Fillable MEDICAID MARYLAND PART B (MCDMD) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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MEDICAID MARYLAND PART B (MCDMD) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• Maryland Medical Care Programs Submitter Identification Form
• Trading Partner Agreement
o Both forms must have original signature. Medicaid Maryland requires both Office Ally’s signature and
the provider’s
• Mail form to:
Office Ally
PO Box 872020
Vancouver, WA 98687
• Office Ally will sign the document(s) and mail them to Medicaid Maryland
o If you would like to track the mailing of your enrollment form (from OA to payer), you may include a
prepaid certified envelope when sending your enrollment to Office Ally
• Standard processing time is 2 weeks
• Send an email to dhmh.hipaaeditest@maryland.gov and include your NPI and Provider Number. In your
email ask if your provider numbers have been linked to Office Ally’s Submitter Number 330897513.
• Once you receive confirmation that you have been linked to Office Ally, you MUST email
Support@officeally.com
with the below information PRIOR to submitting claims electronically.
Email Subject: Medicaid Maryland Part B (MCDMD) – EDI Approval
Body of Email:
Please log my EDI approval for Medicaid Maryland Part B.
o Provider name
o NPI
o Tax ID
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICAID MARYLAND PART B (MCDMD)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
MARYLAND MEDICAL CARE PROGRAMS
SUBMITTER IDENTIFICATION FORM
For Version 005010 HIPAA Transaction Set
Submitter-Identification-Form-005010
Revised: 03/21/2012
Maryland Medicaid needs some EDI information to exchange HIPAA transactions with you. Please provide
the information below. If you are not processing your own EDI transactions, please have your Electronic
Submitter assist you in completing this form, specifically with items #3 and #4.
1. This is a Select Media if New Application:
[ ] New Application [ ] Electronic Transfer & Paper Voucher
[ ] Change of Submitter Agent [ ] Paper Voucher Only
[ ] Submitter Identification Form Update
2. Provider Information
a) Provider Name:
b) Provider Address:
c) Provider Number (must be 9 digits):
d) National Provider Identifier (NPI #)
3. Electronic Submitter Information
a) Submitter Name:
b) Submitter Address:
c) Submitter ID(ISA Qualifier and ISA ID):
4. EDI Information
Please select the transactions that you want to exchange with Maryland Medicaid out of the following
transactions:
CHECK TRANSACTIONS VERSION
270/271 Eligibility Inquiry & Response 005010X279A1
276/277 Claim Status & Response 005010X212
837 Health Care Claim Institutional / 277CA Claim Acknowledgment 005010X223A2 / 005010X214X
837 Health Care Claim Professional / 277CA Claim Acknowledgment 005010X222A1 / 005010X214X
837 Health Care Claim Dental / 277CA Claim Acknowledgment 005010X224A2 / 005010X214X
820 Premium Payment 005010X218
835 Health Care Claim Payment/Advice
835 GS Receiver ID __________________
(Required, if Checked)
Receiver EDI Information (Required if different from above listed Submitter ID
or if you are a Pharmacy Provider or Business Associate requesting an 835):
Receiver Name:
Receiver Address:
ISA Qualifier and ISA ID:
005010X221A1
X
X
Office Ally
PO Box 872020, Vancouver, WA 98687
330897513
330897513
X
MARYLAND MEDICAL CARE PROGRAMS
SUBMITTER IDENTIFICATION FORM
For Version 005010 HIPAA Transaction Set
Submitter-Identification-Form-005010
Revised: 03/21/2012
The provider, ________________________________ hereby authorizes
PROVIDER NAME
___________________________________________________, hereafter
SUBMITTER AGENT
referred to as Submitter Agent, to transmit HIPAA transactions to Maryland Medical Care Program, and
further authorizes Maryland Medical Care Program to transmit to the Submitter Agent the return computer
electronic files of all data processed. The Submitter Agent agrees to protect the confidentiality of this data
as required by law.
______________________________ _____________________________
Signature of Provider Signature of Submitter Agent
______________________________ ______________________________
Print Name of Signature Print Name of Signature
___________________ __________ ___________________ ___________
Telephone Number
Date
Telephone Number Date
Note: This form requires completion of all requested information and original signatures to be
processed.
