Unity Provider Forms
Electronic Health Care Claim Payment / Advice (835)

 

Authorization Agreement For Electronic Health Care Claim Payment / Advice (835)


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Section 1: Provider Information





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Section 2: Provider Identifiers Information


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

Provider may list multiple NPI #’s if they share the Federal Tax ID listed above.
A separate Implementation form needs to be completed for each unique Federal Tax ID.
Enter each NPI number on its own line.


Section 3: Provider Contact Information







Section 4: Electronic Remittance Advice Information



e.g. SFTP via Unity SFTP server connection


Section 5: Electronic Remittance Advice Clearinghouse Information





Section 6: Electronic Remittance Advice Vendor Information





Section 7: Submission Information






The information contained within this form will be applied to all applicable contracts with Unity Health Plans Insurance Corporation, Quartz Health Solutions, Inc. f/k/a SPWI TPA, Inc. d/b/a Quartz, and Gundersen Health Plan, Inc.



Authorized Signature


By checking this box, I authorize the provider to enroll with ERA with Unity Health Plans
Insurance Corporation and/or SPWI TPA, Inc., d/b/a Quartz.