Fill - Free fillable MEDICAID MISSISSIPPI (77032) PRE-ENROLLMENT INSTRUCTIONS (Office Ally) PDF form

• EDI Provider Agreement and Enrollment Form

• ACS EDI Gateway, Inc. Provider Agreement

o The Trading Partner Agreement has been signed by OA, but you will need to insert the date

• Fax the form(s) to (888) 495-8169; OR

• Mail the form(s) to:

Mississippi Medicaid Program

Provider Enrollment

PO Box 23078

Jackson, MS 39225

• Standard processing time is approximately 1-2 weeks

• Call (866) 225-2502 and ask if your Provider Number and/or NPI Number have been linked to Office Ally’s

Submitter ID 90849

• Once you have received notification that you have been linked, you MUST contact Office Ally at (360) 975-

7000 option 1 and notify us of the approval PRIOR to submitting claims electronically

Oﬃce Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000

MEDICAID MISSISSIPPI (77032)

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?

EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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Revised6/24/2014

MSEDIENROLL

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Please complete the following Mississippi Medicaid Provider EDI Enrollment Packet. The package consists of

the Xerox EDI Provider Enrollment Form, Mississippi EDI Provider Agreement and the Xerox EDI Gateway Inc.,

Trading Partner Agreement. Once the package has been completed and signed please return it to the address

above for processing. If you have any questions about the Xerox EDI Provider Enrolment Form or EDI Trading

Partner Agreement, contact the EDI Support Unit at 1-866-225-2502, Monday-Friday 8AM-5PM CST.



Attention!! Effective January 1, 2014, providers will need to submit a separate ERA Enrollment Form

for 835 transactions. This form is available for download or online submission on the MS Medicaid Web

Portal at www.ms-medicaid.com.

Please print or type. Complete all areas of Agreement and Enrollment form, unless otherwise indicated.

EDI PROVIDER ENROLLMENT FORM

Section 1

Application

Type- Please select all that apply



New Submitter

(I would like to become a trading partner with Xerox EDI to submit my claims such as 837.)

New

Retriever

(I would like to become a trading partner with Xerox EDI to retrieve my responses such as 277.)

Change/Correction

(I am a current trading partner with Xerox, I would like to update my current trading partner profile.)

Billing Agent/Clearinghouse Authorization

(I am a provider who will allow a billing agent/clearinghouse to submit and/or

retrieve transactions on my behalf.)



Section 2 Provider

Information

Provider/Business Name

Street Address

City, State, Zip Code

Telephone Fax

Pay-to Provider Number

EIN (Required if your pay-to number is registered as a group provider number with Mississippi Medicaid.)

Email Address

Section 3

Submitter/Trading

Partner ID

Number

If you are currently submitting electronic transactions directly to Xerox

EDI Gateway, Inc., please indicate your Xerox EDI Gateway

Submitter/Trading Partner ID.

(This section is required if you have chosen

application type “change/correction” in section 1.)



EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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Revised6/24/2014

MSEDIENROLL

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Section 4

Individual

Contact

Information-

Please indicate contact if different from Provider Information in

Section 2 (Attach additional sheets if necessary)

Contact Name Contact Title

Street Address

City, State, Zip Code

Telephone Fax

Email address



Section 5

Submission

Method- Please indicate how you plan to submit your electronic transactions to

Medicaid.



Vendor Software

(If you select this option then you are required to complete sections 6 and 11.)



WINASAP5010

(If you select this option then you are required to complete section 10)



Web Portal

(If you select this option then you are required to complete section 12.)



I plan to develop my own software

(If you select this option then you are required to complete sections 7 and 11.)



I plan to use a Billing Agent/Clearinghouse

(If you select this option then you are required to complete sections 8 and 11.)



Section 6 Software Vendor

Information-

If you have indicated that you plan to use the services of a

Software Vendor to submit your transactions electronically to Xerox EDI Gateway, please provide the following

information regarding your agent. Your Software Vendor is required to enroll and receive their own unique

trading partner ID to test with Xerox EDI Gateway. Please indicate your Software Vendor’s Xerox EDI Gateway

trading partner ID. Please contact your Software Vendor for this required information.



