If you are a Riverbend customer who recently enrolled to use Electronic Funds Transfer (EFT) to receive your Medicare payments, please watch 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 SIPP 3 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 and to sign and date the form.
Dear Provider:
Welcome to Highmark Medicare Services, the Jurisdiction 12 (J12) Medicare Administrative Contractor (MAC). Our goal is to ensure a smooth transition of your services from your current contractor to Highmark Medicare Services. As part of this transition, we are 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. Since you are newly enrolled for EFT, this is our first request for the CMS-588 EFT Agreement Form. Failure to complete and submit a CMS-588 Form immediately may result in a delay or interruption of your Medicare payments at and after transition.
In order to avoid delays in your Medicare payments, please complete the enclosed CMS-588 form, fax it now to Provider Enrollment at 1-717-302-3667, and mail the original to us at the following address by August 29, 2008 to:
Highmark Medicare Services
Provider Enrollment
1800 Center Street, PO Box 890157
Camp Hill, PA 17089-0157
Please read the following tips for correct completion of the form. The CCN noted at the top of this letter is the CMS Certified Number, formerly known as your OSCAR Number. Part II of the CMS-588 form requires the CCN to be reported as the “Medicare Identification Number.” Please remember to list Highmark Medicare Services as the contractor on page 2 in Section V. 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.
NOTE: You are not required to complete a CMS-855A 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