Submitter Information. For the claims for MEDICAID, or which you will CHARITY CARE check boxes located at the top of the form, indicate the type of be submitting electronic claims. Check one box only. A separate New Jersey Medicaid HIPAA EDI Agreement is required for each provider number you will be electronically submitting claims for unless the provider is a group practice and the group is responsible for the billing of the individual providers associated with the provider group.
Submitter Information. Please complete the appropriate submitter information. Your email address will be kept confidential, and will only be used as a means of distributing general information to New Mexico Medicaid Program.
Submitter Information. 1. Submitter Name: Enter the name of the Pharmacy or Clearing house/Billing Service Name as registered with New Jersey Medicaid/DXC Technology.
Submitter Information. Every EDI submitter assigned a Submitter ID by New Jersey Medicaid must complete, sign and submit this New Jersey Medicaid Submitter ID/Provider Relationship Agreement before the submitter is authorized to submit claims for a New Jersey Medicaid provider. In some cases the submitter may be a New Jersey Medicaid provider and in other cases the submitter may be a third party billing service. Regardless, New Jersey Medicaid cannot process claims submitted with a specific Submitter ID for a specific New Jersey Medicaid provider number unless this agreement has been properly completed and submitted to New Jersey Medicaid or their designated agent. By signing this agreement, the New Jersey Medicaid provider is authorizing the submitter to submit claims electronically to New Jersey Medicaid on their behalf. A separate agreement is required for each New Jersey Medicaid Billing Provider Number. All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and State funds and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws, or both.
Submitter Information. Please complete the appropriate submitter information. Your email address will be kept confidential, and will only be used as a means of distributing general information to Colorado Medical Assistance Program submitters.
Submitter Information. First Name: Degree: Academic Position (or Title): Institution: Department: Street Address: City: State/Province: Zip/Postal Code: Country: Phone: FAX: Institutional E-mail Address: Point of Contact (POC) Name (if different from the Submitter): POC Phone: POC E-mail Address:
Submitter Information. If your company intends to exchange transactions directly with OHA, enter the name (as listed in Section 1) as this will become the submitter name; or • If you intend to use a submitter or clearinghouse, complete this part with their information. *Submitter or clearinghouse name: Office Ally *Address: PO Box 872020 *City, State and Zip: Vancouver, WA 98687 *Submitter EDI Mailbox number: MB000 Please keep a copy for your records 2 of 4 200-393903_OHA 2080 (04/2024) Form Section *Section 5: Authorized transactions – Check all transactions that OHA should authorize for your EDI submitter. HIPAA 5010A1 transactions: 005010X222A1 837P Professional claim submission 005010X223A2 837I Institutional claim submission 005010X224A2 837D Dental claim submission 005010X221A1 835 Electronic remittance advice 005010X279A1 270 and 271 Eligibility benefits inquiry and response 005010X212 276 and 277 Claims status request and response 005010X218 820 Group premium payments (not available to all provider types) Pharmacy carve-out RX carve-out file Pharmacy 340B file Pharmacy 340B file *Section 6: Trading Partner Signature – By signing below, the Trading Partner certifies the following: • I have read the Electronic Data Transmission Oregon Administrative Rules (Chapter 943, Division 120) at Secretary of State OAR rules website, and understand my responsibilities as stated in these rules. • I authorize OHA to transmit to the EDI Submitter listed in Section four (4) of this form the return computer file electronic vouchers of all transactions I have marked in Section five (5) of this form. *Business name: (from section one of this form) *Email address: (individual, not a group) *Phone number with extension: *Authorized signer’s printed name: (person listed in Section1) *Authorized signer signature: Signature date:
