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Electronic Trading Partner Agreement WHAT FORM(S) SHOULD I (Office Ally)

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WHAT FORM(S) SHOULD I DO?
• Electronic Trading Partner Agreement
WHERE SHOULD I SEND THE FORM(S)?
• Mail original form to:
HMSA
Attn: EDI/HHIN Support-Room 521
PO Box 860
Honolulu, HI 96808-0860
WHAT IS THE TURNAROUND TIME?
• Approximately 5 – 10 business days
HOW DO I CHECK STATUS?
• Call 800-377-4672 and provide them with the provider’s name and HMSA provider ID. Ask if the provider
has been linked to Office Ally’s Submitter ID OFF001.
BLUE CROSS BLUE SHIELD OF HAWAII (HMSA1)
PRE-ENROLLMENT INSTRUCTIONS
Office Ally | P.O. Box 872020 | Vancouver, WA 98687
www.officeally.com
Phone360-975-7000
Fax: 360-896-2151
• Once you receive confirmation that you’ve been linked to Office Ally, you must email
support@officeally.com with
the below information prior to submitting claims electronically.
Email Subject: Blue Cross Blue Shield of Hawaii (HMSA1) - EDI Approval
Body of Email:
Please log my EDI approval for Blue Cross Blue Shield of Hawaii.
o Provider Name
o NPI
Tax ID
o Provider Submitter ID (Example: ABC123)
o
Electronic Trading Partner Agreement (v. 2.05) Rev. 10/2015
ELECTRONIC TRADING PARTNER AGREEMENT
This Agreement is by and between _____________________________________
(“Trading Partner”) and Hawaii Medical Service Association (“HMSA”), and is made
effective on the date last signed below.
RECITALS
WHEREAS, HMSA provides health plan benefits to and provides benefit payments on
behalf of HMSA Members and Trading Partner provides health care services and supplies
to HMSA Members; and
WHEREAS, HMSA has developed electronic data interchange networks and sub
networks, databases, and software, including the Hawaii Healthcare Information Network
and HMSA’s EDI Center (collectively referred to as “Electronic Data Systems”), to
enhance communication of information needed to administer health plans and deliver and
pay for health care services and supplies; and
WHEREAS, HMSA has agreed to offer access to its Electronic Data Systems to Trading
Partner and Trading Partner has elected to access certain Electronic Data Systems offered
by HMSA for purposes of conducting business with HMSA; and
WHEREAS, HMSA and Trading Partner consider their mutual interests to be served by
engaging in the electronic transfer of data as a means of furthering their respective
business objectives; and
WHEREAS, HMSA anticipates that Trading Partner may use, in the performance of this
Agreement, various third party subcontractors in the electronic exchange of such Data;
NOW, THEREFORE, in consideration for the mutual promises herein, the parties agree
as follows:
I. DEFINITIONS
The following terms with initial capitals have these meanings:
1.1 Breach Notification Rule means the Notification in the Case of Breach of
Unsecured Protected Health Information rule, 45 C.F.R. Part 164, Subpart D as
may be amended or modified from time to time.
1.2 Business Associate means a third party organization that is designated by and
contracts with Trading Partner to perform services to facilitate the electronic
transfer of Data or to conduct other business functions with HMSA on behalf of
Trading Partner. Examples of Business Associates include, without limitation,
clearinghouses, billing services, service bureaus, and accounts receivable
management firms.
2
1.3 Companion Guides are the manuals or guides HMSA publishes containing
requirements and instructions for Trading Partner’s automated electronic data
interchange of Data with HMSA.
1.4 Data means formalized representation of specific facts or concepts suitable for
communication, interpretation, or processing. Data may include Protected Health
Information.
1.5 Data Transmission means transfer or exchange of Data, pursuant to the terms and
conditions of this Agreement, between HMSA and Trading Partner or its Business
Associates by means of HMSA’s Electronic Data Systems.
1.5 Electronic Data Systems will have the meaning established in the Recitals to this
Agreement.
