Revised 03/2017 Provider Name: ______________________________________________________
Entity/Business EDI Form Page 2
4. 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 LDH.
5. The Provider shall provide upon request of LDH or any authorized agent of LDH any supportive
documentation to ensure that all technical requirements are being met, i.e. program listings, data
submissions, flow charts, file descriptions, accounting procedures, etc.
6. 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 certification statement is attached
and is hereby incorporated by reference into this paragraph.
7. It is expressly understood that LDH 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.
8. The Provider agrees that this election does not in any way modify the requirements to the Policies and
Procedures applicable to their provider type, except as the claims submission procedures which will be
transmitted in electronic format rather than hardcopy.
9. LDH 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.
10. The Provider agrees to submit to LDH, 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.
11. The Provider acknowledges and accepts responsibility for the provisions of Public Law 95-142 pertaining to
12. The Provider and LDH 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.
13. 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 at no cost.
14. 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 LDH's limited obligations as set in a certain Provider
Agreement between LDH and the Provider.
15. I attest that all claims submitted under the conditions of this Agreement are certified to be true, accurate and
16. 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.
17. 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.
Printed Name of Authorized Representative
Signature of Authorized Representative
click to sign
click to edit
click to sign
click to edit