Montana > Workers Compensation
Electronic Data Interchange Trading Partner Agreement Third Party Administrator Attachment - Montana
| Electronic Data Interchange Trading Partner Agreement Third Party Administrator Attachment Form. This is a Montana form and can be used in Workers Compensation . |
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EDI Trading Partner Agreement - Attachment ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT Third Party Administrator Attachment Third party administrators often send reports to DLI/ERD for several insurers. Please complete the following for each insurer Federal Employer Identification Number (FEIN). Insurance company name: _____________________________________________________ FEIN: ____________________________ Insurance company name: _____________________________________________________ FEIN: ____________________________ Insurance company name: _____________________________________________________ FEIN: ____________________________ Insurance company name: _____________________________________________________ FEIN: ____________________________ Insurance company name: _____________________________________________________ FEIN: ____________________________ <<<<<<<<<********>>>>>>>>>>>>> 2 DLI/ERD Trading Partner Profile Trading Partner Type: Jurisdiction Master Trading Partner Name: State of Montana - Employment Relations Division Master FEIN: 81-0302402 Physical Address: 1805 Prospect Ave City: Helena State: Montana (MT) Postal Code: 59601 Mailing Address: PO Box 8011 City: Helena State: Montana Postal Code: 59604-8011 Contact Information: Business Contact: Technical Contact: D ave Elenbaas M ichelle Wiseman Phone: (406) 444-1574 (406) 444-3343 FAX: (406) 444-4140 (406) 444-4140 E-mail: daelenbaas@state.mt.us mwiseman@ state.mt.us Transmission Profile DLI/ERD Receiver Specifications Receiver Name: State of Montana, Employment Relations Division Master FEIN: 81-0302402 Transaction sets for this profile: Transaction Information Acknowledgement Information Transaction Flat File ANSI Response Level Release Version Period (All/Err/Rejects) 24 Hours, Monday- Friday_ All_________ 148/148 01 3041 A49/148 1A 3041 AK1/824 01 3041 Transmission Frequencies: May transmit Monday through Friday. Electronic Mailbox(s) for this Profile: Ty pe A ccount I D U se r ID Claimport UNICOMMTUNICOMMT N/A IVANS/Advantis WCST WCST014 Celerity AT&T Easylink N/A N/A Workcomp.net As assigned As assigned Health Tech As assigned As assigned Direct Reporting FTP As assigned As assigned <<<<<<<<<********>>>>>>>>>>>>> 3 Flat File Record Delimiter: Carriage return line feed. ANSI Information: Segment Terminator: OA ISA Information: Test /Production Data Elements Separator: * Qualifier: ZZ Sub-Element Separator: > ID: 810302402T or P Acknowledge 824 Transmissions Yes/No Senders Trading Partner Profile Trading Partner Type: __ Montana Adjuster __ Carrier __ Third Party Administrator __ Employer __ Service Bureau Sender Name: _____________________ Senders FEIN: ______ _______________ Senders Postal Code: ______________ Physical Address: ______________________ City: ______________________ State ______________________ Postal Code: ______________________ Mailing Address: ______________________ City: ______________________ State: ______________________ Postal Code: ______________________ Contact Information: Business Contact: Technical Contact: Name: ______________________ ______________________ Title: ______________________ ______________________ Phone: ______________________ ______________________ Fax: ______________________ ______________________ Email: ______________________ ______________________ Transmission Profile Senders Response Receiver Name: State of Montana - Employment Relations Division Master FEIN: 81-0302402 Postal Code: 59604 Trading Partner Type: __ Montana Adjuster __ Carrier __ Third Party Administrator __ Employer __ Service Bureau Sender Name: ________________________________________ Senders FEIN: ____ ________________ Senders Postal Code: ______________ Transaction set for this profile: Transaction Information Transaction Flat File ANSI Release Version 148/148 A49/148 AK1/824 Transmission Frequencies: May transmit Monday through Friday. <<<<<<<<<********>>>>>>>>>>>>> 4 Electronic Mailbox(s) for this Profile: Type A ccount ID U ser ID Claimport UNICOMMTUNICOMMT N/A IVANS/Advantis WCST WCST014 Celerity AT&T Easylink N/A N/A Workcomp.net As assigned As assigned Health Tech As assigned As assigned Direct Reporting FTP As assigned As assigned
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