independent
Medco recognized chain (enter 4 digit Medco chain#): ____________
+
*
Contact your financial institution for assistance
Medco recognized chains, leave field blank
This form must be signed in order to be processed.
Owner’s name (please print): ______________________________________________ Date: ______________
Authorized Signature: ___________________________________________Title: ________________________
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