Skip to main content

EFT

Last updated on

Instructions for completing the EFT Page.

Select the Application Type from the left navigation menu.

Complete all sections below and upload a copy of a voided check or a signed letter from your bank-on-bank letterhead.

If you do not wish to be reimbursed electronically, you may select “I do not wish to participate in the EFT program.” This will opt you out and paper checks will be mailed to your accounting/billing address.

The following fields are pre-populated or filled out for you using information you provided on the Participant Information and Accounting/Billing Information pages.

Provider name

Doing Business As

Street

City

State

Zip Code/Postal Code

Country Code

Provider Identifiers Information

 The following fields are either pre-populated/fill out for you or not required for ITP registrants.

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): this field is prepopulated from the W9 page.

National Provider Identifier: this field is prepopulated from the NPI on the NPI/Taxonomy page.

Provider Type: This field is prepopulated as ITP

Provider License Number: this field is not required

License Issuer: this field is not required

Provider Taxonomy Code: this field is not required

Assigning Authority: this field is prepopulated as Medicaid.

Trading Partner ID: this field is not required

Other Identifier: this field is not required

Contact Information

Contact Name: Enter your first and last name

Title: this field is not required

Email Address: Enter your email address

Phone Number: Enter your phone number

Extension: Enter your phone number extension, if you have one

Fax Number: Enter your fax number, if you have one

Agent Information

The following fields are not required for ITP registrants.

Agent Name: this field is not required

Agent Contact Name: this field is not required

Title: this field is not required

Street: this field is not required

City: this field is not required

State: this field is not required

Zip Code: this field is not required

Zip Code +4: this field is not required

Country Code: this field is not required

Email Address: this field is not required

Agent Phone Number: this field is not required

Agent Phone Number Extension: this field is not required

Agent Fax Number: this field is not required

Federal Agency Information:

The following fields are not required for ITP registrants.

Federal Program Agency Name: this field is not required

Federal Program Agency Identifier: this field is not required

Federal Program Agency Code: this field is not required

Retail Pharmacy Information

The following fields are not required for ITP registrants.

Pharmacy Name: this field is not required

Chain Number: this field is not required

Parent Organization Name : this field is not required

Payment Center ID: this field is not required

NCPDP Provider ID Number: this field is not required

Medicaid Provider Number: this field is not required

Financial Institution Information

Financial Institution Name: Enter the name of your Bank

Account Number: Enter the account number for your bank account

Routing Number: Enter the routing number for your bank account

Type of Account: Select Checking or Savings from the available drop-down menu

Account Number Linkage to Provider Identifier: Select either Provider Tax Identification Number or National Provider ID (NPI):

If you select Provider Tax Identification Number. This will be pre-populated from the W9 form page.

If you select National Provider ID (NPI), this will be pre-populated from the NPI/Taxonomy page.

A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

Street: Enter the street for your bank

City: Enter the City for your bank

State: Enter the State for your bank

Zip Code: Enter the Zip Code for your bank

Zip Code +4: Enter the Zip Code +4 for your bank, if you have this information.

Contact Phone Number: Enter the Contact Phone number for the bank

Extension: Enter the extension for the Phone Number for the bank, if applicable.

Submission Information

Reason for submission:

New Enrollment

Change Enrollment

Cancel Enrollment

Include with Enrollment Submission: Select the attachment you will be sending with your bank information.

Voided Check: This will be a blank check with your address, routing, and account number information clearly shown.

Bank Letter: This is a letter from your bank that shows your account information.

Authorized Signature

You must electronically sign this document on the Agreement page.

For any required documents, select "Click here to select files".

Click Save.

Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application

Instructions for completing the EFT Page.

Complete all sections below and upload a copy of a voided check or a signed letter from your bank-on-bank letterhead.

If you do not wish to be reimbursed electronically, you may select “I do not wish to participate in the EFT program.” This will opt you out and paper checks will be mailed to your accounting/billing address.

The following fields are pre-populated or filled out for you using information you provided on the Participant Information and Accounting/Billing Information pages.

Provider name

Doing Business As

Street

City

State

Zip Code/Postal Code

Country Code

Provider Identifiers Information

 The following fields are either pre-populated/fill out for you or not required for ITP registrants.

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): this field is prepopulated from the W9 page.

National Provider Identifier: this field is prepopulated from the NPI on the NPI/Taxonomy page.

Provider Type: This field is prepopulated as ITP

Provider License Number: this field is not required

License Issuer: this field is not required

Provider Taxonomy Code: this field is not required

Assigning Authority: this field is prepopulated as Medicaid.

Trading Partner ID: this field is not required

Other Identifier: this field is not required

Contact Information

Contact Name: Enter your first and last name

Title: this field is not required

Email Address: Enter your email address

Phone Number: Enter your phone number

Extension: Enter your phone number extension, if you have one

Fax Number: Enter your fax number, if you have one

Agent Information

The following fields are not required for ITP registrants.

Agent Name: this field is not required

Agent Contact Name: this field is not required

Title: this field is not required

Street: this field is not required

City: this field is not required

State: this field is not required

Zip Code: this field is not required

Zip Code +4: this field is not required

Country Code: this field is not required

Email Address: this field is not required

Agent Phone Number: this field is not required

Agent Phone Number Extension: this field is not required

Agent Fax Number: this field is not required

Federal Agency Information:

The following fields are not required for ITP registrants.

Federal Program Agency Name: this field is not required

Federal Program Agency Identifier: this field is not required

Federal Program Agency Code: this field is not required

Retail Pharmacy Information

The following fields are not required for ITP registrants.

Pharmacy Name: this field is not required

Chain Number: this field is not required

Parent Organization Name : this field is not required

Payment Center ID: this field is not required

NCPDP Provider ID Number: this field is not required

Medicaid Provider Number: this field is not required

Financial Institution Information

Financial Institution Name: Enter the name of your Bank

Account Number: Enter the account number for your bank account

Routing Number: Enter the routing number for your bank account

Type of Account: Select Checking or Savings from the available drop-down menu

Account Number Linkage to Provider Identifier: Select either Provider Tax Identification Number or National Provider ID (NPI):

If you select Provider Tax Identification Number. This will be pre-populated from the W9 form page.

If you select National Provider ID (NPI), this will be pre-populated from the NPI/Taxonomy page.

A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

Street: Enter the street for your bank

City: Enter the City for your bank

State: Enter the State for your bank

Zip Code: Enter the Zip Code for your bank

Zip Code +4: Enter the Zip Code +4 for your bank, if you have this information.

Contact Phone Number: Enter the Contact Phone number for the bank

Extension: Enter the extension for the Phone Number for the bank, if applicable.

Submission Information

Reason for submission:

Update Enrollment

Change Enrollment

Cancel Enrollment

Include with Enrollment Submission: Select the attachment you will be sending with your bank information.

Voided Check: This will be a blank check with your address, routing, and account number information clearly shown.

Bank Letter: This is a letter from your bank that shows your account information.

Authorized Signature

You must electronically sign this document on the Agreement page.

For any required documents, select "Click here to select files".

Click Save.

Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application

This page is not applicable for Maintenance selection. Please continue to the next page.