MNDHS: How to Request Electronic Remittance Advice in Billiyo

To receive your electronic remittance advice in Billiyo, we will need to request it from the Minnesota Department of Human Services. To do this, please complete this form.

When filling our the form, please enter the following information:

Clearinghouse and Billing Organization Information 

• CLEARINGHOUSE OR BILLING ORGANIZATION UNIQUE MINNESOTA PROVIDER IDENTIFIER (UMPI)
  • A477415400 
• CLEARINGHOUSE OR BILLING ORGANIZATION NAME
  • Billiyo Health Inc.
• NAME OF PERSON COMPLETING THIS FORM
  • Your Customer Sucsess manager's name
• ADDRESS
  • 400 S 4th St Suite 401
• PHONE NUMBER
  • (612) 517-1990
• CITY
  • Minneapolis
• STATE
  • Minnesota
• ZIP
  • 55414

  MHCP Pay-To Provider Information

• PROVIDER NAME
  • Your Agency Name
• NPI oe UMPI
  • You agency UMPI/NPI
    • You have multiple UMPIs with the DHS, then you will need to complete this form multiple times One for each ID.
• AFFILIATE TO CLEARINGHOUSE OR BILLING ORGANIZATION EFFECTIVE DATE
  • Today's Date
• REMOVE AFFILIATION TO CLEARINGHOUSE OR BILLING ORGANIZATION
  EFFECTIVE DATE
  • Leave Blank
• CONTACT NAME
  • Your Name
• PHONE NUMBER
  • Your phone number
• SELECT THE TYPE OF ACCESS FOR
  • BOTH
• ADD REMITTANCE MEDIA TYPE
  • 835x12
• REQUESTED START DATE 
  • Today's Date
• REMOVE REMITTANCE MEDIA TYPE (if applicable)
  • Leave blank
• REQUESTED END DATE
  • Leave blank
• PAY-TO PROVIDER PRINTED NAME
  • Your name
• PAY-TO PROVIDER SIGNATURE
  • Leave Blank
• DATE
  • Today's Date

Submitting the Form

After completing this form, please FAX it to the Minnesota Department of Human Services. You can fax this document to 651-431-7462