Magellan Rx Management

Magellan Rx Management is providing this website to satisfy the CAQH Committee Operating Rules for Information Exchange (CORE) mandate requiring online capability for both Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) enrollment. Enrollment is defined as a new enrollment, request to terminate enrollment EFT/ERA participation, or request for change to existing EFT/ERA information.

The website will only allow users to submit EFT or ERA applications, not allow them to view or update existing EFT/ERA information.

Providers will use the existing customer service number for questions and/or to verify the status of submitted applications.

Magellan Rx Management will continue to accept paper applications as we do today.

Select the appropriate button below (or menu item above) to enroll or update your existing enrollment information.

Instructions: Enter your information below. Move your mouse over the field name for additional information about that field. All fields are required. When finished, click the Submit button.

Provider Information

Client Program :

Provider Name :

Street :

City :

State/Province :

Zip Code/Postal Code :

Provider Identifiers

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) :

National Provider Identifier (NPI) :

Provider Contact Information

Provider Contact Name :

Telephone Number :

Telephone Number Extension :

Email Address :

Fax Number :

Electronic Remittance Information

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) :

Provider Tax Identification Number (TIN) National Provider Identifier (NPI)

Method of Retrieval :

Health Plan website Clearinghouse

e.g. download from health plan website, clearinghouse, etc.

Clearinghouse Name :

Submission Information

Reason for Submission :

New Enrollment Change Enrollment Cancel Enrollment

New Enrollment — Select this option if you would like to receive an Electronic Remittance Advice via 835.
Change Enrollment — Select this option if you would like to change who receives your Electronic Remittance Advice/835 i.e. a different PSAO or individual.
Cancel Enrollment — Select this option if you want to cancel your ERA/835. You may also cancel your ERA by faxing a signed request to 888-656-6214. Please include your NPI on any faxed requests.

Printed Name of Person Submitting Enrollment :

By entering my name into this field, I am certifying that I have legal authority to make these changes.

Printed Title of Person Submitting Enrollment :

Please check all data for accuracy prior to clicking the Submit button.

Submit

Instructions: Enter your information below. Move your mouse over the field name for additional information about that field. All fields are required. When finished, click the Submit button.

Provider Information

Client Program :

Provider Name :

Street :

City :

State/Province :

Zip Code/Postal Code :

Provider Identifiers

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) :

National Provider Identifier (NPI) :

Provider Contact Information

Provider Contact Name :

Telephone Number :

Telephone Number Extension :

Email Address :

Fax Number :

Financial Institution Information

Financial Institution Name :

Street :

City :

State/Province :

Zip Code/Postal Code :

Financial Institution Routing Number :

Type of Account at Financial Institution :

Checking Savings

Provider’s Account Number with Financial Institution :

Account Number Linkage to Provider Identifier :

Provider Tax Identification Number (TIN) National Provider Identifier (NPI)

Submission Information

Reason for Submission :

New Enrollment Change Enrollment Cancel Enrollment

New Enrollment — Select this option if you are establishing EFT payments. Allow a minimum of 16 days for EFT to begin. Please fax a voided check or a letter from the bank verifying the account to which you want payments deposited, to 888-656-6214.
Change Enrollment — Select this option if you are changing your financial institution, account number, type of account, etc. Do not close your old account until this change takes place. Allow a minimum of 16 days for the EFT change to become effective. Please fax a voided check or a letter from the bank verifying the account to which you want payments deposited, to 888-656-6214.
Cancel Enrollment — Select this option if you want to cancel EFT payments. You may also cancel EFT payments by faxing a signed request to 888-656-6214. Please include your NPI on any faxed requests. Allow a minimum of 16 days for cancellation to take effect.

Printed Name of Person Submitting Enrollment :

By entering my name into this field, I am certifying that I have legal authority to make these changes.

Printed Title of Person Submitting Enrollment :

Please check all data for accuracy prior to clicking the Submit button.

Submit

Success!

Thank you for your request. Please allow minimum of 16 days for request processing. For future reference please note down reference number . You can verify your status by calling 1-800-441-6001 with your reference number.

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