EDI Application - University of Utah

Health Choice Utah - EDI Form

(835 and EFT Enrollment)

Provider Information

Provider Name

Street Address (No PO Box)

City

State

Zip

Provider Identifier Information

Tax ID (TIN)

XXXXXXXXX Format

10 Digits

Do you have multiple Billing NPI’s (Type 2) under this TIN?

Yes No

Trading Partner ID (if known)

Check if you ONLY want to submit electronic claims

Provider Contact Information

Provider Contact Name

Title

Telephone Number

Tel.# Ext.

Email Address

Provider Remittance Advice Clearinghouse Information

Clearinghouse Name

Email Address

Financial Institution Information for EFT Enrollment Only (Note: To receive the ERA it must be linked to an EFT)

Financial Institution Name

City

State

Zip

Bank Routing Number

Provider's Bank Account Number (Checking Only)

Submission Information

Reason for Submission

Requested EFT Start/Change/Cancel Date

Requested ERA Start/Change/Cancel Date

Same as Provider Contact

Name of Person Submitting Enrollment

Title of Person Submitting Enrollment

Has the provider ever submitted a claim?

Yes No

W-9 Form:

Voided Check or Bank Letter:

This EFT request form authorizes Health Choice Utah to deposit funds for claims payment directly into a vendor's bank account. This request form also allows for reversal of payments that were made in error. This authority is to remain in full force and effect until Health Choice Utah has received written notification from the vendor of its termination in such time and manner as to afford Health Choice Utah a reasonable opportunity to act on it.

EDI participation is not an indication of contracting status. To verify contracting status, please contact customer service at (877) 358-877.

EDI Department, University of Utah Health Plans
Email: edi@healthchoiceutah.com