Electronic Data Interchange (EDI) Registration for Oregon Medicaid
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1 Electronic Data Interchange (EDI) Registration for Oregon Medicaid Learn how to complete the following forms: Oregon MMIS Trading Partner Agreement ( 2080) Exhibit A Application for Authorization ( 2081) Exhibit B EDI Registration ( 2082) Division of Medical Assistance Programs
2 Introduction Before you can exchange electronic data about health care transactions (e.g., for claim payments) with, you must complete the Oregon MMIS Trading Partner Agreement (TPA) and required Exhibits. The current version is dated 10/11. will not accept earlier versions. All EDI registration forms are available at The Trading Partner Agreement and Exhibits will be returned if required fields are not completed, potentially delaying the process. 2
3 Requirements The TPA ( 2080), Exhibit A ( 2081) and Exhibit B ( 2082) must be mailed to with original ink signatures (in a color other than black) as a complete package of information. does not accept stamped or copied signatures. Signing in non-black ink allows to distinguish copies and faxes from original documents. does not accept copies of the TPA or Exhibits. will reject faxes, scans, or ed attachments as copies. Documents that have white-out on them will be rejected. If you are a current Trading Partner and you change to a different clearinghouse, you will need to submit a new TPA, Exhibit A and Exhibit B with the different clearinghouse information and signatures. 3
4 Mailing instructions Read and complete all information required. Sign and date in ink, in a color other than black. Retain a copy of the TPA and Exhibits for your records. Prepare the TPA and Exhibits to be returned to. If you choose, you may send your TPA and Exhibits by registered mail. Send all signed, original documents to: Operations 500 Summer St NE, E44 Salem, OR
5 Definitions Authorized signer: A person responsible for business activities of the named provider and authorized to sign binding agreements. Provider number: The 6- or 9-digit Oregon Medicaid provider number assigned by. Submitter number: The mailbox number assigned to an EDI submitter by for EDI submissions (begins with MB######). 5
6 Trading Partner Agreement The TPA is a binding agreement between and the Trading Partner as defined in Oregon Administrative Rule (OAR) All Trading Partner information must be consistent with how the provider or prepaid health plan is enrolled with. Division of Medical Assistance Programs
7 TPA page 1 7
8 TPA page 1 Provider Number: Enter the number issued to you when you enrolled as a Oregon Medicaid provider. (Note: this cannot be a billing service.) Name of Provider, Prepaid Health Plan, Clinic or Allied Agency: Enter your (the provider or plan s) name as enrolled with (e.g., name of clinic). 8
9 TPA page 5 9
10 TPA page 5 Enter your (the provider s): Name as enrolled with (to match page 1 of TPA). Phone number. The original ink signature (in a color other than black) of the person authorized to sign contracts for your business. This person must be the same on all signed documents submitted to (TPA, Exhibits A and B). Type or print the authorized signer s name. Enter the date the agreement was signed. 10
11 Exhibit A - Application for Authorization This form tells who will submit your electronic transactions. If you authorize another entity to be your EDI submitter, Exhibit A indicates which, if any, actions may be taken by the submitter on your behalf. Exhibit A obligates the EDI submitter to abide by the OHA EDT rules as secured by the required signature. Division of Medical Assistance Programs
12 Exhibit A page 1 Please read the instructions! If you (the provider or plan) are the EDI submitter, complete Sections A and C. If another entity will submit for you, complete Section A and have your submitter complete Section B. 12
13 Exhibit A page 1 New Application - Check this box if this is a new application. Updated Application - Check this box if updating information (changing or adding a submitter). Indicate the date that the updates are effective. 13
14 Exhibit A page 1 - section A All Trading Partners must complete this section. At a minimum, you must check the last box ( Conduct my registered transactions ). Check all boxes that may apply. 14
15 Exhibit A page 1 - section A Check this box if you want the submitter to participate in business to business testing with, to test their software s ability to submit your transactions for processing in the Oregon MMIS (OR-MMIS). 15
16 Exhibit A page 1 - section A Checking this box gives the submitter permission to request advancement into production (e.g., submitting actual claims for payment) from a test mode after going through the testing phase. approval to conduct transactions does not certify the HIPAA compliance of electronic transactions exchanged. approval indicates that our internal testing processes have been completed and a production status is assigned. 16
17 Exhibit A page 1 - section A Check this box if you want to give the submitter permission to send changes or updates to their Exhibit A information directly to. If you leave this box unchecked, will only accept changes to Exhibit A when submitted by you (the provider or plan). 17
18 Exhibit A page 1 - section A Check this box if you give the submitter permission to send changes or updates of Exhibit B directly to. If you leave this box unchecked, will only accept changes to Exhibit B when submitted by you (the provider or plan). 18
