Computer Sciences Corporation Attn: Provider Enrollment Support P.O. Box 4614 Rensselaer, NY 12144
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1 Security acket B GEEMEN for emedny System CCESS Instructions for Completion 1. lease read the greement. Your signature indicates acceptance to the terms and conditions of this greement. 2. Complete the information requested at the bottom of the greement form and sign the greement. lease print or type the following information: a) NI/Medicaid rovider Number (ll providers and vendors are required to enroll in the Medicaid rogram) Enter your ten-digit NI or, if NI exempt, enter your eight-digit Medicaid rovider ID Number, which was assigned by the Department of Health at the time of your enrollment in the Medicaid rogram. b) rovider/vendor Name Enter the name of the rovider/vendor that will be subject to the agreement. (Enter the name associated with the NI/Medicaid rovider ID Number entered above). c) Street ddress, City, State, Zip Enter the address where you would like to receive correspondence from CSC. lease note that it must be a Street ddress, not a.o. Box. d) By rint the name of the authorized person who signs the greement. e) itle rint the title of the authorized person who signs the greement. f) Date Enter the date on which the greement is signed. 3. Mail the completed form to: Computer Sciences Corporation ttn: rovider Enrollment Support.O. Box 4614 ensselaer, NY /08/2010
2 GEEMEN for emedny System CCESS WHEES, the New York State Department of Health (the Department ) and Computer Sciences Corporation ( CSC ), have entered into an agreement whereby CSC provides direct electronic access to MEDICID eligibility verification, claims submission, and other electronic transactions, for Medical roviders/vendors and their agents (rovider/vendor) to the emedny System; and WHEES, rovider/vendor performs certain medical services and/or provides medical supplies for recipients who are eligible for MEDICID benefits, or performs data processing services for such entities; and WHEES, rovider/vendor has requested direct electronic access to the emedny System; NOW, HEEFOE, CSC and rovider/vendor agree as follows: 1. CSC-eMedNY will supply to rovider/vendor the technical specifications required to establish the link to the emedny System (Exhibit ). rovider/vendor is responsible for all costs associated with complying with such requirements. 2. rovider/vendor agrees to comply with the system requirements and any additional terms set forth on Exhibit. 3. fter rovider/vendor has obtained initial access to the emedny System, rovider/vendor agrees to re-test its link to the System in the event: rovider s/vendor s link is changed or modified in any way, or he technical specifications change in response to Department mandated program changes rovider/vendor agrees to follow CSC s then current procedures for obtaining such access. 4. rovider/vendor agrees to pay any hosting charges for any equipment above and beyond the standard interface equipment specified by CSC, including installation, provisioning and utility charges. hese charges may be paid in a single one-time charge depending upon the configurations of equipment requested. 5. rovider/vendor is expected to manage provisioning and management of their respective connections to emedny. 6. rovider/vendor agrees to pay any damages that are caused by, result from, or are in any way attributable to rovider/vendor, its employees, agents and independent contractors negligent use of the emedny System, fraud or intentional misconduct or rovider s/vendors failure to certify or re-certify its link to the emedny System. 7. rovider/vendor agrees to exercise due diligence in protecting rovider/vendor systems so that malicious software is not introduced to emedny Systems. 8. rovider/vendor accepts and agrees to comply with the rovisions of this emedny Security greement. 9. his greement shall become effective upon approval by CSC-eMedNY, on behalf of the New York State Department of Health and shall continue thereafter until terminated by either party on 60 days notice in writing. NI/Medicaid rovider Number By: lease print name rovider/vendor Name Signature Street ddress itle: City, State, Zip Date: 2 12/08/2010
3 GEEMEN for emedny System CCESS **EXHIBI ** SYSEM EQUIEMENS Batch C-to-Host (Dial-up F): oint-to-oint rotocol () C/I rotocol with File ransfer rotocol (F) Compliance with HI File Format OHE EMS 1. rovider/vendor shall order the telecommunication lines and equipment necessary to link rovider s/vendor s system to the emedny System. rovider/vendor will be responsible for monitoring, diagnosing and establishing dial backup on the telecommunication lines and equipment. 2. CSC does not provide consultation services beyond simple installation troubleshooting. For example, we cannot assist with the installation of the operating system or configuration issues involving the rovider s/vendor s LN, C, modem or printer. CSC does not support rovider/vendor hardware or software. 3. For qualified roviders/vendors, CSC will provide support for the eces, and other electronic transaction software supplied by CSC, so long as CSC is the State of New York emedny contractor and rovider/vendor has not altered or modified the software in any way. 3 12/08/2010