Software Vendor Company Name



Contact Name Contact Title



Telephone Fax



Email Address Software Vendor’s Xerox EDI Gateway Trading Partner ID



(required)

EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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Revised6/24/2014

MSEDIENROLL

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Section 7 I plan to develop my own software - If you plan to develop your own software, you must test

your software with Xerox EDI Gateway. Please provide the following information.

Software Name Software Version Protocol



Section 8

Billing Agent/Clearinghouse Information -

If you have indicated that you plan to allow a

Billing Agent/Clearinghouse to submit and/or retrieve transactions electronically with Xerox EDI Gateway

on your behalf, please provide the following information regarding your agent. Your Billing

Agent/Clearinghouse is required to enroll and receive their own unique trading partner ID to test and transmit

with Xerox EDI Gateway. Please indicate your agent’s Xerox EDI Gateway trading partner ID. Please contact

your agent for the required information.

Billing Agent/Clearinghouse Company Name



Contact Name Contact Title



Telephone Fax



Email Address Billing Agent/Clearinghouse Xerox EDI Gateway Trading



Partner ID

(required)



Section 9 Delimiter

Information -

If you are submitting X12N transactions, please provide the following.

(If nothing is entered the default delimiter will be used). (Note: Providers may need to contact their third-

party vendor for this information.)

Element Delimiter to

be used:

Default Delimiter

(asterisk)



Segment Delimiter

to be used:

Default Delimiter

(tilde)



Sub-Element

Delimiter to be used:

Default Delimiter

(colon)



Section 10

Transactions

- WINASAP5010

Request for Software

I will download the WINASAP5010 Software. (www.ms-medicaid.com)



Please mail me a CD-ROM of the software.

X12N 837P (Professional Claim) X12N 837I (Institutional Claim)

X12N 837D (Dental Claim)



Office Ally

Customer Service

360-975-7000 Option 1

360-896-2151

info@officeally.com

EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

Page4of5

Revised6/24/2014

MSEDIENROLL

Section 11

Transactions

- Other than WINASAP5010

X12N 837P (Professional Claim) X12N 270 (Eligibility Inquiry)

X12N 837D (Dental Claim) X12N 276 (Claim Status Inquiry)

X12N 837I (Institutional Claim) X12N 278 (Prior Authorization)

Section 12 Web

Transactions

X12N 837P (Professional Claim-batch only)) X12N 270 (Eligibility Inquiry- batch only)

X12N 837D (Dental Claim-batch only) X12N 276 (Claim Status Inquiry- batch only)

X12N 837I (Institutional Claim- batch only) X12N 278 (Prior Authorization- batch only)

Section 13

Electronic

Response and Report Retrieval for

Provider

Are you

interested

retrieving

your reports and/or

responses electronically?

Yes

If yes, please fill out the appropriate sections below

Reports A

ailable

ia Xerox EDI Gatewa

iDex (Internet Data

Exchang

http://edionline.acs-inc.com/

271 - Eligibility Response 997 - Functional Acknowledgement

(

X12N submissions onl

278 - Prior Authorization Response



277 - Claims Status Response

820 - Premium Payment 824 - Error Report

Section 14

Electronic

Response and Report Retrieval for

Billing

Agent or

Clearinghouse

Do you authorize your

Billing Agent/Clearinghouse

to retrieve your response and/or reports

electronically

your

behalf? Yes

If yes, please fill out the appropriate sections below

Billing Agent/Clearinghouse Company Name (required) Billing Agent/Clearinghouse Xerox EDI Gateway Trading

Partner ID (required)

271 - Eligibility Response 997 - Functional Acknowledgement

(X12N submissions only)

278 - Prior Authorization Response



277 - Claims Status Response

820 - Premium Payment 824 - Error Report

Office Ally

,Inc

EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225



Page5of5



Revised6/24/2014

MSEDIENROLL

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Section 15 Web Portal (Note: You will not be able to receive an X12 response unless you submitted an X12

transaction)

I will retrieve my reports from the web. (Note: Only available if transactions were submitted through the web portal- see

Section 12)

Reports Available via Web

Portal

www.ms-medicaid.com

271 - Eligibility Response 824 - Error Report

278 - Prior Authorization Response 997 - Functional Acknowledgement

(

X12N submissions onl

820 - Premium Payment 277 - Claims Status Response

EDI Provider Agreement and

Enrollment Form

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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Page1of1

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MSDOMTPA

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The following constitutes an Electronic Data Interchange Agreement (“EDI Agreement”) between the Health Care Provider

listed in Section II (“Provider”) and the Mississippi Division of Medicaid (“DOM”) or its designated Fiscal Agent. This EDI

Agreement defines the requirements for Electronic Data Interchange between the Provider and the DOM or its designated

Fiscal Agent. Any references in this EDI Agreement to the submission of electronic transactions, refers to electronically

submitted transactions as chosen by the Provider.



