SOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0) Please carefully read all instructions before beginning. The documents in this top section must be completed and sent to MD On-Line with your contract. PLEASE NOTE THAT THE CONTRACT MUST BE FAXED OR EMAILED TO MD ON-LINE. MD On-Line Documents 1. Claims Registration Authorization Form: Complete this page with the information regarding the provider/supplier you are billing for. NOTE: This form only needs to be completed once per Tax ID. If you are enrolling for EDI with more than one payer, you only need to complete this form once. Complete the form and send back with your Univera EDI Contract. Please note that if this form is completed and returned to MD On-Line within 30 days after your office has signed up with MD On-Line, any claims set up fees will be waived. You can obtain the form by clicking HERE 2. Contract Set Up Form: Complete this page and return with your contract to MD On-Line. You can obtain the form by clicking HERE 3. If you are enrolling for ERA s as well as claims, complete this additional document: ERA Registration Authorization Form: Complete this page with information regarding the providers/supplier you are billing for. Please send this form back to us with your ERA enrollment contract. Please note that if this form is completed and returned to MD On-Line within 30 days after your office has signed up with MD On-Line, any ERA setup fees will be waived. You can obtain the form by clicking HERE Be sure to complete ALL required sections of each document. Failure to do so will result in forms being rejected and returned to you, delaying your approval to send claims electronically. Carrier Specific Documents Print these instructions. Keep them with you to refer to during the registration process. This contract consists of 7 pages that must be completed, then printed, signed and faxed or emailed to MD On-Line. Page 1: EMDEON CLAIMS PROVIDER INFORMATION FORM Section 1: Provider Organization Fill in the provider s information for whom you are enrolling in electronic billing.
Section 2: Vendor Nothing to complete in this section. Section 3: Payer Fill in the Group ID or Individual ID and the corresponding NPI. Section 4: Confirmations Nothing to complete in this section. Page 2: Page 3: Page 4: Page 5: Page 6: Page 7: SC MEDICAID TRADING PARTNER AGREEMENT ENROLLMENT FORM INSTRUCTIONS Nothing to complete on this page. TRADING PARTNER AGREEMENT ENROLLMENT FORM Fill in the provider s information for whom you are enrolling in electronic billing. Have the provider sign this page. The transaction needed is already checked off for you. ADDITIONAL PROVIDERS List any additional providers you will be doing billing for. SC MEDICAID TRADING PARTNER AGREEMENT ENROLLMENT FORM INSTRUCTIONS Nothing to complete on this page. TRADING PARTNER AGREEMENT ENROLLMENT FORM. Fill in the provider s information for whom you are enrolling in electronic billing. Have the provider sign this page. The transaction needed is already checked off for you. ADDITIONAL PROVIDERS List any additional providers you will be doing billing for. When complete, print out all pages of the form. Sign where indicated on pages 3 and 6. Fax or Email ALL pages to: 888-837-2232 setup@mdol.com NOTE: PLEASE DO NOT FAX THE ORIGINAL FORMS DIRECTLY TO MEDICAID. FAX OR EMAIL THE FORM TO MD ON-LINE ENROLLMENT ONLY. Have questions or need assistance? Contact the MD On-Line Enrollment Department at 888-499-5465 or setup@mdon-line.com
PAYER ID: SUBMITTER ID: Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name Tax ID Client ID Site ID Address City/State Zip Code Contact Name E-mail Address Telephone Fax 2 Vendor (Emdeon certified vendor used to submit files to Emdeon) Vendor Name Contact Name E-mail Address 3 Payer Vendor Submitter ID Division ID Payer ID Group ID Individual Provider ID NPI ID 4 Confirmations Send Emdeon Claim Confirmations To: Special Instructions: All Payer Registration forms must contain signatures when applicable, stamped signatures or photocopies are accepted. SUBMIT COMPLETED FORM TO: Fax: (615) 231-4843 Email: batchenrollment@emdeon.com BOTH AGREEMENTS MUST BE COMPETED WITH ORIGINAL SIGNATURE. FIRST AGREEMENT WITH PROVIDER INFORMATION AND THE SECOND AGREEMENT HAS EMDEON'S INFORMATION PREFILLED. EMDEON REVISION FORM DATE:
