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Submitter-Provider Relationship EDI Agreement EDI-201 - New Jersey
| Submitter-Provider Relationship EDI Agreement Form. This is a New Jersey form and can be used in Medicaid Management Information System Statewide . |
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For Internal Use Only EMCAGREE DOCTYPE Submitter ID Submitter & Provider Name 837-I-D-P E-RA SIGN ADD Update Initials Date QA Initials/Date Provider Group Number TERM Submitter/Provider Relationship EDI Agreement MEDICAID CHARITY CARE SUBMITTER ID/PROVIDER RELATIONSHIP EDI AGREEMENT SECTION 1: SUBMITTER INFORMATION 8.4 Every EDI submitter assigned a Submitter ID by New Jersey Medicaid must complete, sign and submit this New Jersey Medicaid Submitter/Provider Relationship Agreement before the submitter is authorized to submit claims for a New Jersey Medicaid Provider. In some cases the submitter may be a New Jersey Medicaid provider and in other cases the submitter may be a third party Clearing House/Billing Service. Regardless, New Jersey Medicaid cannot process claims submitted with a specific Submitter ID for a specific New Jersey Medicaid provider number unless this agreement has been properly completed and submitted to New Jersey Medicaid or their designated agent. By signing this agreement the New Jersey Medicaid provider is authorizing the submitter to submit claims electronically to New Jersey Medicaid on their behalf. A separate agreement is required for each New Jersey Medicaid Billing Provider Number. 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. 1) Submitter Name: 3) Submitter Street Address: (P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the physical street address of the submitter). 2) Submitter ID: 4) City, State, Zip Code: 5) Submitter Representative's Signature (must be original) 6) Date Signed 7) Submitter Representative's Name Please Print Clearly 8) Submitter Representative Telephone Number/Ext: ( 10) Submitter Representative Email Address: 11) 2nd Submitter Contact Person: 13) 2nd Submitter Contact Person Email Address: 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". ) / 9) FAX:( ) 12) Phone/Ext ( ) / EDI-201 Page 1 of 3 Page 43 of 245 Trading Partner Agreement January 2013 Version American LegalNet, Inc. www.FormsWorkFlow.com Submitter/Provider Relationship EDI Agreement Provider Name: Provider #: SECTION 2: PROVIDER INFORMATION 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. 14) Action Requested: 15) Provider Name: 16) New Jersey Medicaid Provider Number: 17) Provider NPI Number: 18) Provider Street Address: (P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the physical street address of the submitter). 19) City, State, Zip Code: 20) Provider EDI Contact Person: 22) FAX: ( ) 23) Email Address: 21) Phone/Ext:( ) / Add New Provider Terminate Existing Provider 24) Provider Representative's Signature (must be original) 25) Date Signed 26) Provider Representative's Name Please Print Clearly 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 3: PROVIDER SOFTWARE VENDOR INFORMATION This section is to identify the third party software vendor practice management system that the provider is using to exchange information with their third party billing service. This section may also be repeated if a secondary billing service is being used in addition to a clearing house. 27) SOFTWARE VENDOR NAME: 28) STREET ADDRESS: (P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the physical street address of the software vendor). EDI-201 Page 2 of 3 Page 44 of 245 Trading Partner Agreement January 2013 Version American LegalNet, Inc. www.FormsWorkFlow.com Submitter/Provider Relationship EDI Agreement Provider Name: Provider #: 29) CITY, STATE, ZIP CODE: 30) SOFTWARE CONTACT PERSON: 32) SOFTWARE CONTACT PERSON EMAIL ADDRESS: 33) 2nd SOFTWARE CONTACT PERSON: 35) SOFTWARE CONTACT PERSON EMAIL ADDRESS: 36) FAX: ( ) 34) PHONE/EXT:( ) / 31) PHONE/EXT: ( ) / 37) SOFTWARE PRODUCT NAME: 38) SOFTWARE PRODUCT VERSION/RELEASE NUMBER/NAME: 39) SOFTWARE PRODUCT RELEASE DATE: *** PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS. *** Return the completed EDI Agreement to Molina Medicaid Solutions at the following address: Via U.S. Mail EDI Unit Molina Medicaid Solutions P.O. Box 4804 Trenton, New Jersey 08650 4804 Other Carriers EDI Unit Molina Medicaid Solutions 3705 Quakerbridge Road, Suite 101 Trenton, New Jersey 08619 EDI-201 Page 3 of 3 Page 45 of 245 Trading Partner Agreement January 2013 Version American LegalNet, Inc. www.FormsWorkFlow.com
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