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.

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.