North Carolina workers’ compensation electronic funds transfer enrollment

Beginning January 1, 2015, North Carolina requires workers’ compensation carriers to offer electronic payment to medical providers.

If you are a workers’ compensation medical provider and would like to receive payments via electronic funds transfer (EFT), select an enrollment option after agreeing to the following terms:

Provider agrees to the following: This Authorization is between the Provider listed below (Provider) and Sentry Insurance Company, its affiliates and subsidiaries (“Sentry Insurance”) and governs Provider’s enrollment and use of the Electronic Funds Transfer (“EFT”) service. The contact person identified on the Authorization warrants and represents that he/she is authorized to act on behalf of the Provider and that his/her acceptance of the terms of this Authorization creates a legally enforceable obligation of the Provider. Provider authorizes Sentry Insurance to electronically transfer funds for all eligible and authorized claim payments to the bank account provided and understands that upon activation of the EFT service, Provider will no longer receive paper checks for claims payments. Provider warrants and represents that all information listed on this Authorization is accurate and agrees to immediately notify Sentry Insurance of any changes to the information or if it wishes to cancel enrollment. Sentry Insurance is not liable for any loss that Provider may incur as a result of the EFT service. Provider agrees to indemnify Sentry Insurance from and against all suits, claims, or losses arising from or alleged to arise from the Provider’s use of the EFT service. This Authorization constitutes the entire agreement between Sentry Insurance and Provider for the EFT service.

Please note:

• Please allow Sentry Insurance 7-14 days from receipt of all documentation to process EFT remittance, changes, or cancellation requests.

• Contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ data elements needed for reassociation of the payment and the ERA. (The Corporate Credit or Debit is an ACH standard for EFT which is used to make/collect payments to/from other corporate entities. The CCD+ ACH Standard can include one record of payment-related information of up to 80 characters. Health Plans use the CCD+ to send payments via EFT, with a reassociation number that matches the EFT to its associated ERA (Electronic Remittance Advice)).

• Mail your completed form to:
  Sentry Insurance Company
  PO Box 8032
  Stevens Point, WI 54481

• Enroll online if you agree to the terms above.

• Print an enrollment form.