SC Medicaid Trading Partner Agreement Enrollment Form Instructions The purpose of the Trading Partner Agreement Enrollment Form is to enroll all EDI trading partners. It is important that instructions are followed and that all required information is completed. Incomplete forms will be returned to the applicant, delaying the enrollment process. Completing and Submitting Your Enrollment Request Once completed please mail to SC Medicaid TPA, P.O. Box 17, Columbia, SC, 29202 or fax* to (803) 870-9021. The field descriptions in the table below and the form on the next page will aid in completing the form. Form Field Name Date Action Requested: New Trading Partner ID Change Cancel Trading Partner Name Trading Partner ID NPI & Medicaid Provider ID Number Federal Tax ID # Type of Business Start Date End Date South Carolina Medicaid Web Based Claims Submission Tool Protocol Agreement Software Vendor Or Billing Agent Contact Information Transactions Requested Instructions for Field Completion Enter today s date. Indicate the action to be taken on the enrollment form. 1. To apply for a new Trading Partner ID, check New Trading Partner ID. 2. To change Trading Partner information, check Change. 3. To cancel your enrollment, check Cancel. Enter the name of the entity that will be submitting/receiving electronic transactions with SCDHHS. The Trading Partner ID is assigned by SCDHHS to identify trading partners to our system. If the Trading Partner is a Provider, enter the NPI and/or the SCDHHS assigned Medicaid Provider ID Number. Enter the trading partner s Federal Tax Identification Number. Select the type of primary business the trading partner conducts. If you check Other, indicate the type of business on the line provided. Indicate, in mm/dd/ccyy format, the date the trading partner plans to begin transaction testing with SCDHHS. If this form is being used to cancel an account, indicate, in mm/dd/ccyy format, the date the trading partner intends to terminate its trading partner account. For Trading Partners requesting access to the tool, please check box. Check FTP or ASYNC to specify the communication method. If ASYNC dial up is checked, then specify the product. Please check the appropriate boxes to indicate your agreement with the terms and conditions of the Trading Partner Agreement for Electronic Claims and Related Transactions. Please sign and print your name below. Indicate the software vendor or billing agent you will be using. Enter Contact Name, E-mail, Phone Number and Fax Number Mark yes (Y) or no (N) for each transaction. *When faxing original forms must be kept on file in your office REV. 11/06/2009 For Assistance with this form call the EDI Support Center at 1-888-289-0709.
Trading Partner Agreement Enrollment Form Mail to: SC Medicaid TPA, P.O. Box 17, Columbia, SC 29202 or fax to (803) 870-9021 Date: Action Requested: (Check One) New Trading Partner ID X Change Cancel Trading Partner Name: Trading Partner ID: (If Applicable) NPI: Type of Business: (Check One) Medicaid Provider No: X Medicaid Provider Clearinghouse Software Vendor Billing Service Other (indicate): Start Date: (mm/dd/ccyy) End Date: (mm/dd/ccyy) (Required when canceling an account) South Carolina Medicaid Web Based Claims Submission Tool: # of IDs requested: Protocol: (Check One) SecureFTP WS_FTP Pro CD Diskette I have read, understand and agree with the conditions set forth in the South Carolina Medicaid Trading Partner Agreement for Electronic Claims and Related Transactions Signature: Print Name: Software Vendor or Billing Agent: Software Vendor or Billing Agent:_ Contact Information: Contact Name: E-mail: Phone: ( ) Fax: ( _) Transactions Requested Transmission* Y/N** Transmission* Y/N** ASC X12N 820 (004010X061A1) ASC X12N 834 (004010X095A1) ASC X12N 270 (004010X092A1) ASC X12N 837I(004010X096A1) ASC X12N 271 (009010X092A1) ASC X12N 837P(004010X098A1) X ASC X12N 276 (004010X093A1) ASC X12N 277 (004010X093A1) ASC X12N 837D (004010X097A1) ASC X12N 835 (004010X091A1) ASC X12N 278 (004010X094A1) Submitter ID: SC Medicaid EDI Help Desk Use Only Date: REV. 11/06/2009 For Assistance with this form call the EDI Support Center at 1-888-289-0709.
If your business is authorized to send or receive transactions on behalf of another provider, please provide the Provider s name, Medicaid ID Number, NPI and service/physical address state. Provider Name Medicaid ID Number NPI State Add/Change/ Remove (A/C/R) REV. 11/06/2009 For assistance with this form call the EDI Support Center at 1-888-289-0709.