1.6 Electronic Media Claims System (“EMC System”) is the Electronic Data System
HMSA maintains to enable users to conduct automated electronic data
interchange transactions, including claims, remittance advice, eligibility
verification, claims status, and other transactions relevant to Trading Partner’s
relationship with HMSA.
1.7 Hawaii Healthcare Information Network (“HHIN”) is the web-based Electronic
Data System HMSA maintains to enable users to gain direct access to HMSA
Data to conduct claims, remittance advice, eligibility verification, claims status,
and other transactions relevant to Trading Partner’s relationship with HMSA.
1.8 HHS means the United States Department of Health and Human Services.
1.9 HMSA Member means a person for whom HMSA processes or administers
claims for health care services or supplies for which a governmental or private
health plan may be responsible to pay.
1.10 Information System means an interconnected set of information resources under
the same direct management control that shares common functionality. A system
normally includes hardware, software, information, Data, applications,
communications, and people. HMSA’s Information System includes the
Electronic Data Systems.
1.11 Privacy Rule means the Privacy of Individually Identifiable Health Information
rule, 45 C.F.R. Part 164, Subpart E as may be amended or modified from time to
time.
1.12 Proprietary Information means information used or created by a party in the
conduct of its business activities that is not normally made available to the party’s
customers, competitors or third parties, the disclosure of which will or may impair
the party’s competitive position or otherwise prejudice its ongoing business.
3
1.13 Protected Health Information has the meaning established in 45 C.F.R. § 160.103,
limited to information that relates to HMSA Members.
1.14 Security Access Code means an alphanumeric code that HMSA assigns to
Trading Partner to allow Trading Partner access to HMSA’s Electronic Data
Systems for the purpose of executing Data Transmissions or otherwise carrying
out this Agreement.
1.15 Security Rule means the Security Standards for the Protection of Electronic
Protected Health Information, 45 C.F.R. Part 164, Subpart C as may be amended
or modified from time to time.
1.16 Standard Identifier means standard unique health identifiers adopted by HHS in
the Transactions Rule, including identifiers for HMSA Members, employer’s (the
Employer Identification Number (EIN)), health plans, and providers (the National
Provider Identifier (NPI)), or, with respect to identifiers not adopted by HHS in
the Transactions Rule, the identifiers HMSA’s Companion Guides require
Trading Partner to use.
1.17 Standard Transaction means an electronic transaction that complies with the
applicable standard and associated operating rules adopted under the Transactions
Rule.
1.18 Transactions Rule means the Standards for Electronic Transactions, 45 C.F.R.
Parts 160 and 162, as may be amended or modified from time to time.
II. OBLIGATIONS OF THE PARTIES
2.1 Mutual Obligations.
(a) Data Transmission Accuracy. The parties shall take reasonable care to
ensure that Data Transmissions are timely, complete, accurate and secure.
Each party shall take reasonable precautions in accordance with Article IV
of this Agreement to prevent unauthorized access to the other party’s
Information System and Data Transmissions.
(b) Information Systems.
(i) Maintenance of Information System. Each party shall obtain and
maintain an Information System that complies with the technical
standards and specifications set forth in the Companion Guides or
separately set forth in writing by HMSA. Each party’s Information
System will include trained personnel, equipment, and software
necessary for timely, complete, accurate and secure Data
Transmission pursuant to this Agreement.
(ii) Cost of Information System. Each party shall obtain and maintain
its Information System at its own expense and shall pay its own
4
costs related to Data Transmissions under this Agreement. Each
party is responsible for its own expenses incurred for translating,
formatting, and sending or receiving Data Transmissions. HMSA
shall not be responsible for the cost of alterations to Trading
Partner’s equipment or software necessary for Trading Partner to
maintain access to HMSA’s Electronic Data Systems.
(c) Transmission Format.
