Texas > Workers Compensation > Carrier
EDI Trading Partner Profile EDI-01 - Texas
| EDI Trading Partner Profile Form. This is a Texas form and can be used in Carrier Workers Compensation . |
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Texas Department Of Insurance Division of Workers' Compensation Information Management Services 7551 Metro Center Dr. Ste.100 · MS-05 Austin, TX 78744-1609 (888) 489-2667 (512) 490-1039 fax www.tdi.state.tx.us EDI TRADING PARTNER PROFILE IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. By submitting this form, the trading partner agrees to transmit data as required by the Texas EDI Implementation Guides. TO: Receiver Name: Texas Department of Insurance, Division of Workers' Compensation E-mail: TXCOMP.Help@tdi.state.tx.us TRADING PARTNER TYPE* (check all that apply): Insurer (includes self-insurers) Service Co/Third Party Administrator Vendor TRADING PARTNER INFORMATION: Sender Legal Name* (no abbreviations): ________ Sender ID: The Federal Employer Identification Number of your business entity. This, along with your 9-digit Postal Code (Zip+4), will be used to identify a unique trading partner. The Sender FEIN and Postal Code provided below should be the same FEIN and Postal Code that will be sent for the SENDER ID in the Header Record for your EDI transmissions. Sender FEIN*: Postal Code* (9 digits): Customer ID*: Physical Address/Office Location: Address Line 1*: Address Line 2: City*: State*: Postal Code*: Mailing Address/Office Location: (same as above) Address Line 1*: Address Line 2: City*: State*: Postal Code*: Claims EDI Contact Information: Business Contact*: Name: Title: Phone: FAX: E-mail: Technical Contact*: Name: Title: Phone: FAX: E-mail: Medical EDI Contact Information: Business Contact*: Name: Title: Phone: FAX: E-mail: Technical Contact *: Name: Title: Phone: FAX: E-mail: May TDI release your email addresses in response to a public information request? Yes No Note: With few exceptions, you are entitled on request to be informed about the information that TDI collects about you. Under §§552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code, you are entitled to have TDI correct information about you that is incorrect. For more information, contact the TDI Open Records section at (512) 804-4434. DWC-EDI-01 Rev. 12/07 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com EDI TRANSMISSION PROFILE SENDER'S SPECIFICATIONS Transaction Information: Type FROI (148) SROI (A49) Medical (837) Health Plan Claim Matching (251) ANSI or Flat Release/Version ANSI-148 3041 FLAT IA Release 1 ANSI-148 3041 FLAT IA Release 1 ANSI 837 4010; IA Release 1 Jurisdiction Defined Format -- Contained in Implementation Guides Select One Per Type Projected Annual Number of Transactions Transmission Frequencies: Daily (Monday through Friday, excluding holidays) Weekly Specify Day(s): SUN MON TUE WED THU FRI SAT Flat File Record Delimiter (not applicable to Medical/837): Carriage Return Line Feed (CRLF) ANSI Information: Claims EDI (148/A49) Segment Terminator: ~ (tilde) Data Element Separator: * (asterisk) Sub-Element Separator: > (greater than) Medical EDI (837) Segment Terminator: ~ (tilde) Data Element Separator: * (asterisk) Sub-Element Separator: : (colon) Transmission Payments: The Trading Partner is responsible for any transmission costs for all reports being sent to or received by the Texas Department of Insurance. EDI TRANSMISSION PROFILE RECEIVER'S SPECIFICATIONS Receiver Name: Texas Department of Insurance, Division of Workers' Compensation Date: September 2007 Receiver Type: Jurisdiction Receiver ID FEIN: 746000119 Postal Code For Claims EDI (9 digits): 787047491 Postal Code For Other EDI (9 digits): 787441609 Acknowledgement Information: Mode Normal Production (EDI/Paper/None) Response Period Type Functional Detail FROI (148) ANSI 997 ANSI 824/IAIABC AK1 EDI One Business Day SROI (A49) ANSI 997 ANSI 824/IAIABC AK1 EDI Three Business Days Medical (837) ANSI 997 ANSI 824 EDI One Business Day Health Plan Claim Jurisdiction Defined Format -- Contained in EDI One Week Matching (251) Implementation Guides Secure File Transfer Protocol: Web Site Test Production URL: sftpt.tdi.state.tx.us sftpp.tdi.state.tx.us Security Protocol: SFTP, user logon and password SFTP, user logon and password Note: Trading Partners using Value Added Networks must provide the Account Number, User ID Message, and Message Class Code. Flat File Record Delimiter (not applicable to Medical/837): Carriage Return Line Feed (CRLF) ANSI Information: Claims EDI (148/A49) Segment Terminator: ~ (tilde) Data Element Separator: * (asterisk) Sub-Element Separator: > (greater than) Medical EDI (837) Segment Terminator: ~ (tilde) Data Element Separator: * (asterisk) Sub-Element Separator: : (colon) DWC-EDI-01 Rev. 12/07 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com EDI TRADING PARTNER INSURER/CLAIM ADMINISTRATOR ID LIST IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. TO: Receiver Name: Texas Department of Insurance, Division of Workers' Compensation E-mail: TXCOMP.Help@tdi.state.tx.us FROM: Trading Partner*: Sender Legal Name, if different* (no abbreviations): Sender FEIN*: Postal Code* (9 digits): NOTE: The Sender FEIN and Postal Code should be the same as those that your company will use as the SENDER ID in the Header Record for EDI transmissions, and must match information submitted on your "EDI Trading Partner Profile". In the first column of the table below, provide the full Legal Name for all Insurers for which EDI filings will be sent, including self-insurers and intergovernmental risk pools. In the second column, provide each Insurer FEIN. In the third column, provide the Division-assigned Customer Identification Number for each Insurer (the customer ID# can be found in the TXCOMP Organization Profile). If the Carrier Identification Number does not exist, submit the DWC-27 form to Records Management and Support and verify the customer ID # prior to including that carrier on your list). The third column is not required for EDI251 trading partners. This list will be used to reconcile profile identification records. If after filing this form with the Division, any entries are added or removed from the listing, the trading partner shall submit a revised EDI Trading Partner Insurer/Claim Administrator ID List. # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16 18 19 20 Insurer Legal Name* Insurer FEIN* Insurer Customer ID* Use additional page(s) to report more than 20 insurers. DWC-
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