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Electronic Remit Regeneration Requests

This web form is used to request an electronic regeneration of a previously sent remittance. This service is not intended to replace or change your normal remittance delivery method and should only be used as a temporary exception. If you have a current issue receiving remittances, please ensure that it is resolved prior to submitting this request.

You may request up to 12 cycles using this web form. Frequent submissions from the same requestor may be subject to internal review. Additional information or documentation may be required to process this request.


Requestor Name:*
Requestor Email:*
Provider Name:*
NPI or MMIS: *
Reason For Request: *
Are there any ongoing issues preventing you from receiving Remittances?    


Please provide as much of the below information as possible (at least one is required): *
Cycle or Remittance Number Check/EFT Number  
ETIN Number:
User ID:


ReCaptcha: *







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