(i) EMC System. With respect to any transaction for which HHS has
established a standard under the Transactions Rule, the parties
shall conduct the transaction as a Standard Transaction. To the
extent not inconsistent with the applicable standard under the
Transactions Rule, the parties shall conduct all such transactions in
accordance with the applicable Companion Guide. With respect to
any transaction for which HHS has not established a standard
pursuant to the Transactions Rule, the parties shall conduct the
transaction in accordance with the applicable Companion Guide.
(ii) HHIN. With respect to all transactions for which HHS has
established a standard under the Transactions Rule, the parties
shall use data content and data conditions, but not the data format,
required in the applicable Standard Transaction.
(d) Lost, Indecipherable, or Misrouted Transmissions. In the event that a
party receives an electronic transaction under this Agreement (i) that the
party cannot process because it is garbled or incomplete, regardless of how
or why the electronic transaction was rendered garbled or incomplete, or
(ii) that is not intended for that party, the party shall immediately notify
the other party and shall immediately delete the electronic transaction and
any copy of the electronic transaction from its Information System.
(e) Standard Identifiers. The parties shall use Standard Identifiers in all Data
Transmissions.
2.2 Trading Partner Obligations.
(a) Access and Use. Trading Partner shall not obtain access by any means to
HMSA’s Data, Data Transmissions, or Electronic Data Systems except as
specifically permitted under this Agreement. Trading Partner shall not
copy, disclose, publish, distribute, alter or use HMSA’s Data or
Proprietary Information for any purpose, except as specifically authorized
under the terms of this Agreement. HMSA grants Trading Partner access
to HMSA’s Electronic Data Systems on the terms and conditions set forth
herein. Trading Partner may use the Electronic Data Systems solely to
conduct electronic transactions with HMSA as permitted by the
Transactions, Security, and Privacy Rules and other applicable law.
5
(b) Security Access Codes and Passwords. Trading Partner shall:
(i) Use Security Access Codes on each Data Transmission as an
electronic signature to authenticate that (1) Trading Partner sent
the transmission and (2) the Data in the transmission are valid.
(ii) Protect and maintain the confidentiality of Security Access Codes
issued to Trading Partner by HMSA.
(iii) Limit disclosure of Security Access Codes to authorized personnel
on a need-to-know basis and apply the restrictions contained in
Article IV of this Agreement to the Codes.
(iv) Promptly request HMSA to terminate Security Access Codes to
which unauthorized personnel, including former employees, have
access.
(v) Trading Partner shall use passwords that:
Contain at least seven characters;
Are different than the previous 4 passwords Trading
Partner has used;
Contain a combination of upper case letters, lower case
letters, numbers, and special characters, such as @, #, $, or
*;
Do not contain easily-guessable elements such as proper
names or nicknames of people or pets, significant dates
such as birthdays or anniversaries, favorite sports teams,
telephone numbers and zip codes or dictionary words in
any language.
(c) Companion Guide. Trading Partner shall comply with all instructions and
requirements set forth in Companion Guide that HMSA makes available to
Trading Partner. Any failure to comply with these requirements shall
constitute a material breach of this Agreement by Trading Partner.
(d) Accuracy of Data. Trading Partner shall ensure the accuracy of all
information provided by Trading Partner or on Trading Partner’s behalf.
Trading Partner shall research and correct any and all billing discrepancies
caused by it or its Business Associate. Trading Partner shall reimburse
HMSA for any and all claims against HMSA resulting from
misrepresentations, discrepancies and errors in any claim, whether
submitted by Trading Partner or its Business Associate.
(e) Duplicate Claims. Trading Partner shall not submit claims for services
that have already been submitted on Trading Partner’s behalf or for which
Trading Partner has already received payment, unless Trading Partner
6
notes in the claim transmission the previous transmission or previous
payment, as applicable.
(f) Change of IP Address. Trading Partners that utilize a site to site VPN
connection shall notify HMSA a minimum of two weeks prior to changing
any IP address.
