EDI for Entity / Business

Louisiana Medicaid Program
Louisiana Medicaid
Election to Employ
Electronic Data
Interchange (EDI) Form
For Entity/Business
Providers
(Enrollment packet is subject to change without notice)
Revised 01/09
Entity / Business
Louisiana’s Medicaid Program
INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY
ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING
IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM
Prior to submitting electronic claims to Louisiana Medicaid, a seven-digit submit number (450XXXX) must be
obtained from the Molina Medicaid Solutions Provider Enrollment Unit. The submitter number must be linked to
all provider numbers for whom claims will be submitted.
The following form(s) is (are) to be completed if the Entity / Business enrolling at this time plans to submit claims
electronically to Louisiana Medicaid.
EDI Contract
Louisiana Medicaid Provider Number – enter the Louisiana Medicaid provider number for which claims will be
electronically submitted to Molina Medicaid Solutions. (Leave blank if applying for new Provider Number.)
National Provider Identifier (NPI) – enter the NPI of the provider for which claims will be electronically submitted.
Note: Atypical providers leave this blank.
Doing Business As Name of Enrolling Entity – enter the name of the entity / business enrolling or the business
provider name associated with the provider number and NPI listed above.
Name of Contact Person – enter the name of the person designated as the point of contact for questions
regarding this request.
Contact Phone Number – enter the phone number of Contact Person.
Submitter Number – if linking to a submitter who already has a Louisiana Submitter number, then you are required
to enter the Louisiana Medicaid submitter number you want to link to. (Leave blank if applying for a new submitter
number.)
Billing Agent / Submitter Business Name – enter the business name of the billing / submitting agent.
Signature of Authorized Representative – enter the signature of the person authorized to enter into a binding
agreement with Louisiana Medicaid.
Date of Signature – enter the date the authorized representative signed the form.
EDI Power of Attorney
Louisiana Medicaid Provider Number – enter the Louisiana Medicaid provider number for which claims will be
electronically submitted to Molina Medicaid Solutions. (Leave blank if applying for a new Provider Number.)
National Provider Identifier (NPI) – enter the NPI of the provider for which claims will be electronically submitted.
Note: Atypical providers leave this blank.
Doing Business As Name of Enrolling Entity – enter the name of the entity / business enrolling or the business
provider name associated with the provider number and NPI listed above.
Business/Practice Address – enter the address of the provider name entered.
Submitter Number – if linking to a submitter who already has a Louisiana Submitter number, then you are required
to enter the Louisiana Medicaid submitter number you want to link to. (Leave blank if applying for a new submitter
number.)
Billing / Submitter Agent Business Name – enter the business name of the billing / submitter agent.
Billing / Submitter Agent Contact Person – enter the name of the person designated as the point of contact for
the Billing / Submitter Agent business.
Billing / Submitter Agent Phone Number – enter the phone number of the Billing / Submitter Agent contact
person.
Enter the Parish (or County) Name where the Notary Public is located
Enter City, State and Date of Notarization
Signature of Authorized Representative – enter the signature of the person authorized to enter into a binding
agreement with Louisiana Medicaid.
Notary Public Signature – the Notary Public should sign the form and affix his/her seal
**If the provider will be using a Third Party Biller or Clearinghouse, a Limited Power of Attorney MUST be
completed and notarized. Please complete the enclosed Limited Power of Attorney in its entirety to be mailed
with your completed EDI Contract.
Revised 01/09
PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS
FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM
(EDI CONTRACT FOR BUSINESS / ENTITY)
4
Louisiana Medicaid Provider Number (7 digits)
5
0
Submitter Number (7 digits)
(leave blank if applying for new number)
National Provider Identifier (NPI) (10 digits)
DBA Name of Enrolling Business / Entity:
Billing Agent/ Submitter Name / Name of
Business that will be submitting claims
(provider name or third party biller’s name):
Name of Contact Person:
Contact Phone Number:
The Medicaid File can hold a maximum of three Submitter Numbers per Medicaid Provider Number at any one
time. Current policy is to close old Submitter Numbers as new ones are opened unless otherwise requested by
the provider. It is also vital to identify which Submitter Number will be designated to download the Electronic
Remittance Advices (ERA).
In order for Lousiana Medicaid to gather this information, complete the following, if applicable:
When a new Submitter Number is issued, it will be set up to retrieve ERAs. If a previously
assigned Submitter Number is to be used to retrieve ERAs as well, then place it in the spaces
provided below.
4
5
By checking this box you are giving authorization to
have 835s produced for the Individual listed above and
available for download by either this new submitter
number or the previously assigned submitter number.
0
List other Submitter Number(s) that are currently on file which will NOT be used for
835 ERA, but which need to remain open in the spaces below:
4
5
0
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5
0
I am currently enrolled or am requesting enrollment in Louisiana Medicaid and wish to submit my own claims electronically to
Louisiana Medicaid.
I am currently enrolled or am requesting enrollment in Louisiana Medicaid and wish to use a Third Party (Clearinghouse,
Billing Agent, Submitter, etc.) to submit my claims electronically to Louisiana Medicaid. (Power of Attorney form is
required.)
1.
2.
On the date of signature below, the undersigned elects and agrees to submit Louisiana medical assistance claims by
means of the electronic media claims processing method in accordance with Paragraphs 1 through 16 below. This is
done in consideration for the Louisiana Department of Health and Hospitals, Bureau of Health Services Financing's
(hereinafter referred to as "State Agency") processing of provider claims, as well as other valuable considerations.
