Kansas Medicaid ERA EDI Form

ET024
KANSAS MEDICAID
PAYER ENROLLMENT INSTRUCTIONS
✔ Professional
✔ Institutional
Claims
✔ ERAs
Important - HeW provides the EDI paperwork pre-populated with our submitter information as a courtesy to our clients.
Please note that even though we make all attempts to have the most current form available, we are not always notified
by the carriers when their EDI forms are updated.
FORM INSTRUCTIONS
The paperwork is designed for you to type into while opened in Adobe Reader. Please use your Tab key on your
keyboard to move to the next field.
* This form requires an authorized signature.
* There is a separate ERA assigning process. You will need to sign into the KMAP portal at:
https://www.kmap-state-ks.us/provider/security/logon.asp
and assign ETTCORP (HeW) as your ERA receiver. (Instructions on page 2 of this document. Call Kansas
Medicaid EDI (800-933-6593 Option 4) if you have any questions on their provider portal.)
PAPERWORK SUBMISSION
RCM Clients: Please submit the online enrollment along with submitting page 4 of this document directly to the payer
by fax to 785-276-7689 or by mail to the address below. Then click here to send HeW your list of payers.
HeW Clients: Please submit the online enrollment along with submitting page 4 of this document directly to the payer
by fax to 785-276-7689 or by mail to:
HP Enterprise Services
EDI Department
P.O. Box 3571
Topeka, KS 66601-3571
For assistance with this form, call the EDI Help Desk at 1-800-933-6593, option 4, or email them at
[email protected].
Updated: 08/19/2016
Enrollment for 835 / Electronic Remittance Advice has a two-part process. There is an enrollment
form as well as an online 835 receiver assignment that must be completed.
1.
2.
3.
4.
5.
6.
7.
Please login at https://www.kmap-state-ks.us/provider/security/logon.asp.
Then go to Account and you will see a screen similar to the below picture.
Go down to the Receiver section and select ‘Remittance’ under Transaction Type.
Enter ETTCORP in the “Provider/Business Assoc.” field
Select the Add button
Select the Save button (if you do not save, your changes will not be kept).
Then contact HeW Enrollment Department to alert that you have completed the online enrollment
process.
Kansas Medicaid
Page 1
ERA - Medicaid of KS
Kansas MMIS Electronic Data Interchange Application
INSTRUCTIONS FOR EDI APPLICATION
An electronic data interchange (EDI) application is necessary for billing entities submitting electronic
transaction files. It is not applicable if submitting PAPER claims or submitting claims on the Kansas Medical
Assistance Program (KMAP) website.
Section 1
Fill in the entity type and contact information.
Section 2
Indicate the software the billing entity will use. If the software is not Provider Electronic Solutions, indicate the
name of the software that will be used.
Section 3
Select only one submission method. This is the method by which the billing entity intends to deliver the
electronic information to KMAP.
Section 4
Select all of the transaction types the billing entity will submit to or retrieve from KMAP.
Section 5
This section contains information on how to return the completed EDI application to KMAP.
All applications must include name, signature, title, and date of completion.
For assistance with this form, call the EDI Help Desk at 1-800-933-6593, option 4,
or email them at [email protected].
Kansas MMIS Electronic Data Interchange Application
1. Complete this section:
 Clearinghouse
Billing Entity Type:
✔ Provider __________________________________

KMAP Provider ID Number
Business Name: ______________________________________
Address: ______________________________ City: __________________ State: ____ Zip: ______________
Contact Person: ________________________________ Contact Telephone: _____________________________
; [email protected]
Email Address: ___________________________________________________
2. Please choose any that apply:
What software will the billing entity use?
 Provider Electronic Solutions
 Other
__________________________________
Software Name
3. Please select only one submission method:
 RAS file transfer
(Trade Files-Batch)

(Trade Files-Batch)
✔ Internet file transfer
4. Select ALL electronic transaction types you wish to test using media type selected in Section 3:
5010 Transaction files
 837 Professional

✔ 835Remittance/277 Pended Claims
 834 Benefit Enrollment
 837 Institutional
 270/271 Eligibility
 820 Capitation Payments
 837 Dental
 276/277 Claim Status
 278 Prior Authorization
5. Complete this form and return it:
By fax:
785-267-7689
By mail:
HP Enterprise Services
EDI Department
P O Box 3571
Topeka, KS 66601-3571
(Print & Sign Here)
_________________________________
_____________________________
Signature
Title
____________________
Date
_________________________________
Printed Name
Last Revised 1/4/2012
Important: Disregard this application if the billing entity is ONLY
submitting paper claims or using direct data entry on the KMAP website.