Electronic Funds Transfer (EFT) Form

This form may be used to enroll in EFT.

Community Health Plan of Washington can issue EFT’s to all healthcare provider types, including those receiving capitation.

Use the following guide when completing your EFT form. Fields with an asterisk ( *) are required; sections left blank or illegible will delay processing.

  • Complete the EFT form and email to DS-CHPW_prov_maint@dell.com OR mail to Community Health Plan of Washington PO Box 269002 Plano, TX 75026-9002 along with a pre-printed voided check that has the account holder name imprinted on the check or bank letter (deposit slips, starter checks, handwritten or altered checks are not accepted).

  • Include your billing NPI (NPI receiving payment) on the enrollment form.

    Note: If you DO NOT want all claims processed under this TIN set up for EFT, please choose from one of the following options:

    • NPI Level Setup – EFTs will only be transmitted for the billing NPIs that are enrolled. Be sure to list the two or more NPIs you would like to enroll.
    • Billing Address Level Setup – EFTs will be transmitted based on the specific billing address(s) enrolled only. Please list the billing address(s) you would like to enroll.

  • The EFT form must be signed by an authorized healthcare individual. The signing authority must match the legal entity associated with the tax ID. e.g. Practitioner (MD, DO, DC, DDS, PhD, etc.) or Corporate Officer/Authorized Manager (CEO, CFO, Office Manager, etc.)

  • IMPORTANT - Please allow 15 business days for processing. Processing times may vary depending on the number of enrollments received and the accuracy of information provided. An email confirmation will be sent letting you know when your EFT will start.

  • Once we transmit an EFT to your bank, your bank has 3 business days to settle the funds and make them available in your account. Claims already in process on or before your effective date will still generate paper checks. Note: your bank must be a participating member of the Automated Clearinghouse Association (ACH)

  • You must contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA.

  • If you are requesting EFT for your capitated payments, you must be set up for capitation. Once EFT is effective, all medical claims and capitated payments will be made via EFT.

  • EFT email notifications are sent when EFT is active and a claim has been processed and payment has been issued.

    Request to unsubscribe or change/update your email address can be completed by emailing edi.support@chpw.org .

  • For questions regarding the 835, electronic RA/EOP (explanation of payment), please contact EDI Support at edi.support@chpw.org .

You are responsible for notifying CHPW of any changes to your banking information.

Electronic Funds Transfer (EFT) Form

Asterisk (*) indicates required fields

SUBMISSION INFORMATION

PROVIDER INFORMATION

PROVIDER IDENTIFIER INFORMATION

PROVIDER CONTACT INFORMATION

FINANCIAL INSTITUTION INFORMATION

AUTHORIZATION AGREEMENT

I hereby authorize Community Health Plan of Washington (CHPW), on behalf of its affiliates, including Community Health Network of Washington, to initiate credit entries to the bank account listed on this form for all medical claims and capitated payments. This agreement will remain in effect until the provider notifies CHPW of the desire to change or cancel this service, or until CHPW provides notification that this service has been terminated. It is understood that reasonable time will be allowed to execute instructions.

The bank listed on this form is authorized to accept any credit entries made by CHPW to such account and to credit the same to such account. CHPW will not debit or deduct funds directly from the bank account listed for claim overpayments and/or refund request. CHPW will seek permission to debit the listed bank account for any adjustments or corrections to resolve duplicate payments (where “duplicate” is defined as CHPW sending multiple identical payments in error) or erroneous payment due to a bank account setup in error. CHPW will attempt to recover the duplicate or erroneous payment via a debit to the account to the extent permitted by state law and with prior contact to the provider. If an electronic debit is unsuccessful, CHPW will notify the provider in writing to reach an alternative arrangement for reimbursement.

*CHPW strictly adheres to the National Automated Clearing House Association (NACHA) guidelines.

By signing below, I hereby agree that I have read and agree to the terms and conditions stated on this form. Furthermore, the undersigned certifies that the information provided is true and accurate in all respects and that he/she has been duly authorized by all necessary and appropriate action.

Email - DS-CHPW_prov_maint@dell.com
Community Health Plan of Washington
PO Box 269002
Plano, TX 75026-9002