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Medical EDI Compliance Coordinator And Trading Partner Notification EDI-03 - Texas
| Medical EDI Compliance Coordinator And Trading Partner Notification Form. This is a Texas form and can be used in Carrier Workers Compensation . |
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DWC EDI-03 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-5 Austin, TX 78744-1645 (888) 489-2667 phone · (512) 490-1039 fax For TDI-DWC Use Only Medical EDI Compliance Coordinator and Trading Partner Notification (Fax form to TDI-DWC at the number shown above or email to TXCOMP.Help@tdi.state.tx.us) I. INSURANCE CARRIER INFORMATION 1. Insurance Carrier's Name 2. Insurance Carrier's Federal Employer ID Number (FEIN) 3. Insurance Carrier's TXCOMP Customer Number II. MEDICAL ELECTRONIC DATA INTERCHANGE (EDI) COMPLIANCE COORDINATOR INFORMATION In accordance with Rule 134.808, the Medical EDI Compliance Coordinator must be a centrally-located employee of the insurance carrier who has the responsibility for Medical EDI reporting. An employee of another company, including a third party administrator or a trading partner, may not be listed as the Medical EDI Compliance Coordinator. 4. EDI Compliance Coordinator's Name (First, Middle, Last) 5. EDI Compliance Coordinator's Working Title 6. EDI Compliance Coordinator's Mailing Address (Street or PO Box, City State Zip) 7. EDI Compliance Coordinator's Email Address 8. EDI Compliance Coordinator's Telephone Number ( ) 9. EDI Compliance Coordinator's Fax Number ( ) III. TRADING PARTNER ADDITION OR REMOVAL NOTIFICATION 10. Check the appropriate box to add or remove trading partners authorized by the insurance carrier's Medical EDI Compliance Coordinator to submit Medical EDI transactions on behalf of the insurance carrier. The insurance carrier shall report any changes, including the addition or removal of trading partners, within five working days of any amendment to data sharing agreements. Action Effective Date Trading Partner's Name Trading Partner's FEIN Add Add Add Add Add Add Add Add Remove Remove Remove Remove Remove Remove Remove Remove IV. INSURANCE CARRIER AFFIRMATION 11. The undersigned insurance carrier EDI Compliance Coordinator affirms that all trading partners requested to be added have entered into a contract with the insurance carrier to electronically submit and receive EDI transactions on behalf of the insurance carrier. By signing below, the EDI Compliance Coordinator acknowledges that the insurance carrier is responsible for the acts or omissions of its designated trading partners and that the EDI Compliance Coordinator understands the EDI requirements set forth in the Texas Workers' Compensation Act and rules. The EDI Compliance Coordinator affirms that any contract with the trading partner includes provisions that the workers' compensation information involved in EDI transactions remains subject to the confidentiality requirements of Subtitle A, Title 5, Texas Labor Code (Texas Workers' Compensation Act) and that the trading partner shall store all such workers' compensation claim information in a secure environment with all appropriate security and privacy safeguards so as to prevent unauthorized access to or disclosure of the information. __________________________________________________ EDI Compliance Coordinator's Signature __________________________________ Date NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC EDI-03 Rev. 06/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 DWC EDI-03 Frequently Asked Questions Medical Electronic Data Interchange (EDI) Compliance Coordinator And Trading Partner Notification (DWC EDI-03) Does every insurance carrier have to submit the DWC EDI-03 form? Yes. The provisions of 28 TAC §134.808(b) and (c) provide no exemptions to these notification requirements. These requirements apply to all insurance carriers as defined by Texas Labor Code §401.011(27), including an insurance company, a certified self-insurer for workers' compensation, a certified self-insurance group, and a governmental entity that self-insures, either individually or collectively. When does this form need to be filed? Under the provisions of 28 Texas Administrative Code (TAC) §134.808(c), an insurance carrier must submit this information at least five days before sending its first transaction to TDI-DWC. Failure to submit the DWC EDI-03 may result in rejection of medical EDI records and an administrative violation. How do I report a change to information reported on the DWC EDI-03 form? If any information reported on the DWC EDI-03 form changes, including the addition or deletion of a trading partner, you must file a new DWC EDI-03 within five working days. Where do I get the insurance carrier's TXCOMP Customer Number? The insurance carrier's TXCOMP Customer Number can be found using the "Locate Insurance Carrier" function on the TXCOMP automated system located at https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp. This function allows the user to search for the insurance carrier using its name or FEIN. Where do I get the Trading Partner's FEIN? The insurance carrier should request this information from the trading partner during the contract negotiation process. The trading partner's FEIN reported in Section III of this form should match the EDI Sender's FEIN reported to TDI-DWC in Section II, field 3 of the DWC EDI-02, Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile. Questions? If you have questions about this form or need more information about the Medical Electronic Data Interchange (EDI), contact the EDI/TXCOMP Help Desk at TDI-DWC by telephone at 888-4-TXCOMP (888-489-2667) or by email at TXCOMP.Help@tdi.state.tx.us. DWC EDI-03 Rev. 06/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2
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