19 Exhibit A page 1 - section A Check this box if you give the submitter permission to request a password and log-on information (if the password should need changing or they are having difficulty logging in). 19
20 Exhibit A page 1 - section A You must check this box. It allows the submitter identified in Section B or C to submit and/or receive your EDI transactions, such as: 835 Claims Remittance Advice 270 Client Eligibility inquiry 271 Client Eligibility response If you do not check this box, will not allow your submitter (billing service/clearinghouse) to exchange transactions on your behalf. 20
21 Exhibit A page 1 section A Enter your (the provider or plan s): Name (to match page 1 of TPA). Business phone number (to match page 5 of TPA). Oregon Medicaid provider number (to match page 1 of TPA). Tax ID number (as enrolled with ). NPI and taxonomy code(s). Enter the current date. The authorized signer must sign here in ink (in a color other than black, to match page 5 of the TPA and page 2 of Exhibit B). 21
22 Exhibit A page 2 The entity who will submit on your behalf (the EDI submitter) must read these conditions and sign the certification at the bottom of the page. If only you (the provider or plan) are going to submit transactions, then skip to section C. 22
23 Exhibit A page 2 section B The EDI submitter (billing service or clearinghouse) MUST complete all fields in this certification, including a dated signature. The signature must be in ink, in a color other than black so that we can tell it is an original signature. 23
24 Exhibit A page 3 24
25 Exhibit A - page 3 section C If you (the provider or plan) choose to submit your own transactions, you must complete this section. If you only want the EDI submitter identified in section B to submit transactions, then skip this section. 25
26 Exhibit A - page 3 section C This line should match what you entered on page 1 of the TPA. 26
27 Exhibit A page 3 - section B This line should match the name of the authorized signer from page 5 of the TPA. 27
28 Exhibit A page 3 - section B Enter your (the provider or plan s) physical business address. 28
29 Exhibit A - page 8 - section B Enter your (the provider or plan s): Phone number Fax number address 29
30 Exhibit A page 3 - section C Tax ID information is the your (the provider or plan s) Tax ID as enrolled with. Submitter Number: Enter your Oregon Medicaid provider number here (to match page 1 of TPA). If your enrollment arrangement with is such that this number is different, will notify you. Trading Partner Signature: The authorized signer must sign here in ink (in a color other than black, to match page 5 of the TPA). 30
31 Exhibit B - EDI Registration Form You must complete Exhibit B for each EDI Submitter you authorized on Exhibit A (including yourself). Exhibit B tells the specific transactions you or your EDI submitter will exchange with. Exhibit B also tells whom to contact about any technical or claims inquiries. You can enter up to two contacts for each contact type, and add more contacts on the back of the form if needed. Division of Medical Assistance Programs
32 Exhibit B page 1 32
33 Exhibit B - page 1 section 1 Check if new or revised registration and effective date. Enter your (the provider s): Name (to match the name entered on page 1 of the TPA). Physical address (actual location). Secondary address if applicable. City, State and ZIP Code (+4). Phone number and fax number. 33
34 Exhibit B page 1 section 2 Enter your (the provider or plan s): Oregon Medicaid provider number (to match page 1 of TPA). NPI number(s). Associated taxonomy code(s). 34
35 Exhibit B page 1- section 3 This section is the information for the authorized signer. This must be the same as page 5 of the TPA, and page 1 of Exhibit A. You must complete all fields. An authorized signer may designate a secondary contact as having signing authority. Please print secondary signer information, if available. 35
36 Exhibit B page 1 - section 4 Due to HIPAA Privacy rules, will only discuss claims information with the individuals you list in section 4. highly recommends that you list at least two contacts familiar with claims submissions. If you need to add more than two contacts, add them to the back of the document or attach a contact list using letterhead. 36
37 Exhibit B page 2 37
38 Exhibit B page 2 - sections 5 & 6 The EDI submitter must complete the information in these two sections. If you (the provider or plan) are self-submitting, you will complete this information. Select Self as the Submitter Type in section 5. 38
39 Exhibit B page 2 - section 7 Select the transaction(s) you (the provider or plan) wish to exchange with. Not all transactions are available to all providers. Only check those that are appropriate for your particular line of business. For example, if you are not a -contracted Prepaid Health Plan, do not check any marked as PHP only. If you are a dentist, make sure you check the 837D. 39
40 Exhibit B page 2 - section 8 Sign and date the form using ink in a color other than black. The name, phone number, signature and name (of authorized signer) must match page 5 of the TPA and page 1 of Exhibit A. Please print your name clearly. 40
41 Need help? If you have specific EDI registration or testing questions, please contact at: Phone:
42 Division of Medical Assistance Programs Thank you!
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