Electronic Funds Transfer (EFT) Enrollment

Electronic Funds Transfer (EFT) Enrollment

Carelon's preferred payment method is electronic transfer of funds (EFT) for claim payments to a contracted Healthcare Provider's bank account.

*This is for Home Health Agencies only*

Generally, a Provider can access EFT funds sooner than a Provider deposited remittance received through traditional paper checks.

The following outlines the process for setup of an EFT payment to a Provider's bank account:

Requirement 1: Copy of a voided check (An account verification letter from your bank is also acceptable.)
Requirement 2: Completed Electronic Funds Transfer Authorization form.
Requirement 3: Copy of Provider W9. If you have a remit change, please submit a change request prior to EFT enrollment.

Please Note:

A separate Electronic Funds Transfer Authorization and W9 is required for each Provider Tax ID number to be set up for EFT.
A Provider Tax ID number may be associated to only one bank account number.
Carelon verifies the bank name and the bank transit or routing number.
All EFT payments are made at the Provider Tax ID number level. All locations under the submitted Tax ID will be enrolled with the provided bank and routing number.
EFT enrollment requires Providers to access EOPs on the Carelon Provider Portal.

*If information submitted on the form cannot be validate the banking information or does not match the current information we have in our system, we will not be able to complete the enrollment. Please ensure you are submitting the most up to date information. If you are submitting a EFT change, you must provide the current EFT information we have on file. If your cannot confirm the current information, you change request will not be approved.*

If you are using a non business email domain, we are requiring validation of that email address. If you have a business domain, please use that instead as this is the preferred domain.

*For questions please contact providerdatamanagement@carelon.com*

Please allow no less than 72 business hours for your EFT enrollment to be processed.

Reason for Submission:*

Select

Agency Information

National Provider Identifier Number (NPI):*

*Please list all NPIs associated with this enrollment*

Federal Tax Identification Number (TIN):*

Legal Agency Name*

Parent Name

Doing Business As (dba) Name*

*N/A if non-applicable*

Remit Address*

*This must match your uploaded W9*

Remit City*

*City must be entered*

Remit State*

*State must entered*

Remit Zip Code*

*Zip Code must be entered*

Agency Contact Information

*This is who is submitting the form*

Agency Contact Name*

Contact Title*

Contact Email Address*

Phone Number*

Banking Information

Financial Institution Name:*

Financial Institution Account Type:*

Old Financial Institution ACH Routing Number:*

*Required for EFT update/change request*

New Financial Institution ACH Routing Number:*

Old Financial Institution Account Number:*

*Required for EFT update/change request*

New Financial Institution Account Number:*

Please upload BOTH a Voided check/bank statement and your W9 here.*

Drag and drop files here or

Carelon Electronic Funds Transfer (EFT) Authorization

This Authorization is between the Provider listed below (Provider) and Carelon, which governs Provider’s enrollment and use of the Electronic Funds Transfer ("EFT") service. The contact person identified on the Authorization warrants and represents that he/she is authorized to act on behalf of the Provider and that his/her acceptance of the terms of this Authorization creates a legally enforceable obligation of the Provider. Provider authorizes Carelon to electronically transfer funds for all eligible and authorized claim payments to the bank account listed below and understands that upon activation of the EFT service, Provider will no longer receive paper checks for claims payments. Provider warrants and represents that all information listed on this Authorization is accurate and agrees to immediately notify Carelon of any changes to the information. Carelon may revoke this Authorization at any time and for any reason. Carelon is not liable for any loss that Provider may incur as a result of the EFT service. Provider agrees to indemnify Carelon from and against all suits, claims, or losses arising from or alleged to arise from the Provider's use of the EFT service. This Authorization constitutes the entire agreement between Carelon and Provider for the EFT service; any prior agreements or promises relating to the EFT service are of no force and effect. This Authorization does not modify the terms or conditions in Provider’s Network Participation Agreement, including the payment terms. This Authorization is governed by the laws of the State of Tennessee.

I attest/confirm*

Send me a copy of my responses

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