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CAQH CORE - Electronic 835 Consent Form
Follow this link for a List of Field Definitions.
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Provider Information
Provider Contact/Agent Information
Federal Agency Information
Electronic Remittance Advice Information
Preference for Aggregation of Remittance Data: *
Electronic Remittance Advice Clearinghouse Information
Electronic Remittance Advice Vendor Information
Submission Information
Reason for Submission: *
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Electronic Signature of Person Submitting enrollment
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Enrollment Field Definitions

Provider Name - Complete legal name of institution, corporate entity, practice or individual provider

Doing Business as Name (DBA) - A legal term used in the United States meaning that the trade name, or fictitious business name under which the business or operation is conducted and presented to the world is not the legal name of the legal person ( or persons) who actually own it and are responsible for it.

Provider Street - The number and street name where a person or organization can be found

Provider City - City associated with provider address field

Provider State/Province - ISO3166-2 Two Character Code associated with the State/Province/Region of the applicable Country

Provider Zip Code/Postal Code - System of postal-zone codes (zip stands for "zone improvement plan") introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities

Country Code - ISO-3166-1 Country Code

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) - A Federal Tax Identification Number, also known as an Employer Identification Number (EIN), is used to identify a business entity.

National Provider Identifier (NPI) - A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique 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 HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions

Assigning Authority - Organization that issues and assigns the additional identifier requested on the form, e.g. Medicare, Medicaid

Trading Partner ID - The provider’s submitted ID assigned by the health plan or the provider's clearinghouse or vendor

Provider License Number
Provider License Issuer


Provider Type - A proprietary health plan-specific indication of the type of provider being enrolled for ERA with specific provider type description included by the health plan in its instruction and guidance for ERA enrollment (e.g., hospital, laboratory, physician, pharmacy, pharmacist, etc.)

Provider Taxonomy Code - A unique alphanumeric code, ten characters in length. The code set is structured into three distinct “Levels” including provider Type, Classification and Area of Specialization

Provider Contact Name - Name of a contact in provider office for handling ERA issues

Provider Contact Title

Provider Contact Phone Number - Associated with contact person

Provider Contract Phone Number Extension

Provider Contact Email Address - An electronic mail address at which the health plan might contact the provider

Provider Contact Fax Number - A number at which the provider cab be sent facsimiles

Provider Agent Name - Name of provider’s authorized agent

Provider Agent Street - The number and street name where a person or organization can be found

Provider Agent City - City associated with address field

Provider Agent State/Province - ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country

Provider Agent Zip Code/Postal Code - System of postal-zone codes (zip stands for "zone improvement plan") Introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities

Provider Agent Country Code - ISO-3133-1 Country Code

Provider Agent Contact Name - Name of a contact in agent office for handling EFT issues

Provider Agent Contact Title

Provider Agent Contact Phone Number - Associated with contact person

Provider Agent Contract Phone Number Extension

Provider Agent Contact Email Address - An electronic mail address at which the health plan might contact the provider

Provider Agent Contact Fax Number - A number at which the provider cab be sent facsimiles

Federal Agency Information - Information required by the Veterans Administration

Federal Program Agency Name
Federal Program Agency Identifier
Federal Agency Location Code


Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Provider preference for grouping (bulking) claim payment remittance advice - must match preference for EFT payment

Provider Tax Identification Number (TIN)
National Provider Identifier (NPI)


Method of Retrieval - The method in which the provider will receive ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.)

Clearinghouse Name - Official name of the provider's clearinghouse

Clearinghouse Contact Name - Name of contact in clearinghouse office for handling ERA issues

Clearinghouse Contact Phone Number - Phone number of contact

Clearinghouse Contact Email Address - An electronic mail address at which the health plan might contact the provider's vendor

Vendor Name - Official name of the provider's vendor

Vendor Contact Name - Name of a contact in vendor office for handling ERA issues

Vendor Contact Phone Number - Phone number of contact

Vendor Contact Email Address - An electronic mail address at which the health plan might contact the provider's vendor

Vendor IP Address - The Internet Protocol (IP) Address by which communication is allowed between the Vendor and the health plan

Reason for Submission - new, changed or canceled enrollment

Submission Date - The date on which the enrollment is submitted

Requested ERA Effective Date - Date the provider wishes to begin ERA; per Phase III CORE Health Care Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0: There may be a dual delivery period depending on whether the entity has such an agreement with its trading partner

Name of Person Submitting Enrollment - The name of the person signing the form; may be used with electronic and paper-based manual enrollment

Title of Person Submitting Enrollment - The title of the person signing the form; may be used with electronic and paper-based manual enrollment

Electronic Signature of Person Submitting enrollment - Enter Name of person submitting eform and Check the Box

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