New Facility Claim Requirements
If you are a new provider to IMCare and need to submit a claim or payment request for health care services or supplies, you must submit the following forms for provider set-up before we can process your claims:
- Non-Contracted Facility Information Form (PDF)
- Practitioner NPI/UMPI Notification/Request Form (PDF)
- Request for Taxpayer Identification Number and Certification (W-9) (PDF)
- Electronic Funds Transfer (EFT) Authorization Agreement
- Electronic Remittance Advice (ERA) Authorization Agreement
If you would like a provider registration packet emailed to you, please send an email to email@example.com with your request.
Please return all forms even if you are exempt from backup withholding, and make sure you complete all forms in their entirety and in accordance with the instructions. The forms must be legible and contain accurate and current information.
All completed forms can be returned by fax to 1-218-327-5545 or emailed to firstname.lastname@example.org
The EFT Authorization Agreement must be mailed to:
IMCare Claims Department
1219 SE 2nd Avenue
Grand Rapids, MN 55744
Non-Contracted Facility Information FormIMCare requires all facilities to register prior to submitting claims. As part of the registration process, please complete the Non-Contracted Facility Information Form (PDF). This form will enable IMCare to add your facility to our claims processing system in a timely and accurate manner. Please include all requested information. IMCare will not accept claims electronically prior to receiving this information from your facility.
Practitioner NPI/UMPI Notification/Request Form
If your claim requires a referring or ordering provider, please verify that the provider is eligible to refer or order. If the services are Medicare-covered, the referring/ordering provider needs to be enrolled with the Centers for Medicare & Medicaid Services (CMS) or have opted out of enrollment with CMS. (If opted out, include the affidavit with the provider registration packet). If the services are covered by Minnesota Medical Assistance (Medicaid), the referring/ordering provider needs to be registered with Minnesota Health Care Programs (MHCP).
W-9 Tax FormIn compliance with Internal Revenue Services (IRS) regulations, IMCare requests that you also provide a completed W-9 Form (PDF). Please pay particular attention to the following for the W-9 form:
Individual Taxpayer Identification Number (TIN):
- When including a Social Security Number (SSN): Only the name of the person whose SSN is included should be entered on the first line. Include the last name, first name, and middle initial.
- When including an Employer Identification Number (EIN): The name of the partnership, corporation, sole proprietorship, club, or other entity must be entered on the first line exactly as it was registered with the IRS when the Federal EIN was assigned.
Please do not submit a TIN that has not been assigned to your name. For example, a health care provider who submits his/her name on a W-9 must have his/her own SSN. If a health care provider uses the clinic name, then the W-9 must contain the Federal EIN of the clinic.
Submit one TIN on the form. Do not list both an SSN and an EIN.
Electronic Remittance Advices
Electronic Remittance Advices (ERA) was mandated by Minnesota Statute 62J.536, which requires all providers in the State of Minnesota to receive explanations of payment (EOPs) electronically after December 15, 2009.
The ERA is a time saver both in terms of posting payments and accuracy. IMCare requires all Minnesota providers to register to receive their ERA 835 remittances through their clearinghouse or to retrieve them from the IMCare provider web portal HealthX (https://secure.healthx.com/Itascaprovider). Both ERA options require the provider to complete the Electronic Remittance Advice (ERA) Authorization Agreement. Minnesota providers failing to complete and return the ERA form will be set up to retrieve EOPs from our provider web portal.
Electronic Funds Transfer
IMCare recommends that providers sign up to have claim payments automatically deposited into their bank account by completing the Electronic Funds Transfer (EFT) Authorization Agreement.
The EFT is a time saver as it will streamline your payments and provide an transaction number allowing you to retrieve your remittance directly from the IMCare provider web portal HealthX (https://secure.healthx.com/Itascaprovider).