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Get Vdp Electronic Remittance Advice Authorization Agreement Form
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How to fill out the VDP Electronic Remittance Advice Authorization Agreement Form online
Completing the VDP Electronic Remittance Advice Authorization Agreement Form online is an essential step for pharmacies participating in the Vendor Drug Program. This guide will walk you through each section of the form, ensuring you fill it out accurately and efficiently.
Follow the steps to complete the form online with ease.
- Click ‘Get Form’ button to access the VDP Electronic Remittance Advice Authorization Agreement Form and open it in your chosen document editor.
- Fill in the pharmacy provider information. Start with the 'Provider name', followed by 'Doing Business As (DBA) Name', and complete the address fields including 'Street', 'City', 'State/Province', and 'ZIP Code/Postal Code'.
- Enter the provider identifier information. Provide the 'Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)' and the 'National Provider Identifier (NPI)', which is required.
- Complete the provider contact information section. This includes the 'Provider Contact Name', 'Title', 'Telephone Number', 'Email address', and 'Fax Number'.
- Fill in the electronic remittance advice information. Repeat the 'Provider Tax Identification Number (TIN)' and 'National Provider Identifier (NPI)', and specify the 'Method of Retrieval' for the ERA.
- Provide the electronic remittance advice vendor information by filling out 'Vendor Name', 'Vendor Contact Name', 'Telephone Number', and 'Email Address'.
- Indicate the submission information. Choose one of the options: 'New Enrollment', 'Change Enrollment', or 'Cancel Enrollment'. Then provide the 'Electronic Signature of Person Submitting Enrollment', 'Written Signature of Person Submitting Enrollment', 'Printed Name of Person Submitting Enrollment', 'Submission Date', and 'Requested ERA Effective Date'.
- Once you have filled out all required fields, review the form for accuracy. After verification, you can save changes, download, print, or share the form as needed.
Complete your document online today to ensure your participation in the Vendor Drug Program.
An electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like: Contract agreements. Secondary payers.