(g) Genetic Information. Trading Partner shall not include in a Data
Transmission any genetic information. For purposes of this provision,
“genetic information” will include information indicating the
manifestation of a disease or disorder in an individual’s family member.
(h) Privacy and Security Rule Compliance. Trading Partner represents and
warrants that it is either (1) subject to the Privacy and Security Rules as a
“covered entity,” as defined in 45 C.F.R. § 160.103, or (2) the Business
Associate of a “covered entity,” subject to a business associate agreement
that complies with Privacy and Security Rule requirements.
(i) National Provider Identifier. If Trading Partner is a health care provider
as defined in 45 C.F.R. § 160.103, Trading Partner shall, if eligible, obtain
one or more National Provider Identifiers (NPIs) and use the identifiers to
identify itself in all Standard Transactions with HMSA in accordance with
45 C.F.R. Part 162, Subpart D. If Trading Partner is not eligible for an
NPI under 45 C.F.R. Part 162, Subpart D, Trading Partner and HMSA will
agree on an appropriate identifier, which Trading Partner shall use to
identify itself in all Standard Transactions with HMSA.
2.3 HMSA Obligations.
(a) Access to Electronic Data Systems. HMSA shall provide Trading Partner
access to Electronic Data Systems to conduct Data Transmissions.
Trading Partner acknowledges that the Electronic Data Systems may, from
time to time, be inaccessible for a variety of reasons. Notwithstanding
Article 8.5 of this Agreement, HMSA may, at any time and in HMSA’s
sole discretion, terminate Trading Partner’s or any Business Associate’s
access to any or all of HMSA’s Electronic Data Systems.
(b) Security Access Codes. HMSA shall provide Trading Partner Security
Access Codes that will allow Trading Partner access to HMSA’s
Electronic Data Systems. HMSA reserves the right to change Security
Access Codes at any time and in such manner as HMSA, in its sole
discretion, deems necessary.
III. RELATIONSHIPS WITH THIRD PARTIES
3.1 HMSA’s Vendor Obligations. HMSA may contract with one or more vendors to
perform services related to this Agreement. HMSA shall require any such vendor
to comply with the terms of this Agreement.
7
3.2 Trading Partner’s Business Associate Obligations. Trading Partner may contract
with one or more Business Associates to perform services related to this
Agreement, such as billing services or service bureaus. HMSA shall permit
Trading Partner’s Business Associates to use HMSA’s Electronic Data Systems,
provided that:
(a) Completion of Business Associate Authorization. Trading Partner submits
to HMSA for each Business Associate acting on Trading Partner’s behalf
a complete, executed Business Associate Authorization form (Exhibit A of
this Agreement) authorizing HMSA to conduct transactions with Business
Associate as Trading Partner’s representative and designating the
Electronic Data System (or Systems) to which the Business Associate is to
have access; and
(b) Compliance with Terms of Agreement. Trading Partner requires each
Business Associate to comply with the terms of this Agreement.
3.3 Business Associate Authorization. A Business Associate Authorization form (see
Exhibit A) will be effective and incorporated into this Agreement on the date it is
received by HMSA. With respect to any Business Associate that Trading Partner
designates in a Business Associate Authorization, Trading Partner shall notify
HMSA at least fourteen (14) days prior to the date of any material change to (i)
Trading Partner’s relationship with the Business Associate or (ii) the information
in the applicable Business Associate Authorization.
3.4 Unauthorized Changes in Data. Trading Partner shall prohibit Business Associate
from making unauthorized changes to the Data Trading Partner furnishes
Business Associate for submission to HMSA in Data Transmissions.
3.5 Responsibility for Business Associate. Trading Partner shall be liable to HMSA
for its Business Associate’s compliance with provisions of this Agreement and the
accuracy of Data that Business Associate submits to HMSA in claims and other
Data Transmissions.
