Read NJ_Medicaid_Agreement.pdf text version

Agreement to submit electronic claims to New Jersey Medicaid

This agreement must be completed and approved by New Jersey Medicaid prior to sending electronic claims through the Secure EDI. 1. General instructions: a. Complete one agreement for the group. b. Return ALL pages of the enrollment. 2. Please complete the following: a. Medicaid HIPAA Companion Guide ­ 837 Electronic Claims Input · DO NOT ENTER INFORMATION ON SECTIONS 1, 4, 5, and 6 · Section 2 - Complete the provider or group name, Medicaid provider number, address, phone and contact information. · Section 3 ­ Include the ORIGINAL provider's signature or authorized representative. Date the form. Include the provider number. 3. After completing the agreement, mail the original agreement to: Secure EDI Attn: Enrollment Dept. 200 South Tryon St Suite 1700 Charlotte, NC 28202 NOTES: · Remember to keep a copy for your records. · Do not submit any claims electronically for this payer through Secure EDI until this agreement has been approved.

Contact us at 888-466-9656 or via e-mail [email protected] if you have questions about this enrollment document.

NJMCD ­ ENS ­ 6/2010

Medicaid HIPAA Companion Guide

837 ­ ELECTRONIC CLAIMS INPUT

MEDICAID SECTION 1: FISCAL AGENT USE ONLY PROVIDER #: _______________ SUBMITTER NAME: _________________________________ SUBMITTER #: _____________ AUTHORIZED BY: SECTION 2: PROVIDER 01) Medicaid Provider Name: 03) Street Address: 04) City, State, Zip Code: 05) EDI Contact Person: 07) Fax: (_____) ____________ 09) 2nd EDI Contact Person: SECTION 3: AGREEMENT I certify that the information on these claims will be true, accurate and complete; and agree to keep such records as are necessary to disclose fully the extent of services provided, and to furnish information for such services as the State agency may request; and that the services covered by these claims and the amounts charged will be in accordance with the regulations of the New Jersey Health Services Program; and that no part of the net amount payable under these claims has been paid; and that payment of such amount will be accepted as payment in full without additional charge to the patient or to others on his behalf. 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 I also certify that for each Medicaid service performed and claim submitted for payment, the patient certification will be on file at the provider's location. 11) (Provider's Signature) 14) (Billing Agent's Signature) 15) (Date) 12) (Date) 16) 13) (Medicaid Provider ID)

9903739

ENCOUNTER

CHARITY CARE

DATE:________________

DOCTYPE: EMCAGREE

02) Medicaid Provider Number:

06) Phone/Ext: (_____) ____________ / 08) E-Mail: 10) Phone/Ext: (_____) ____________ /

(Submitter ID)

NOTICE: Anyone who misrepresents or falsifies essential information requested by these claims (or in the electronically produced data) may upon conviction be subject to fine and imprisonment under "State and Federal Law".

SECTION 4: HIPAA TRANSACTION SETS & CERTIFICATION 17) Transaction Sets: 004010X096A1

837 Institutional

Version 4010 Addenda: 004010X097A1 004010X098A1

837 Dental 837 Professional

NCPDP Pharmacy: Version 1.1 Batch Version 5.1 Point of Sale (POS) 19) Certification Attached: Yes No

18) Certification Vendor Name: 20) Requested Effective Date: 21) Claims Input Media: Internet BBS via Modem

CD-ROM

Cartridge

4010A1-PART A

A Electronic Data Interchange August 2009 Version

Medicaid HIPAA Companion Guide

837 ­ ELECTRONIC CLAIMS INPUT - continued

01) Medicaid Provider Name: SECTION 5: SOFTWARE VENDOR 22) Company Name: 23) Street Address: 24) City, State, Zip Code: 25) EDI Contact Person: 27) Fax: (_____) ____________ 29) 2nd EDI Contact Person: SECTION 6: BILLING AGENT 31) Submitter Name: 33) Street Address:

Electronic Network Systems, Inc.

02) Medicaid Provider Number:

26) Phone/Ext: (_____) ____________ / 28) E-Mail: 30) Phone/Ext: (_____) ____________ /

(Unisys would like to know the company name/author of the software you are using to submit claims to Unisys) 32) Medicaid Submitter ID: 9903739

1755 Telstar Dr. Ste. 400 Colorado Springs, CO 80920

367 866 36) Phone/Ext: (_____) ____________ / 9778

38) E-Mail: 40) Phone/Ext: (_____) ____________ /

34) City, State, Zip Code: 35) EDI Contact Person:

877 630-2064 37) Fax: (_____) ____________

39) 2nd EDI Contact Person:

41) 2nd EDI Contact Person E-Mail: (This section should be completed if anyone but the provider is submitting claims to Unisys) *** PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS. *** Return the completed EDI Agreement to Unisys at the following address: Via U.S. Mail Provider Enrollment Unisys P.O. Box 4804 Trenton, New Jersey 08650 - 4804 Other Carriers Provider Enrollment Unisys 3705 Quakerbridge Road, Suite 101 Trenton, New Jersey 08619

For detailed instructions on completing this agreement, please refer to the New Jersey Medicaid HIPAA Companion Guide ­ Section 2.

4010A1-PART B

B Electronic Data Interchange August 2009 Version

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