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Welcome UCare Providers

EFT/ERA Instructions

Provider Payment & Remittance Selection
Instructions for Completing Provider Payment and Remittance Request Form


Fields in bold are required. Below are the instructions on how to complete the Provider Payment and Remittance Request form. Please allow a minimum of 30 days for processing.

If you have questions on how to complete the form, please send an e-mail to EFT835@ucare.org.

1. Select a Reason for Submission

A reason and sub-reason for submission must be selected for the form.

  • Select a reason for submission from the Reason for Submission field.
  • Select a sub-reason for submission from the Sub-reason for Submission field.

2. Complete the Provider Information Section

The Provider Information section must be completed for all submission reasons.

  • Enter the legal name of the institution, corporate entity, practice or individual provider into the Provider Name field.
  • Enter the number and street name a facility can be found into the Provider Address Street field.
  • Enter the city associated with the provider address into the Provider Address City field.
  • Enter the two-character code associated with the State/Province/Region of the applicable country associated with the provider address into the State/Province field.
  • Enter the zip code/postal code associated with the provider address into the Zip Code/Postal Code field.

3. Complete the Provider Identifiers Section

The Provider Identifiers section must be completed for all submission reasons.

A Provider Federal Tax Identification Number (TIN), also known as an Employer Identification Number (EIN) is a nine-digit number used to identify a business entity. The Federal TIN must be entered exactly as it appears on your SS-4 (corporate) or Social Security card (individual).

A National Provider Identifier (NPI) is a unique ten-digit 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 HIPPA. The NPI must be used in lieu of legacy provider identifiers in the Health Insurance Portability and Accountability Act (HIPAA) standards transactions.

If the requester is an atypical provider enrolled with the Minnesota Department of Human Services, the provider’s unique Minnesota provider identifier (UMPI) should populate the NPI field.

  • Enter a nine-digit number into the Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) field.
  • If the Provider has been enumerated with an NPI enter the ten-digit number into the National Provider Identifier (NPI) field; add all of the NPIs associated with the TIN/EIN to be included with this election.

4. Complete the Provider Contact Information Section

The Provider Contact Information section must be completed for all submission reasons.

  • Enter the name of a contact in the provider office for handling EFT issues into the Provider Contact Name field.
  • Enter the telephone number associated to the contact person in the Telephone Number field.
  • Enter the electronic mail address at which the health plan might contact the provider in the Email Address field.
  • Enter a number at which the provider can be sent facsimiles in the Fax Number field.
  • Complete the Financial Institution Information Section.

5. Complete the Current Financial Institution Information Section

The Current Financial Institution Information section must be completed for all EFT change requests. If the provider is moving from paper to electronic payment, the reason for submission should be New Enrollment.

  • When the current payment method is EFT, enter the official name of the provider’s financial institution into the Financial Institution Name field.
  • When the current payment method is EFT enter the nine-digit identifier of the financial institution where the provider maintains an account to which payments being deposited into the Financial Institution Routing Number field.
  • When the current payment method is EFT, enter the provider’s account number at the financial institution to which EFT payments is being deposited into the Provider’s Account Number field.
  • When the payment method is EFT enter the provider preference for claim payments – must match preference for v5010 X12 835 remittance advice. When NPIs have been entered into the Provider Identification section they will be automatically displayed in this section. If there are no NPIs enter the provider TIN into the Provider Tax Identification Number (TIN) field.

6. Complete the Financial Institution Information Section

The Financial Institution Information section must be completed for all payment selection submissions.

  • Select the payment method from the Payment Method field.
  • When the payment method is Paper Check, enter the address information where payment should be mailed into the Payment Address fields.
  • When the payment method is EFT enter the official name of the provider’s financial institution into the Financial Institution Name field.
  • When the payment method is EFT select the type of account the provider will use to receive EFT payments, e.g., Checking, Saving into the Type of Account at Financial Institution field.
  • When the payment method is EFT enter the nine-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited into the Financial Institution Routing Number field.
  • When the payment method is EFT enter the provider’s account number at the financial institution to which EFT payments are to be deposited into the Provider’s Account Number field.
  • When the payment method is EFT enter the provider preference for claim payments – must match preference for v5010 X12 835 remittance advice. When NPIs have been entered into the Provider Identification section they will be automatically displayed in this section. If there are no NPIs enter the provider TIN into the Provider Tax Identification Number (TIN) field.

7. Complete the Current Electronic Remittance Advice Clearinghouse Information Section

The Current Electronic Remittance Advice Clearinghouse Information section must be completed for change ERA requests. If the provider is moving from paper to electronic remittance, the reason for submission should be New Enrollment.

  • When the current method of retrieval is Clearinghouse, select the official name of the provider’s clearinghouse from the Clearinghouse Name field.

8. Complete the Electronic Remittance Advice Clearinghouse Information Section

The Electronic Remittance Advice Clearinghouse Information section must be completed for all remittance selection submissions.

  • Select the method in which the provider will receive the ERA from the health plan from the Method of Retrieval field.
  • When the payment method is Paper (option not available to Minnesota providers), enter the address information where remittance should be mailed into the Remittance Address fields.
  • When the method of retrieval is Clearinghouse, select the official name of the provider’s clearinghouse from the Clearinghouse Name field.
  • When the payment method is EFT enter the provider preference for claim payments – must match preference for v5010 X12 835 remittance advice. When NPIs have been entered into the Provider Identification section they will be automatically displayed in this section. If there are no NPIs enter the provider TIN into the Provider Tax Identification Number (TIN) field.

9. Complete the Authorized Signature Section

The Authorized Signature section must be completed for all submission reasons.

  • Enter the name of the person signing the form in the Electronic Signature of Person Submitting Enrollment field.
  • Enter the printed title of the person signing the form in the Printed Title of Person Submitting Enrollment field.
  • To submit the form, click on the Submit button. The system will verify that all required fields have been completed.
  • To cancel the form, click on the Cancel button. Please note that the form cannot be saved and submitted at a later time.