Section I - Terms of

Agr

eement

The Provider agrees to abide by the requirements for Administrative Simplification as defined in the provisions of the

Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) based on the compliance date of the final rules

or a date mutually agreed upon between the Provider and the DOM or its designated Fiscal Agent.



The Provider agrees to abide by the requirements for EDI submissions and submitters as published in the appropriate

DOM Electronic Transactions Submission Manual.



The Provider agrees to send and receive data in a manner that protects the integrity and confidentiality of the transmitted

information according to the relevant provisions of state and federal laws and regulations.



The Provider agrees that if a Billing Agency or Clearinghouse is used for the submission of electronic

transactions, the Billing Agency or Clearinghouse identified in Section III must have a Trading Partner Service Agreement

on file with the DOM or its designated Fiscal Agent.



If using a Billing Agency or Clearinghouse, the Provider agrees to report information accurately and

completely to the Billing Agency or Clearinghouse as required in the Appropriate DOM Electronic

Transactions Submission Manual and agrees to be completely responsible for the electronic transactions generated from

the information submitted to the DOM or its Fiscal Agent by the Billing Agency or Clearinghouse.



If using a Billing Agency or Clearinghouse, the Provider agrees to not use any Billing Agency or Clearinghouse except the

one listed in Section III of this agreement until this EDI Agreement has been terminated in writing to the DOM or its

designated Fiscal Agent.



If using an EDI software vendor for submission of electronic transactions, the Provider agrees to insure that all data meets

the requirements for EDI submissions and submitters as published in the appropriate DOM Electronic Transactions

Submission Manual.



If any information supplied in this EDI Agreement changes at any time during the Provider’s enrollment in the Mississippi

Medicaid program, the Provider agrees to notify the DOM or its designated Fiscal Agent immediately in writing. Failure to

do so may invalidate this EDI Agreement.



Whenever necessary, this EDI Agreement may be amended by mutual consent of the DOM and the Provider to meet

federal or other operational requirements.



The Provider agrees that the EDI Submitter ID is confidential and is not transferable or assignable.

This EDI Agreement is not transferable or assignable and may be terminated on thirty (30) days written notice by either

party.



This EDI Agreement is automatically terminated in the event the Provider’s license is revoked by the

Appropriate Board, the Provider is disqualified through a federal administrative action, or as set forth in Miss.

Code Ann. Section 43-13-121(l) (1972, as amended).



Authorization



I certify that all statements made herein are true and complete to the best of my knowledge.

Authorized Signature Date



Xerox EDI Gateway, Inc. Provider

Agreement

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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XeroxEDITPA

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ACS EDI GATEWAY, INC.

TRADING PARTNER AGREEMENT



THIS TRADING PARTNER AGREEMENT (“Agreement”) is

by and between TRADING PARTNER (“Trading Partner”)

and ACS EDI GATEWAY INC. (“EDI Gateway”) collectively

“the parties”.

WHEREAS, Trading Partner desires to transmit Transactions

to EDI Gateway for the purpose of submitting data to a

Health Plan;

WHEREAS, EDI Gateway desires to receive such

transactions for this purpose recognizing the EDI Gateway

performs such services on behalf of the Health Plan; and

WHEREAS, Trading Partner is subject to the Transaction

and Code Set Regulations with respect to the transmission of

such transactions.

Now, therefore, the Parties agree as follows:

1. Definitions

EDI Gateway means ACS EDI Gateway, Inc.

Trading Partner means the party identified as “Trading

Partner” on the signature line of this Agreement who is a

Health Care Provider or Health Care Clearinghouse as

defined in 45 CFR 160.103.

Standard is defined in 45 CFR 160.103.

Transaction and Code Set Regulations means those

regulations governing the transmission of certain health

claims transactions as published by DHHS under

HIPAA.