IV. CONFIDENTIALITY AND SECURITY
4.1 Data Security. Each party shall develop, implement, and maintain safeguards
reasonably necessary to ensure the security of a) Protected Health Information
transmitted or maintained by the party, b) each party’s own Information System,
and c) each party’s records relating to its Information System. Each party shall
maintain adequate policies and procedures to a) prevent unauthorized access to
Data, Data Transmissions, Security Access Codes, backup files, Information
Systems, and HMSA’s Electronic Data Systems; b) assure Data are not
inappropriately modified, deleted, or destroyed; and c) assure the availability of
Data. Each party shall document and keep current its security measures. Each
party’s security measures will include, at a minimum, the safeguards required by
the Security Rule.
8
4.2 Data Breaches.
(a) Breach Notification. Each party shall comply with the requirements of the
Breach Notification Rule with respect to a “breach” (as defined under the
Breach Notification Rule) involving Protected Health Information the
party maintains or transmits. The parties shall cooperate as necessary to
comply with any applicable Hawaii State law relating to a “breach” (as
defined under the State law) involving Protected Health Information.
Trading Partner shall promptly notify HMSA of any infringement of
Security Access Codes or other circumstances that may lead to (or may
have caused) a “breach” (as defined under either applicable State law or
the Breach Notification Rule) of HMSA’s Protected Health Information.
(b) Cooperation. The parties shall cooperate in any investigation of a breach
under this Article 4.2. The parties shall cooperate with each other in the
event of litigation concerning the unlawful or unauthorized disclosure or
use of Protected Health Information or Proprietary Information.
4.3 Confidentiality.
(a) Protected Health Information. Each party shall comply with all federal
and state laws regarding protection, use, and disclosure of Protected
Health Information. Trading Partner shall instruct its employees and
agents, including Business Associates, of the terms and conditions of this
Agreement and Trading Partner’s obligations under the Privacy, Security,
and Breach Notification Rules. Trading Partner shall ensure all employees
and agents, including Business Associates, who access HMSA’s Data,
Data Transmissions, or Electronic Data Systems receive appropriate
Privacy and Security Rule training. Trading Partner shall permit its
employees and agents, including its Business Associates, to access
Protected Health Information only related to those HMSA members who
are (or were) patients of health care providers associated with Trading
Partner.
(b) Proprietary Information. Each party shall treat the other party’s
Proprietary Information obtained or learned in connection with this
Agreement as confidential and shall not use the other party’s Proprietary
Information for its own commercial benefit or any other purpose not
authorized by this Agreement. Each party shall safeguard the other party’s
Proprietary Information against unauthorized disclosure and use.
4.4 Survival. The provisions of this Article IV will survive termination of this
Agreement.
V. RIGHT TO AUDIT
5.1 Right to Audit. HMSA shall have the right, with prior notice, to audit relevant
Trading Partner and Business Associate records, as HMSA deems necessary to
9
ensure compliance with this Agreement. Trading Partner and Business Associate
shall cooperate with such audit and shall provide all information necessary to
verify compliance with the terms and conditions of this Agreement.
5.2 Government Requests for Information. Trading Partner shall notify HMSA
immediately upon Trading Partner’s receipt of any request from a government
authority for information or documents relating to this Agreement, except to the
extent such notification is prohibited by law.
VI. WARRANTIES
6.1 Warranties Regarding Business Associates. Trading Partner warrants that
Business Associate will make no unauthorized changes to the Data that Trading
Partner furnishes Business Associate for submission to HMSA in Data
Transmissions. Trading Partner further warrants that Trading Partner will advise
Business Associate of this Agreement and that Business Associate will comply in
all respects with the terms of this Agreement.
6.2 HMSA Warranties.
(a) Interruption of Service. HMSA specifically disclaims any warranty or
guarantee that Trading Partner’s access to Electronic Data Systems will be
uninterrupted.
(b) Implied Warranties. EXCEPT FOR THE EXPRESS WARRANTIES
SET FORTH IN THIS AGREEMENT, HMSA HEREBY DISCLAIMS
ANY AND ALL OTHER EXPRESS WARRANTIES OF ANY KIND
OR NATURE AND ANY AND ALL IMPLIED WARRANTIES,
INCLUDING BUT NOT LIMITED TO, ANY IMPLIED WARRANTY
OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR
PURPOSE.
