BeniComp IncentiCare - Provider ACH Payment and ERA Authorization

Please complete this form with your organization's banking information to authorize BeniComp to disperse your funds via ACH, with a Health Care Claim Payment/Advice (835) transaction.

The ASC X12N Health Care Claim Payment/Advice (835) transaction, also known as the Electronic Remittance Advice (ERA) is used by health plans to communicate details concerning the adjudication of a claim.

A common method for transmitting an EFT is via the Automated Clearing House (ACH) network, utilizing the NACHA Cash Concentration/Disbursement plus Addenda (CCD+) format. Placement of the TRN segment of the ASC X12N Health Care Claim Payment/Advice into the Addenda record of the CCD+ allows the provider to re-associate the payment with the ERA.

Billing Provider/Organization Name
Billing Provider/Organization Email
Federal ID Number/TIN/EIN
Maximum of 9 characters allowed. Currently Entered: 0 characters.
Billing Provider NPI
Must be 10 digits. Currently Entered: 0 digits.
I (We) hereby authorize BeniComp, Inc. to initiate credit entries to my (our) Checking or Savings (select one below) account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY.
Type of account

Type of account Checking Savings
Bank Name
Billing Provider Address Billing Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Billing Provider Preferred Address (PO Box for payments for example) Billing Provider Preferred Address (PO Box for payments for example)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Routing Number
Must be 9 digits. Currently Entered: 0 digits.
Account Number
Maximum of 17 digits allowed. Currently Entered: 0 digits.
Verify Account Number
Maximum of 17 digits allowed. Currently Entered: 0 digits.
This authorization is to remain in full force and effect until BeniComp, Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as to afford BeniComp, Inc. and DEPOSITORY a reasonable opportunity to act on it.
Please apply ACH funding to all invoices after the following effective date: Please apply ACH funding to all invoices after the following effective date: / MM / DD YYYY
HIPAA health care EFT
and ERA transaction standards

HIPAA health care EFT
and ERA transaction standards I agree to opt in to both HIPAA EFT and ERA transactions
Clearing House Name
Person 1
Name Name First Last
Title
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Person 2
Name Name First Last
Title
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
NOTE:

NOTE: All written credit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Authorizing the transfer of funds does not guarantee coverage; the application and base medical plan must meet underwriting requirements prior to our issuing the policy.
PLEASE ATTACH A COPY OF A VOIDED CHECK

Attach Files
Notes Section:

If you would like to use your ACH profile to pull funds for outstanding invoices, please indicate which invoices you would like to be pulled. Thank you!

BeniComp IncentiCare - Provider ACH Payment and ERA Authorization

BeniComp IncentiCare - Provider ACH Payment and ERA Authorization

Person 1

Person 2

NOTE: