For questions about this form or the electronic enrollment process, please contact the EDI Team.
You must be authorized to submit 837s in order to receive 835s.
The EDI support team will contact you upon receipt of the completed ERA Enrollment Form.
Form Submission Fields
Provider Information - please fill out completely
Provider name - Legal name of institution, corporate entity, practice or individual provider
Provider address -
Street - The number and street where individual/organization is located
City - City associated with street address field
State/Province - Two character code associated with the State/Province/Region of the applicable Country
ZIP code/Postal code - System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities
National Provider Identifier (NPI) - A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Provider Federal Tax Identification Number (TIN) - A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), used to identify a business entity
Trading Partner ID - The provider's submitter ID assigned by the health plan or the provider's clearinghouse or vendor
Provider contact information
Provider contact name - Name of a contact in a provider office for handling ERA issues
Telephone number - Associated with provider contact name
Email address - An electronic mail address at which the health plan might contact the provider
Fax number - A number at which the provider can be sent facsimiles
Preference for Aggregation of Remittance Data is National Provider Identifier (NPI)
Method of retrieval is determined by BCBSMA
ERA clearinghouse information
Clearinghouse name - Official name of the provider's clearinghouse
Telephone number - Telephone number of contact
Email address - An electronic mail address at which the health plan might contact the provider's clearinghouse
Reason for submission
Authorized signature - Signature of an individual authorized by the provider or its agent to initiate, modify, or terminate an enrollment
Electronic signature of person submitting enrollment - (usually cursive) A rendering of a name unique to a particular person used as confirmation of authorization and identity
Printed title of person submitting enrollment - Printed title of the person signing the form
ERA Enrollment Form submission date - Date on which the enrollment form is submitted
Requested ERA effective date - Date the provider wishes to begin ERA. Per Phase III CORE Health Care Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0, there may be a dual delivery period based upon a trading partner agreement with BCBSMA
Researching missing / Late files
ERA files that have not been received after 4 business days of receipt of the corresponding EFT file can be researched by contacting the EDI Team