VII. RESPONSIBILITY FOR ACTS
7.1 Responsibility for Acts. Each party is responsible for its own actions
7.2 Participation in Actions. HMSA reserves the right, at its option and expense, to
participate in the defense of any suit or action brought against Trading Partner or
its Business Associate arising out of any act or omission in connection with this
Agreement even if Trading Partner or its Business Associate choose not to pursue
a defense.
7.3 Dispute Assistance. Each party shall reasonably cooperate in providing necessary
assistance to the other party when the other party is actively involved in a dispute
with a third party concerning Data Transmissions that either are or reasonably
could be the source of litigation with that third party.
7.4 Limitation of Liability. Neither party shall be liable for any special, incidental,
indirect, exemplary or consequential damages resulting from any claim or cause
10
of action arising out of any delay, omission or error in any Data Transmission or
the other party’s performance or failure to perform in accordance with the terms
of this Agreement, including, without limitation, loss of use, revenues, profits or
savings, even if a party has been advised in advance of the possibility of such
damages.
7.5 Survival. The provisions of this Article VII will survive termination of this
Agreement.
VIII. MISCELLANEOUS
8.1 Amendments. This Agreement, including the provisions of this paragraph, may
not be changed or modified except by an instrument in writing signed by each
party’s authorized representative.
8.2 Severability. The provisions of this Agreement are severable. If any provision of
this Agreement is held or declared to be illegal, invalid or unenforceable, the
remainder of the Agreement will continue in full force and effect as though the
illegal, invalid or unenforceable provision had not been contained in the
Agreement.
8.3 Automatic Amendment for Regulatory Compliance. This Agreement will
automatically amend to comply with any final regulation or amendment to a final
regulation adopted by HHS concerning the subject matter of this Agreement upon
the effective date of the final regulation or amendment.
8.4 Par Agreements Not Affected. This Agreement in no way supersedes or affects
any participating provider agreement between HMSA and Trading Partner. The
Agreement neither supersedes nor affects any provision of an HMSA plan, plan
certificate or brochure outlining the terms and conditions upon which HMSA has
agreed to provide or pay benefits.
8.5 Termination of Agreement. This agreement will be effective until terminated by
either party. Either party may terminate it for any reason upon sixty (60) days’
written notice to the other party.
8.6 Independent parties. Trading Partner acknowledges that this Agreement
constitutes an agreement between Trading Partner and HMSA and that HMSA is
an independent plan operating under a license from the Blue Cross and Blue
Shield Association, an association of independent Blue Cross and Blue Shield
Plans (the “Association”), permitting HMSA to use the Blue Cross and Blue
Shield Service Marks in the State of Hawaii. HMSA is not contracting as the
agent of the Association. Trading Partner further acknowledges and agrees that it
has not entered into this Agreement based upon representations by any person
other than HMSA and that no person, entity, or organization other than HMSA
shall be held accountable or liable to Trading Partner for any of HMSA's
obligations to Trading Partner created under this Agreement.
11
8.7 Arbitration. If any dispute arises between the parties to this Agreement, the
parties shall settle the dispute by binding arbitration in Hawaii. All expenses of
the arbitration including the arbitrator’s fee, the costs of a reporter and transcript
and the fees of an arbitration service, will be shared equally by the parties. Each
party shall pay its own attorney and witness fees. The decision of the arbitrator
shall be binding on both parties and no action may be brought in any court in
connection with this decision except as stated in The Federal Arbitration Act, 9
U.S.C., § 1 et seq.
8.8 Entire Agreement. This Agreement along with the signature page, attachments
and Companion Guides constitute the entire agreement between the parties.