4 OVIDE/VENDO emedny ccess equest Form Instructions for Completion lease type or print all required information. 1. User Information (User is the rovider enrolled in the New York State Medical ssistance rogram [Medicaid] or the Vendor that supplies switch services to a group of providers) Name If you are an individual rovider, enter your last name, first name, and middle initial (if any) If the NI/Medicaid rovider ID number applies to a business (i.e. harmacy, DME Supplier, Laboratory, etc.), enter the name of the individual authorized to sign the emedny ccess equest on behalf of the provider organization. If you are a Vendor, enter the Company name. ddress Enter the address where you would like to receive correspondence from CSC. Indicate Check the box (only one box please) that best indicate your user status. If you check the box next to Other, please explain. NI/Medicaid rovider ID (all providers and vendors are required to enroll in the Medicaid rogram). Enter your (or your organization s) ten-digit NI or, if NI exempt, enter your eightdigit Medicaid rovider ID Number, which was assigned by the Department of Health at the time of enrollment in the Medicaid rogram. hone Number Enter the phone number at which you can be contacted. 2. lternate ccess equired Check the platform(s) through which you will be accessing emedny. 3. equestor Information equestor s Name Enter the name of the authorized person requesting access to emedny. Date Enter the date on which the request was completed. hone Number Enter the phone number at which CSC can contact you if necessary. LEVE SECIONS 4 ND 5 BLNK. HESE E FO CSC USE ONLY. 4 12/08/2010
5 1. User Information U S E I N F O M I O N OVIDE/VENDO emedny ccess equest Form Last Name: First Name: Middle Initial: osition/itle: ddress: INDICE: Medical rovider Service Bureau Connectivity Switch rovider/vendor Other NI/MEDICID OVIDE ID: hone Number: 2. lternate ccess equired (lease see exhibit for minimum requirements) L F O M You must check applicable platform(s). F batch submission (Dial-up) NCD batch-submission (Dial-up) 3. equestor Information equestor s Name: Date: hone Number: 4. pprovals (For CSC emedny Use Only) 1 pprover s Name: Signature: Date: hone number: pprover s Name: Signature: Date: hone number: 2 5. dministration (For CSC emedny Data Security Use Only) D ype of User ID assigned: Comments: S E C U I Y dministrator Name: Date: dministrator Signature: New USEID Initial password 5 12/08/2010
6 SECUIY GEEMEN FO NEW YOK SE-eMedNY SYSEM Instructions for Completion 1. lease read the USEID ND SSWOD ULES. By signing the greement, you indicate acceptance to the terms and conditions of this greement. 2. Complete the information requested at the bottom of the greement form and sign the greement. lease type or print the following information: a) NI/Medicaid rovider Number (all providers and vendors are required to enroll in the Medicaid rogram) Enter your ten-digit NI or, if NI exempt, enter your eight-digit Medicaid rovider ID Number, which was assigned by the Department of Health at the time of your enrollment in the Medicaid rogram. b) rovider/vendor Name Enter the name of the rovider/vendor that will be subject to the agreement. (If you have a NI/Medicaid rovider ID, enter the name associated with the NI/Medicaid rovider ID Number entered above). c) Street ddress, City, State, Zip Enter the address where you would like to receive correspondence from CSC. lease note that it must be a Street ddress, not a.o. Box. d) By rint the name of the authorized person who signs the greement. e) itle rint the title of the authorized person who signs the greement. f) Date Enter the date on which the greement is signed. 6 12/08/2010
7 SECUIY GEEMEN NEW YOK SE-eMedNY SYSEM ll users of Medicaid data and systems are required to affirm their understanding and agreement to comply with the following USEID and assword rules before access can be granted. USEID ND SSWOD ULES USEID and password will be provided by CSC-eMedNY Data Security upon approval of this security agreement. CSC, in accordance with the Federal Information rocessing Standards and the rivacy ct of 1974, requires that all users of the system be aware of and comply with the following rules regarding USEIDS and asswords: a) USEIDS and asswords must not be shared with anyone. USEID is assigned by CSC-eMedNY Data Security solely to an individual and the individual is responsible for all system activity related to that USEID. b) fter four consecutive password violations (i.e., entering the wrong password) the USEID is revoked. If this occurs, CSC-eMedNY Data Security dministration intervention is required to reactivate the USEID. Contact rovider elations to activate this intervention. I have read and fully understand the USEID and assword rules as set out above. IMON ** LESE ED ** IMON On the line below, you MUS provide a Unique Identifier that will be used to identify this rovider/vendor when corresponding via telephone. he Unique Identifier should be something only this rovider/vendor knows, (i.e. mother s maiden name, pet s name, etc.), and will be used to verify the identity of the person to whom we are providing sensitive information such as account User IDs and passwords. UNIQUE IDENIFIE: By: NI/Medicaid rovider Number lease rint Name rovider/vendor Name Signature itle: Street ddress Date: City, State, Zip 7 12/08/2010
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