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Following Payers Must have Legacy ID s listed to complete Payer Enrollment SB580-SB690- SKAR0-SKMD0 Payer ID Group ID Individual ID NPI list if using option other then default 5 Send Confirmations To enrollments optum.com ERA Merge Group Provider Setup Form Revised 12. 1755 Telstar Drive Ste 400 Colorado Springs CO 80920 www. optum.com 60305 Thank you for choosing Electronic Network Systems Clearinghouse a division of Optum to submit your Claims/ERAs. This form is for Optum use only and will...
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