SC Medicaid Trading Partner Agreement Enrollment Form Instructions The purpose of the Trading Partner Agreement Enrollment Form is to enroll all EDI trading partners. It is important that instructions are followed and that all required information is completed. Incomplete forms will be returned to the applicant, delaying the enrollment process. Completing and Submitting Your Enrollment Request Once completed please mail to SC Medicaid TPA, P.O. Box 17, Columbia, SC, 29202 or fax* to (803) 870-9021. The field descriptions in the table below and the form on the next page will aid in completing the form. Form Field Name Date Action Requested: New Trading Partner ID Change Cancel Trading Partner Name Trading Partner ID NPI & Medicaid Provider ID Number Federal Tax ID # Type of Business Start Date End Date South Carolina Medicaid Web Based Claims Submission Tool Protocol Agreement Software Vendor Or Billing Agent Contact Information Transactions Requested Instructions for Field Completion Enter today s date. Indicate the action to be taken on the enrollment form. 1. To apply for a new Trading Partner ID, check New Trading Partner ID. 2. To change Trading Partner information, check Change. 3. To cancel your enrollment, check Cancel. Enter the name of the entity that will be submitting/receiving electronic transactions with SCDHHS. The Trading Partner ID is assigned by SCDHHS to identify trading partners to our system. If the Trading Partner is a Provider, enter the NPI and/or the SCDHHS assigned Medicaid Provider ID Number. Enter the trading partner s Federal Tax Identification Number. Select the type of primary business the trading partner conducts. If you check Other, indicate the type of business on the line provided. Indicate, in mm/dd/ccyy format, the date the trading partner plans to begin transaction testing with SCDHHS. If this form is being used to cancel an account, indicate, in mm/dd/ccyy format, the date the trading partner intends to terminate its trading partner account. For Trading Partners requesting access to the tool, please check box. Check FTP or ASYNC to specify the communication method. If ASYNC dial up is checked, then specify the product. Please check the appropriate boxes to indicate your agreement with the terms and conditions of the Trading Partner Agreement for Electronic Claims and Related Transactions. Please sign and print your name below. Indicate the software vendor or billing agent you will be using. Enter Contact Name, E-mail, Phone Number and Fax Number Mark yes (Y) or no (N) for each transaction. *When faxing original forms must be kept on file in your office REV. 11/06/2009 For Assistance with this form call the EDI Support Center at 1-888-289-0709.
Trading Partner Agreement Enrollment Form Mail to: SC Medicaid TPA, P.O. Box 17, Columbia, SC 29202 or fax to (803) 870-9021 Date: Action Requested: (Check One) New Trading Partner ID X Change Cancel Trading Partner Name: Trading Partner ID: (If Applicable) NPI: EMDEON WME001 Medicaid Provider No: Type of Business: Medicaid Provider X Clearinghouse (Check One) Billing Service Other (indicate): Software Vendor Start Date: (mm/dd/ccyy) End Date: (mm/dd/ccyy) (Required when canceling an account) South Carolina Medicaid Web Based Claims Submission Tool: # of IDs requested: Protocol: (Check One) SecureFTP WS_FTP Pro CD Diskette I have read, understand and agree with the conditions set forth in the South Carolina Medicaid Trading Partner Agreement for Electronic Claims and Related Transactions Signature: Print Name: Software Vendor or Billing Agent: Software Vendor or Billing Agent:_ Contact Information: Contact Name: E-mail: Phone: ( ) Fax: ( _) Transactions Requested Transmission* Y/N** Transmission* Y/N** ASC X12N 820 (004010X061A1) ASC X12N 834 (004010X095A1) ASC X12N 270 (004010X092A1) ASC X12N 837I(004010X096A1) ASC X12N 271 (009010X092A1) ASC X12N 837P(004010X098A1) X ASC X12N 276 (004010X093A1) ASC X12N 837D (004010X097A1) ASC X12N 277 (004010X093A1) ASC X12N 835 (004010X091A1) ASC X12N 278 (004010X094A1) Submitter ID: SC Medicaid EDI Help Desk Use Only Date: REV. 11/06/2009 For Assistance with this form call the EDI Support Center at 1-888-289-0709.
If your business is authorized to send or receive transactions on behalf of another provider, please provide the Provider s name, Medicaid ID Number, NPI and service/physical address state. Provider Name Medicaid ID Number NPI State Add/Change/ Remove (A/C/R) REV. 11/06/2009 For assistance with this form call the EDI Support Center at 1-888-289-0709.