All published specifications set forth shall be met as to every entry sought to be processed. The effective date for my EDI
submission will be set by Provider Enrollment once the contract has processed.
Entity / Business EDI Contract Page 1 of 2
Revised 01/09
Provider Name:
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The Provider, or his agent, shall be responsible for total compliance with said specifications including 42CFR
447.10 which governs the payment options for Third Party Billers. The Provider's data processing agent for
submission of medical assistance claims is stated above and any changes in the Provider's data processing
agent shall be preceded by 30 days written notice to the State Agency.
The Provider shall provide upon request of the Director of the State Agency any supportive documentation to
ensure that all technical requirements are being met, i.e. program listings, tape or diskette dumps, flow charts,
file descriptions, accounting procedures and the like.
The undersigned Provider shall continue to be ultimately responsible for the accuracy and truthfulness of all
medical assistance claims submitted for payment. Nevertheless, the Provider, if electing a data processing
agent to submit medical assistance claims directly, must give a legal power of attorney to that agent in order
to submit electronic claims and the Annual Certification form . A copy of the said certification statement is
attached and is hereby incorporated by reference into this paragraph.
It is expressly understood that the State Agency or its Fiscal Intermediary (Molina Medicaid Solutions) may
reject an entire submission at any time for failure to comply with the official specifications for submitting claims
on electronic media or for any other reason.
The Provider agrees that this election does not in any way modify the requirements to the Policies and
Procedures applicable to your provider type, except as the claims submission procedures which will be
transmitted in electronic format rather than hardcopy.
The State Agency and the Provider mutually agree that this Agreement may be amended by mutual consent
of the contracting parties. Such amendments must, however, be in writing and must be signed by the
authorized representatives of contracting parties. This Agreement shall not be verbally amended.
The Provider agrees to submit to the State Agency, Fiscal Intermediary or any other authorized agent, upon
request, sufficient documentation to substantiate the scope and nature of services provided for those claims
submitted and for which reimbursement is claimed.
The Provider acknowledges and accepts responsibility for the provisions of Public Law 95-142 pertaining to
fraud.
The Provider and the State Agency agree that each party to this Agreement shall have the right to unilateral
termination of this Agreement upon delivery of written notice of termination upon the other party. The
effective date of such termination shall be 30 days from the receipt of the notice of termination.
Further, for a period of five years, during the course of a federal/state audit or investigation, should
documentation of the existence, nature and scope of the services pertaining to a medical assistance claim be
requested, the Provider shall provide the documentation as requested and produce such for examination and
copying.
The Provider agrees that this election shall be enforced in accordance with the laws of the State of Louisiana
and that this election does not in any way modify the State Agency's limited obligations as set in a certain
Provider Agreement between the State Agency and the Provider.
I attest that all claims submitted under the conditions of this Agreement are certified to be true, accurate and
complete.
I understand that all claims submitted under the conditions of this Agreement will be paid and satisfied from
federal and state funds, and that any falsification or concealment of a material fact, may be prosecuted under
Federal and State laws.
I attest that all information supplied with this Agreement is true, accurate and complete.
Applicable to those receiving 835s: I authorize the Medicaid Fiscal Intermediary to send all HIPAA
required data in the 835 transaction which includes claims information; payment information; and bank
account information, provided by me and currently on file if enrolled in Electronic Funds Transfer, to the
submitter identified above. This authorization will remain in effect until discontinued by written request or
changed by a future request
Print the Name of the Authorized
Representative
Title / Position of Authorized Representative
Signature of Authorized Representative
Date of Signature
Entity / Business EDI Contract Page 2 of 2
Revised 01/09
ENTITY / BUSINESS
MEDICAID ELECTRONIC MEDIA LIMITED POWER OF ATTORNEY
(EDI POWER OF ATTORNEY)
This form is required by all providers who will have electronic claims submitted by a third party.
4
5
0
Submitter Number (7 digits)
(leave blank if applying for new number)
Louisiana Medicaid Provider Number
(7 digits)
National Provider Identifier (NPI) (10 digits)
Billing / Submitter Agent Business Name:
Doing Business As Name of Enrolling Entity
(Provider Name):
Billing / Submitter Agent Contact Person:
Business/Practice Address:
Billing / Submitter Agent Phone Number:
BE IT KNOWN that on this day, BEFORE ME, A Notary Public duly commissioned and qualified
in and for the Parish of
_, State of Louisiana, therein residing:
PERSONALLY CAME AND APPEARED the above named provider, represented herein by the
provider or its duly authorized representative who is of majority and a resident of and domiciled in the
State shown under Provider Address above who declared unto me, Notary, that he does by these
presents, name, constitute and appoint the above named Billing / Submitter Agent, a person or entity
with full legal capacity, to be his true and lawful agent and attorney-in-fact, to execute for him, and in his
name, place and stand, the Louisiana Medical Assistance Program the applicable claims for the
provider type for magnetic tape, diskette, or telecommunication submission of claims processing, the
said appearer further authorizing the said agent to receive all information regarding payments made to
the appearer for such claims, and appearer finally declaring that he or it by these presents does agree
to indemnify and hold harmless the said agent from any and all liability resulting from claims submitted
by the said agent for the said appearer.
THUS DONE AND PASSED BEFORE ME, Notary, in the City of
of
on the
day of
Signature of Authorized Representative
, State
, 20
.
Notary Public Signature
Notary Seal or Notary Identification Number
(required)
Print Name of Authorized Representative
Revised 01/09