New Hampshire Medicaid Billing Agent Agreement

This document is a Billing Agent Agreement for the New Hampshire Medicaid Program. It outlines the requirements for providers who utilize a billing agent or clearinghouse to submit claims on their behalf. Providers must print and sign the agreement, ensuring that only original signatures are submitted. The document specifies that providers must check 'Yes' in the Third Party Billing segment of Section 4 and complete the Billing Agent/Clearinghouse segment in Section 6. Additionally, it includes instructions for submitting the agreement to NH Medicaid Provider Relations and provides contact information for inquiries. The document also details the Electronic Remittance Advice (ERA) Enrollment Application, which includes terms and conditions that providers must agree to in order to receive ERA from the NH Department of Health and Human Services. It emphasizes the importance of contacting financial institutions for necessary information to ensure successful re-association of payments with remittance advice.