8.9 Copyright. If a third party claims that Trading Partner infringes the third party’s
copyright with respect to Trading Partner’s use of an Electronic Data System,
HMSA shall defend Trading Partner against that claim at HMSA’s expense and
pay all costs, damages, and attorney’s fees that a court finally awards, provided
that (a) Trading Partner promptly notifies HMSA in writing of the claim and (b)
Trading Partner allows HMSA to control and cooperates with HMSA in the
defense of the claim and any settlement negotiations related to the claim. This
provision is HMSA’s entire obligation to Trading Partner regarding any claim of
infringement.
8.10 Trade Marks and Service Marks. Neither party grants to the other the right to use
its trademarks, service marks, trade names, or other designations in any promotion
or publication. Notwithstanding the foregoing, this provision does not affect any
rights HMSA may have under an applicable participating provider (or other)
agreement to use Trading Partner’s name, address and telephone number for the
purposes of communicating to HMSA Members, HMSA’s customers and other
parties in connection with the Trading Partner’s relationship with HMSA.
8.11 Assignment. Neither party may assign or otherwise transfer this Agreement
without the prior written consent of the other party and any attempt to do so is
void.
8.12 Governing Law. Except as otherwise indicated herein, this Agreement will be
governed by the laws of the State of Hawaii without reference to its conflicts or
choice of law provisions.
8.13 Force Majeure. Neither party shall be held liable for failure to fulfill its
obligations under the Agreement, if such failure is caused by flood,
communications failure, extreme weather, fire or other natural calamity, acts of
governmental agency, or similar causes beyond the control of such party.
8.14 No Waiver. Failure or delay on the part of either party to exercise any right,
power, privilege, or remedy hereunder shall not constitute a waiver thereof. No
provision of this Agreement may be waived by either party except by a writing
signed by an authorized representative of the party making the waiver.
12
IX. SIGNATURES
The parties shall be bound by all the terms, provisions and conditions of this Agreement upon
execution of the Agreement by each party’s authorized representative.
Trading Partner
Signature
Name (please print)
Practice Name
Address
City, State, Zip Code
(808)
Telephone
Date
Hawaii Medical Service Association
Signature
David R. Herndon
Name (please print)
Senior Vice President
Title
Date
Electronic Trading Partner Agreement (v2.04) Rev. 8-2015
EXHIBIT A
Business Associate Authorization
In consideration of HMSA permitting the “Business Associate” named below to access HMSA’s
Electronic Data Systems on Provider’s behalf, the Provider named below shall require Business
Associate to comply with the terms of HMSA’s “Electronic Trading Partner Agreement.” In the
event HMSA suffers any loss because of improper or inaccurate transmissions sent by Business
Associate on Provider’s behalf, Provider shall reimburse HMSA for such loss, including any
expense incurred to recover said loss.
The appointment of the below-named Business Associate will remain in effect and may be
conclusively relied upon by HMSA, until Provider or Business Associate cancels the
appointment in writing.
Provider Name:___________________________________________________
Office Address:___________________________________________________
___________________________________________________
City ___________________________________ State _______ Zip Code ___________
Provider Signature: ______________________________ Date:_____________
Check the Electronic Data Systems Business Associate may access on Provider’s behalf:
____ Electronic Media Claims System _____ Hawaii Healthcare Information Network
Business Associate __________________________________
Address __________________________________
_______________________________
City ___________________________________ State _______ Zip Code ___________
Contact___________________________________ Phone_________________________
Please fax this completed form for Business Associates to (808) 948-6008 or mail it to:
HMSA
EDI/HHIN Support – Room 521
P.O. Box 860
Honolulu, HI 96808-0860
Please retain a copy of this document for your records
Notes: 1. This form applies to all HMSA business.
2. You must complete a separate form for each Business Associate doing business with
HMSA, on your behalf.
Office Ally (OFF001)
PO Box 872020
Vancouver
WA
98687
Customer Service
360-975-7000 Option 1
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Electronic Trading Partner Agreement WHAT FORM(S) SHOULD I (Office Ally)

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