2. Obligations of the Parties Effective Upon

Execution of this Agreement by Trading Partner

A) The Parties agree, in regard to any electronic

Transactions between them:

1) They will exchange data electronically using

only those Transaction types as selected by

Trading Partner on the ACS EDI Gateway

Trading Partner Enrollment Form (TPEF).

2) They will exchange data electronically using only

those formats (versions) as specified on the TPEF.

3) They will not change any definition, data

condition, or use of a data element or segment in a

Standard transaction they exchange electronically.

4) They will not add any data elements or

segments to the Maximum Defined Data Set.

5) They will not use any code or data elements that

are not in or are marked as “Not Used” in a

Standard’s implementation specification.

6) They will not change the meaning or intent

a Standard’s implementation

specification.

7) EDI Gateway may reject a Transaction

submitted by Trading Partner if the Transaction

is not submitted using the data elements, formats

or Transaction types set forth in the TPEF. EDI

Gateway may refuse to accept any claims from

Trading Partner if Trading Partner repeatedly

submits Transactions that do not meet the criteria

set forth in TPEF or if Trading Partner repeatedly

submits inaccurate or incomplete Transactions to

EDI Gateway.

B) Trading Partner understands that EDI Gateway or others

may request an exception from the Transaction and Code

Set Regulations from DHHS. If an exception is granted,

Trading Partner will participate fully with EDI Gateway in

the testing, verification, and implementation of the

modification to a Transaction affected by the change.

C) EDI Gateway understands that DHHS may modify the

Transaction and Code Set Regulations. EDI Gateway

will modify, test, verify, and implement all modifications or

changes required by DHHS using a schedule mutually

agreed upon by Trading Partner and EDI Gateway.

D) Neither Trading Partner nor EDI Gateway accepts

responsibility for technical or operational difficulties that

arise out of third party service providers’ business

obligations and requirements that undermine Transaction

exchange between Trading Partner and EDI Gateway.

Xerox EDI Gateway, Inc. Provider

Agreement

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

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Page2of3

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XeroxEDITPA

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E) Trading Partner and EDI Gateway will exercise diligence

in protection of the identity, content, and improper

access of business documents exchanged between the

two parties. Trading Partner and EDI Gateway will make

reasonable efforts to protect the safety and security of

individually assigned identification numbers that are

contained in transmitted business documents and used

to authenticate relationships between the parties.

EDI Gateway may publish data clarifications

(“Xerox EDI Companion Guides”) to complement each

Implementation Guide. Trading Partner should use

Xerox EDI Companion Guides in conjunction with the

HIPAA Implementation Guides available at

http://store.x12.org/store/healthcare-5010- consolidated-

guides.

F) Transactions are considered properly received only

after accessibility is established at the designated

machine of the receiving party. Once transmissions are

properly received, the receiving party will properly

transmit an electronic acknowledgement that

conclusively constitutes evidence of properly received

transactions. Each party shall use commercially

reasonable efforts to ensure that a Virus is not sent to

the other party. Each party agrees that it maintains anti-

virus software on its system, which is updated on a

regular basis. For the purposes of this Agreement,

“Virus” shall mean any "back door", "time bomb", "Trojan

horse", "worm", "drop dead device", "virus", "malicious

logic", software routines, devices, computer codes,

program or hardware components or other

undisclosed feature or file which is designed to permit

unauthorized access to software, hardware or data,

unintentionally or intentionally disrupts, disables, harms,

erases, or otherwise impedes the other party's systems,

or would disable such software or technology."

G) Each party will implement and maintain appropriate

policies and procedures and mechanisms to protect the

confidentiality and security of PHI transmitted between

the parties.

H) The parties acknowledge that any person, who knowingly

and with intent to defraud an insurance company or

other person, files a statement of claim containing

materially false information or conceals, with intent to

mislead, information concerning any fact material to a

statement of claim, commits a fraudulent insurance act,

which may involve violations of civil and/or criminal law.

3. Miscellaneous

A) This Agreement is effective on the date set forth in

Section 3.H, below. This Agreement shall continue

until such time as either party elects to give

reasonable written notice of termination to the other

party or termination of Transaction services provided

by EDI Gateway to Trading Partner, whichever is

earlier.

