Special Alert: Due Date Extended to May 16, 2008
If you are a TrailBlazer customer currently using Electronic Funds Transfer (EFT) to receive your Medicare payments, please be on the lookout for this important letter advising you of the transition impact to you and what you need to do to respond. Please mark your CMS-588 Form as “Revision to Current Authorization” and print MAC at the end of that line on the CMS-588 Form to assist in processing. Remember to list Highmark Medicare Services as the contractor in Section V on page 2.
As part of the Jurisdiction 12 (J12) Medicare Administrative Contractor (MAC) implementation, Highmark Medicare Services (HMS) is required to obtain a new CMS-588 EFT Agreement (Electronic Funds Transfer Authorization Agreement) from each provider/supplier who is currently receiving Medicare payments electronically before we may make payment to you via electronic funds transfer. Failure to complete and submit a CMS-588 Form will result in a delay or interruption of your Medicare payments.
In order to avoid delays in your Medicare payments, please complete the enclosed CMS-588 form and return it by April 25, 2008 to:
Highmark Medicare Services
Provider Enrollment Services
1800 Center Street
PO Box 890157
Camp Hill, PA 17089-0157
If you are an individual healthcare practitioner, the form must be signed and dated by you. For groups and organizations, the form must be signed and dated by an authorized or delegated official on file with Medicare. The signature and date fields are on page 2 of the form in Part V. The PTAN noted at the top of this letter is the Provider Transaction Access Number, formerly known as your Medicare number or Provider Identification Number (PIN). Part II of the CMS-588 requires the PTAN to be reported on the form as the “Medicare Identification Number.” Please remember to list Highmark Medicare Services as the contractor on the top of page 2 in Section V.
NOTE: You are not required to complete a CMS-855 Enrollment form as part of this process.
If you have any questions about the completion of the CMS-588 form, contact the Provider Enrollment Helpline at 1-866-488-0549. In addition, further details can be found on our J12 Transition webpage.
Thank you for your cooperation. We look forward to serving you.
Sincerely,
Judy Andidora, Manager
Provider Enrollment Services