Submitter/Provider EDI Agreement
October 2018 Version
Submitter/Provider Relationship EDI Agreement
Submitter/Provider Relationship EDI Agreement (Form EDI-201)
All New Jersey Medicaid and Charity Care Providers desiring to submit HIPAA formatted electronic claims
must complete a New Jersey Medicaid HIPAA 837 Claims EDI Agreement. The various EDI agreements used
by New Jersey Medicaid and the corresponding instructions for their completion are provided later in this
section. The EDI Agreement and HIPAA certification received for the specified HIPAA transaction sets must be
prior approved and on file with DXC Technology before HIPAA formatted claims may be submitted
electronically. DXC Technology will notify the EDI Submitter of New Jersey Medicaid’s approval for the
submission of HIPAA formatted electronic claims.
Submitters who are currently enrolled with DXC Technology for the submission of HIPAA 4010A1 formatted
electronic claims and have completed and returned the Addendum to the existing EDI Agreement along
with a 5010 HIPAA Certification do NOT have to complete the EDI Agreements included in this Companion
Guide. The Addendum Agreement replaces the previously executed EDI Agreement on file with DXC
All other providers/submitters who have not been approved to submit claims electronically with DXC
Technology must complete one of the following New Jersey Medicaid EDI Agreements.
If the provider/submitter intends on submitting the claims directly to New Jersey Medicaid, then the
HIPAA 837 Claims EDI Agreement (Form EDI-101) must be completed and returned to the DXC
Technology EDI Unit. In addition, a copy of the HIPAA certification form certifying their capability to
produce HIPAA compliant transactions must be included as an attachment to the EDI agreement.
Only after the agreement and certification have been received and accepted by the DXC
Technology EDI unit will a Submitter ID be assigned.
A new agreement must be completed when a provider or billing service changes ownership or name
of the company and a new HIPAA Certification is also required to be provided.
It is the responsibility of each submitter to notify the EDI UNIT if there is a change in address, contact
information or email address. Please use the EDI SUBMITTER UPDATE form.
In addition, a completed Submitter/Provider Relationship EDI Agreement (Form EDI–201) for each New
Jersey Medicaid Provider Number under which claims will be submitted needs to be completed and
returned with the HIPAA 837 Claims EDI Agreement (Form EDI-101).
New Jersey Medicaid and Charity Care providers who are submitting claims directly to DXC
Technology that have already been assigned a Submitter ID must complete a Submitter/Provider
Relationship EDI Agreement (Form EDI–201) for each Billing/Pay-to New Jersey Medicaid provider
number they will be billing for.
New Jersey Medicaid and Charity Care providers who are submitting claims through a Clearing
House/Billing Service are required, along with the Clearing House/Billing Service, to complete a
Submitter/Provider Relationship EDI Agreement (Form EDI–201). A separate agreement is required for
each Billing/Pay-to New Jersey Medicaid provider number.
New Jersey Medicaid and Charity Care providers wishing to receive their remittance advice
information electronically must complete the Submitter Electronic Remittance EDI Agreement (Form
Providers using a billing service to submit HIPAA formatted electronic claims must complete the
Submitter/Provider Relationship EDI Agreement (Form EDI–201) along with the billing service. The billing service
is responsible for ensuring that each provider properly completes and submits these agreements to DXC
Technology. If the agreement is not properly completed, it will be returned to the submitter/billing service for