Self-Service Login / Register | bluecrossnepastore.com
Powered by Google

Electronic Remittance Advice Request (835)

Reason for Submission



Provider Information

Provider Name:
Provider Federal Tax Identification Number (TIN):

National Provider Identifier (NPI) & Other Identifiers

Enter the registered Group (Type II) National Provider Identifier (NPI) number(s):
NPI number(s) to be included for First Priority Health® (FPH) and/or First Priority Life Insurance Company® (FPLIC)
NPI:
Line of Business:
Type:

Provider Contact Information

First Name:
Last Name:
Phone Number:
Email Address:

Provider Agent (Billing Agency) Information

Do you have provider agent billing information?

Preference for Aggregation of Remittance Data

Re-association to match preference for EFT payment.
Provider Federal Tax Identification Number (TIN):
NPI
Method of Retrieval

Clearinghouse Information

Clearinghouse Name:
First Name:
Last Name:
Phone Number:
Email Address:
As the authorized person, I affirm my acceptance of this electronic attestation and authorization as the ERA responsible party.
Electronic Signature