MassHealth Attn Customer Service: Supplier Registration and Accreditation P.O. Box 9162 Canton, MA 02021 Send your completed form to the following address. MassHealth Dental Program Attn: Provider Enrollment and Credentialing 12121 N. Corporate Parkway Mequon, WI 53092 Dental providers must send their signed and completed form and required documents to DentaQuest at the following address. Account statement for the specified account. Note: On a bank statement, only the bank name, supplier name, and bank account number are shown. A bank deposit form will not be accepted in place of a bank statement. Send the printed copy of the completed EFT form with your original signature to MassHealth. Copies and faxes are not accepted. (In accordance with Article 4.09 of the Pension Simplification Regulations 2020) Bank letter containing the name of the bank, the name of the supplier, the bank account number and the sort code. If the tax identification number is indicated on the bank letter, it must match the tax identification number on the EFT form and the massHealth provider`s file or registration documents. Note: The bank transit route number (ACH-ABA number) is usually not included on the bank statement.
Note: The transfer number is not required. These numbers must match the information on the cheque or bank attachments; or For more information on economic impact payments (stimulus), please visit the Internal Revenue Service website. Individual practitioners who are registered/registered as part of a group practice and who do not submit payment requests under their National Individual Provider Identifier (NPI) must register with MassHealth as a “no payment” provider. LFS is not compulsory. Registering as a “no pay” provider also eliminates the need to file the Massachusetts Substitute W-9, Data Collection Form (DCF) and Business Partnership Agreement. Applicants submitting applications on paper must write “no payment” in Section I of the application to the right of box 11. Those submitting applications through the Provider`s Online Service Centre (POSC) must provide a “No Pay” statement when submitting the supplier contract. Fill out the EFT form – you can download it below.
This is the only acceptable form for a MassHealth provider application for electronic payments. Electronic transfer form. Suppliers must complete the Authorized Signature (and Date) field in the EFT form. An original signature from the individual supplier or an authorized signature from the company is required. Note: The Commonwealth requires municipal treasurers to sign EFT applications for the city`s EFT forms. MassHealth is committed to 100% compliance with EFT. All suppliers must be paid by electronic direct deposit. In addition, participation in EFT is now required when a provider submits a new application to MassHealth.
The EFT form will be processed at the time of registration. Applications received without a EFT form or without a “No Pay” designation will be returned to the supplier for completion. Documents that are not returned within the 14-day registration period will be rejected. Exceptions to this mandate are not to be expected. The Office of the Comptroller and the Office of the State Treasurer have ordered that all providers registered with MassHealth, including individual practitioners who receive payments directly, participate in the LFS. EFT payments are automatically transferred to a specific bank account. They are more cost-effective to process, very reliable when it comes to depositing into a provider`s account and processing them securely. EfT is useful for streamlining operations by reducing red tape and is a convenient and efficient method of electronic repayment. Invalid verification. The invalid verification must contain a pre-printed name and address of the supplier. This area must not be empty, handwritten or stamped. A bank deposit form will not be accepted in lieu of an invalid cheque.
or direct deposits or electronic money transfers (EFTs) allow the general public, government agencies, businesses and institutions to pay and collect money electronically without having to use paper cheques. Direct deposit (EFT) is safe, efficient and more cost-effective than paper cheque payments and collections. Electronic payments are mandatory! All federal benefits must now be paid electronically. If you receive federal benefits such as Social Security, Supplementary Security Income (SSI), Veterans` Benefits, Public Service Retirement, Federal Military Pension, or Railway Pension Payments, you must receive your benefits by direct deposit (EFT). If you don`t have a bank account, the FDIC website provides information to help you open an account online or at a local bank branch.