Electronic Payment and Remittance Advice Application This application constitutes an agreement between Neighborhood Health Plan of Rhode Island (Neighborhood) and its affiliated professional or institutional provider, as identified below, to accept direct deposit of claim payment to provider’s bank. Direct deposit will be made through Bank of America’s Automated Clearinghouse into the account and bank routing address indicated below. Professional or institutional providers equipped to accept electronic remittance advices are requested to enter their document format preferences in the box provided below. Neighborhood supports remittances in two formats: (1) electronic transmission of standard-format remittance advice file (image of paper RA) via Neighborhood secure e-mail in PDF format OR (2) machine-readable ASCX12 835 (available for retrieval via ftp/sftp). If provider is applying for the standard-format PDF format via Neighborhood secure e-mail), provider warrants that access and retrieval of the .pdf RA using provider’s e-mail address (included below) at their place of business will be in a HIPAA- compliant, secure manner with handling by authorized personnel only. Submission of this completed application to Neighborhood at 910 Douglas Pike, Smithfield, RI 02917 enables participation in Neighborhood’s electronic claim payment and remittance advice transmission processes. Provider will be contacted prior to implementation date for transmission testing if necessary.If you have not been converted to eRA and/or EFT after 40 business days, please contact Neighborhood Provider Services at 1-800-963-1001.APPLICATION REQUEST TYPEAPPLICATION REQUEST TYPENEW Application – New application must be completed in full and signed.REVISED Application - Please fill in applicable details including Business Name, NPI, and sign application.Please select onePlease use the space below to describe the revised application request, e.g., requesting 835 file receipt, change of bank information, etc.* Identification and Bank Routing InformationBusiness Name* Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NPI Number* Please provide Group Billing NPI Tax Identification Number* Name of Bank* ACH Bank Routing Number* [9 digits, please verify with bank] – DO NOT USE routing number from check Bank CHECKING Account Number* [No dashes]Email for Remittance Advice - REQUIRED (only one) for .PDF RA* Enter Email Confirm Email 835 REQUESTS (Optional)Please indicate who will receive the 835Machine readable ASC X12 835 (via ftp) – used for system processing:Machine readable ASC X12 835 (via ftp) – used for system processing:ProviderBilling Company or ClearinghouseNoneProvider/Billing Company/Clearinghouse Name* EDI 835 Business Contact Name* Billing Company/Clearinghouse Contact Telephone*Contact e-mail address* (primary business contact)PROVIDER AUTHORIZATIONAuthorized Banking Transaction Signatory*Printed Name of Authorized Signature* Date* MM slash DD slash YYYY Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network. CAPTCHA