ERA Enrollment

Welcome to the DentaQuest Online Electronic Remittance Advice (ERA) Enrollment Request page. Please be sure to complete all of the required fields (marked with a star) and click on Submit before leaving this screen. Partial entries will not be saved.

There are two steps to complete before an ERA can be sent to your organization via a 5010 X12 835 transaction

1) Complete the Enrollment to receive the ERA below.
2) Complete the Trading Partner Agreement which can be accessed via the link at the end of this enrollment page.

Please enter the following information:

Provider/Organization/Practice Identification:
Provider Name:*
Doing Business As Name (DBA):
National Provider Identifier (NPI): *
Provider Federal Tax Identification Number (TIN):*
 
Organization/Practice Contact Person
Provider Contact Name *
Telephone Number: *
Email Address: *  
 
Organization/Practice Address
Address 1 (Street Address or PO Box)
Address2 (Suite Number, etc.)
City:
Zip Code:
Country:
State/Province:
 
We use an Agent for processes Payments Yes No
 
Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)
Please choose aggregation type base on the identification used by your receiving bank on your bank account. If you are identified on your bank account by TIN, please choose TIN. If by NPI, please choose NPI. If you are identified by TIN, please do *not* choose NPI. The aggregation type must match your banking institution’s identification on your bank account.
 
Method of Retrieval : *
 
Reason for Submission *   New Enrollment:   Change Enrollment:   Cancel Enrollment:
A Trading Partner (TP) Agreement is required before DentaQuest can begin to send remittance advices electronically
 
Please type your name, date, and the requested effective date for this enrollment below:
Full Name Submission Date Requested Date