MAIL TO:
SYSTEMS LIAISON SERVICES
201 W. PRESTON ST., RM SS-18
BALTIMORE, MD 21201
ATTN: HIPAA DESK
For Internal Use Only:
Systems Liaison Services Signature:
Date Received:
360-975-7000
Office Ally
Trading Partner Agreement
Revised: 3/21/12
This Agreement is by and between the Medical Care Program (Medicaid) and
__________________________________. ___________________________________
PROVIDER NAME PROVIDER ADDRESS
__________________________________, hereafter known as the Provider.
CITY, STATE & ZIP CODE
[If applicable] the Provider and Program hereby agree that the Provider may use a
certified clearinghouse (Submitter Agent),
__________________________________. ____________________________________
SUBMITTER AGENT NAME SUBMITTER AGENT ADDRESS
__________________________________, hereafter known as Submitter Agent, to
CITY, STATE & ZIP CODE
transmit HIPAA transactions arising from the Provider’s participation in the Program.
1. Purpose of Agreement- This agreement is intended to facilitate communications
between the Program and the Provider in the processing by the Program of
electronic transactions filed by or on behalf of the Provider.
2. Provider Submission of transactions- The Provider shall submit all data
transmissions pursuant to Program standards. The Provider hereby warrants that
all data will be submitted in compliance with the Program’s regulations,
transmittals, and any provider manual(s) specific to the provider. The Program
reserves the right to modify its regulations, transmittals and other manuals at any
time and to notify Provider of those changes by electronic communication. The
Program reserves the right to reject any transaction which does not conform to its
data submission standards.
3. Program Acceptance of Electronic Transactions
- The Program agrees to accept
valid transactions submitted by the Provider or the Submitter Agent.
4. Cooperation with Testing- During the testing phase, as designated by the
Program, both Program and Provider agree to cooperate with each other, and with
entities performing business associate type functions for the contracting parties,
for the purpose of striving for accuracy, timeliness, security and completeness of
date transmissions.
5. Use of Standard Transactions and Code Set Format- HIPAA regulations, at 45
CFR Part 162 HIPAA Federal Electronic Transactions and Code Sets for Data
Exchange, provide for certain transaction standards for transfer of data between
trading partners. The Provider must submit and the Program will be prepared to
accept, translate, or route HIPAA compliant transactions. As HHS modifies the
standards, the trading partners agree to incorporate by reference any modifications
or changes to 45 CFR Part 162.
Office Ally
PO Box 872020
Vancouver, WA 98687
Trading Partner Agreement
Revised: 3/21/12
6. Prohibited Acts- 45CFR § 162.915 specifies that trading partners will not enter
into an agreement that would: “change the definition, data condition or use of a
data element or segment in a standard; add any data elements or segments to the
maximum defined set; use any code or data elements that are either marked “not
used” in the standard’s implementation specification or are not in the standard’s
implementation specifications(s); or change the meaning or intent of the
standard’s implementations specification(s)”.
7. Expenses- Each party shall bear its own expenses in implementing this process of
transmitting information via this agreement.
8. Confidentiality and Security- Each party shall comply with all HIPAA and State
Security and Confidentiality requirements in the handling of protected health
information and take reasonable precautions to prevent unauthorized access to any
part of the transaction process. In the event that data is improperly sent or
received under this agreement, such data shall be highlighted and disposed of or
returned in an appropriate manner.
9. Provider Identifiers- The parties shall agree on a unique identifier to be used by
Provider. Provider is responsible for disclosing the unique identifier to its agents
and only as is prudent to maintain appropriate security for the identifier.
10. This Trading Partner Agreement may be terminated by the Medical Care Program
at any time.
All other agreements between the Program and Provider remain in full force and effect.
AGREED:
PROVIDER NAME: __________________________________
PROVIDER NUMBER: ___________________
NATIONAL PROVIDER IDENTIFIER (NPI )# ______________________
___________________________________
AUTHORIZED SIGNATURE
DATE: _____________________ Phone # _________________________
RETURN VIA MAIL:
Rita Tate
201 W. Preston St., Rm. LL3
Baltimore, MD 21201
ATTN: HIPAA Billing Agreements
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MEDICAID MARYLAND PART B (MCDMD) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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