B) This Agreement incorporates, by reference, any

written agreements between the parties relating to

the subject matter hereof.

C) This Agreement shall be interpreted consistently with

all applicable federal and state privacy laws. In the

event of a conflict between applicable laws, the more

stringent law shall be applied. This Agreement and all

disputes arising from or relating in any way to the

subject matter of this Agreement shall be governed by

and construed in accordance with New York law,

exclusive of conflicts of law principles. THE

EXCLUSIVE JURISDITION FOR ANY LEGAL

PROCEEDING REGARDING THIS AGREEMENT

SHALL BE IN THE COURTS OF THE STATE OF

New York AND THE PARTIES HEREBY

EXPRESSLY SUBMIT TO SUCH JURISDICTION.

D) Unless otherwise prohibited by statute, the parties

agree that this Agreement shall not be affected by

any state’s enactment or adoption of the Uniform

Computer Information Transaction Act, Electronic

Signature or any other state or federal law. Each

party agrees to comply with all other applicable state

and federal laws in carrying out its responsibilities

under this Agreement. This Agreement shall not be

construed as to impute the application of any law

onto a party or require compliance by a party, if

such law does not already apply to or require

compliance by the party, including but not limited to,

the designation of a party as a “covered entity”

under HIPAA if such status does not already apply

under the law.

E) This Agreement is entered into solely between, and

may be enforced only by Trading Partner and EDI

Gateway. This Agreement shall not be deemed to

create any rights in third parties or to create any

obligations of Trading Partner or EDI Gateway to

any third party.

F) NO WARRANTIES, EXPRESS OR IMPLIED, ARE

PROVIDED BY EDI GATEWAY UNDER THIS

AGREEMENT. EDI GATEWAY’S MAXIMUM

AGGREGATE LIABILITY FOR

Xerox EDI Gateway, Inc. Provider

Agreement

Please return to:

Mississippi

Medicaid

Program

Provider Enrollment

P.O. Box 23078

Jackson, Mississippi 39225

Page3of3

XeroxEDITPA

DAMAGES FOR ANY AND ALL CAUSES

WHATSOEVER ARISING OUT OF THIS

AGREEMENT, REGARDLESS OF THE

MANNER IN WHICH CLAIMED OR THE FORM

OF ACTION ALLEGED, IS LIMITED TO THE

AMOUNT(S) PAID TO EDI GATEWAY BY

TRADING PARTNER UNDER THIS

AGREEMENT.

EDI Gateway may provide proprietary software

to Trading Partner to allow Trading Partner to

submit transactions to EDI Gateway. Trad

ing

artner will protect the software as it protects it

wn confidential information, but in no event

shall this protection be less than pursuant to a

reasonable standard, and will not directly

ndirectly, allow access to or the use of th

oftware or any portion thereof, on any computer

erver, or network, by any person, corporation, or

business entity other than Trading Partner.

Trading Partner may permit use of the software by

contractors or agents of Submitter provided that

any such contractor or agents are not competitors

of EDI Gateway and further provided that an

ch persons agree to protect the confidentiality of

the software. Trading Partner and its contra

ctors

d agents are not permitted to use the

software for any purpose other than submitting

Transactions solely to EDI Gateway.

Trading Partner may elect to execute either a

hard copy or an electronic copy of this Agreement.

Har

d Copy Execution: Trading Partner will sign a

hard copy of this Agreement and mail to EDI

Gateway at the address indicated below. EDI

Gateway will return a copy of the fully executed

greement to Trading Partner. The effective da

of the hard copy Agreement is the date on which

e Agreement is signed by EDI Gateway.

Electronic Copy Execution: Trading Partner should

execute this Agreement by clicking on the “I

Agree” button that appears at the bottom of the

greement. The effective date of the electronic

copy agreement is the date EDI Gateway receives

e electronic transmission of Trading Partner’s

Acceptance to the terms of this Agreement.

TRADIN

G PARTNER:

____

______________________________

Signature

__________________________________

Printed Name and Title

__________________________________

Date

ACS EDI GATEWAY, INC.

PO Box 23078

Jackson, MS 39225

Fax: 1-888-495-8169

__________________________________

Signature

__________________________________

Printed Name and Title

__________________________________

Date

Brian O'Neill (CEO - Office Ally)

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