Wisconsin Physicians Service (Wps) Authorization Form For Electronic Remittance Advice Processing (Era) printable pdf download

Wisconsin Physicians Service (Wps) Authorization Form For Electronic Remittance Advice Processing (Era)

Wisconsin Physicians Service (WPS) Authorization Form for Electronic Remittance

Advice Processing (ERA)

This form is intended to establish Electronic Remittance Advice (ERA) enrollment. The implementation

process cannot begin until this questionnaire is completed. If the form is received as not legible or not

completed correctly, it will be returned to the provider for correction. If you are a direct submitter,

you must be assigned a submitter ID in order to receive the ERA. If you have not registered for a

submitter ID, please access the WPS Trading Partner System (WTPS) at the following website:

If you are not a direct submitter, the

clearinghouse/third-party company/billing service submitter number should be used. Please return this

form to the EDI Department, for the applicable line of business, as listed at the bottom of this form.

. ***

***This request could take up to fourteen business days to complete

Part A providers need to select if this request is for a new submitter or if they want to add providers to their

current submitter.

New Submitter: [ ]

Add Providers: [ ]

Check all lines of business that apply:

Part A J5 [ ]

Part B J5 [ ]

Part A J8 [ ] Part B J8 [ ]

Part A Legacy [ ]

Part B Legacy [ ]

Please identify the company that will be retrieving the Electronic Remittance Advices ERA) in this

section:

Provider/Physician: [ ] Corporate Office: [ ]

Third Party Company/Clearinghouse: [X ]

Provider Name

: _______________________________________________________________________________

Provider Street Address

: _______________________________________________________________________

(If the provider will be retrieving the ERAs, then they need to include the address that the services are rendered)

Provider City/ State/Zip: ________________________________________________________________

Contact Person: _______________________________________________________

(Printed Name)

Contact Phone #:_____________________ Contact Fax #:____________________

(Please incl. ext #)

Contact Email Address: __________________________________________________

WPS Submitter ID: _98120________

(Please use only the WPS issued submitter ID that will be retrieving the ERAs)

Version 1.0

Modified 7/06/2012

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Wisconsin Physicians Service (Wps) Authorization Form For Electronic Remittance Advice Processing (Era)