Please complete the Electronic Data Interchange (ERA) Authorized Agreement Form. If signing up or changing information, fill out the form completely. To cancel the ERA process with Quartz, complete sections one, two, and seven.
Quartz will process your ERA Authorization Agreement within seven business days. At the time the process is complete, your next claims payment advice will be an ERA.
If you would like to know your ERA enrollment status or have a question regarding an ERA, email [email protected].
In order to receive your ERA after your authorization agreement has been confirmed, you must contact your vendor or clearinghouse to arrange for the delivery of the CORE-compliant ERA.
NOTE: If your vendor or clearinghouse does not have an existing trading partner connection with Quartz, please have them complete, sign, and mail two original copies of this Electronic Trading Partner Agreement to this address:
Attn: EDI Dept.
2650 Novation Parkway
Fitchburg, WI 53713
Once both originals are received, approved, and signed by Quartz, one of the originals will be mailed to the vendor or clearinghouse. Then, Quartz will complete one successful round of testing with this vendor or clearinghouse using the ERA claim tests for the provider seeking authorization. When this testing is complete, the enrollment process is confirmed.
If you are unable to fill out this form electronically, please print and mail your completed form to Quartz.