Electronic Payment and Remittance Advice Application

Electronic Payment and Remittance Advice Application - Post Application - Displayed on the Provider Contracting Post application page

This application constitutes an agreement between Neighborhood Health Plan of Rhode Island (Neighborhood) and its affiliated professional or institutional provider, as identified below, to accept direct deposit of claim payment to provider’s bank. Direct deposit will be made through Bank of America’s Automated Clearinghouse into the account and bank routing address indicated below. Professional or institutional providers equipped to accept electronic remittance advices are requested to enter their document format preferences in the box provided below. Neighborhood supports remittances in two formats: (1) electronic transmission of standard-format remittance advice file (image of paper RA) via Neighborhood secure e-mail in PDF format OR (2) machine-readable ASCX12 835 (available for retrieval via ftp/sftp). If provider is applying for the standard-format PDF format via Neighborhood secure e-mail), provider warrants that access and retrieval of the .pdf RA using provider’s e-mail address (included below) at their place of business will be in a HIPAA- compliant, secure manner with handling by authorized personnel only. Submission of this completed application to Neighborhood at 910 Douglas Pike, Smithfield, RI 02917 enables participation in Neighborhood’s electronic claim payment and remittance advice transmission processes. Provider will be contacted prior to implementation date for transmission testing if necessary.
Please allow thirty (30) to forty (40) business days for processing.
Identification and Bank Routing Information
Business Name*
Street Address*
Street Address Address Line 2 City State ZIP Code
NPI Number*

Please provide Group Billing NPI
Tax Identification Number*
Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*
Accepted file types: pdf, Max. file size: 5 MB.
Is your mailing address different than the address listed on the W-9?*
Is your mailing address different than the address listed on the W-9? *
- Yes
- No
Please provide explanation*
Name of Bank*
ACH Bank Routing Number*

[9 digits, please verify with bank] – DO NOT USE routing number from check
Bank CHECKING Account Number*

[No dashes]
Please Attach A Copy of a Voided Check and/or Bank Letter that confirms the banking information.*
Drop files here or

Accepted file types: pdf, Max. file size: 15 MB, Max. files: 2.
Email for Remittance Advice - REQUIRED (only one) for .PDF RA*
Enter Email Confirm Email
835 REQUESTS (Optional)
Please indicate who will receive the 835
Machine readable ASC X12 835 (via ftp) – used for system processing:
Machine readable ASC X12 835 (via ftp) – used for system processing:
- Provider
- Billing Company or Clearinghouse
- None
Provider/Billing Company/Clearinghouse Name*
EDI 835 Business Contact Name*
Billing Company/Clearinghouse Contact Telephone*
Contact e-mail address*

(primary business contact)
PROVIDER AUTHORIZATION
Authorized Banking Transaction Signatory*
Printed Name of Authorized Signature*
Title*
Date*
MM slash DD slash YYYY
Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.
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Identification and Bank Routing Information

835 REQUESTS (Optional)

PROVIDER AUTHORIZATION