Fillable MEDICAID NEW JERSEY (MCDNJ) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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MEDICAID NEW JERSEY (MCDNJ) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• Submitter/Provider Relationship EDI Agreement
o Instructions can be found on pages 2-6
o This form has to be sent to Office Ally for our signature and date in Section 1, Items 5 and 6
• Electronic Remittance Advice (ERA) EDI Agreement
o Instructions can be found on pages 10-12
o This form can be sent directly to the payer (Office Ally signature not required)
o ONLY REQUIRED IF YOU WANT OFFICE ALLY TO RECEIVE YOUR ELECTRONIC REMITTANCE ADVICE ON YOUR
BEHALF
• Mail the original Submitter/Provider Relationship EDI Agreement to:
Office Ally
P.O. box 872020
Vancouver, WA 98687
o Original signatures (from the provider and Office Ally) are required. Faxed copies are not accepted
o Office Ally will sign the forms and mail them to Medicaid New Jersey
• Mail the original Electronic Remittance Advice (ERA) EDI Agreement to:
Molina Medicaid Solutions
P.O. Box 4804
Trenton, NJ 08650-4804
Attn: EDI Unit
o Original signatures (from the provider) are required. Faxed copies are not accepted
• Standard processing time is 8-10 business days
• Call (609) 588-6051 and ask if you are linked to Office Ally’s Submitter ID 9904204
• You MUST call Office Ally at (360) 975-7000 Option 1 and inform us of the approval PRIOR to submitting
claims electronically
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICAID NEW JERSEY (MCDNJ)
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?
Submitter/Provider EDI Agreement
October 2018 Version
Page 1 of 5
Submitter/Provider Relationship EDI Agreement
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
Technology.
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
EDI–801).
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
proper completion.
Submitter/Provider EDI Agreement
October 2018 Version
Page 2 of 5
Submitter/Provider Relationship EDI Agreement
Agreement
Providers must notify DXC Technology in writing when the use of a billing service for the submission of
electronic claims has been terminated. When a provider changes billing services, the new billing service must
ensure that the provider completes a new EDI Agreement form and submits it to DXC Technology along with
a copy of the HIPAA certification form. DXC Technology will notify the billing service when approval to submit
claims electronically has been granted.
Providers must notify DXC Technology in writing when their use of a software developer’s application for the
direct submission of electronic claims to DXC Technology has been terminated. When a provider changes to
a new software product, the provider must complete a new Submitter/Provider Relationship EDI Agreement
(Form EDI–201) and submit it to DXC Technology along with a copy of the HIPAA certification form. DXC
Technology will notify the provider when approval to submit claims electronically has been granted.
All New Jersey Medicaid HIPAA EDI Agreements MUST be submitted to DXC Technology with ORIGINAL
signatures. Facsimile copies of agreements will NOT be accepted. If the agreement is not properly
completed, DXC Technology will return it for proper completion.
Submitter/Provider Relationship EDI Agreement (Form EDI–201) – Instructions
WHO SHOULD COMPLETE THIS AGREEMENT?
WHAT IF I AM THE PROVIDER AND SUBMIT MY CLAIMS DIRECTLY TO NEW JERSEY MEDICAID?
Providers who are submitting their claims directly to New Jersey Medicaid will need to complete an
agreement for each of their New Jersey Medicaid billing/pay-to provider numbers. In this case, the provider is
considered to serve as both the submitter and the provider. In most cases a provider submitting their claims
directly to New Jersey Medicaid will be submitting claims under a single New Jersey Medicaid billing/pay-to
provider number. However, there are cases where the provider may have been issued multiple New Jersey
Medicaid billing/pay-to provider numbers. When this occurs, a separate agreement is required for each
provider number.
WHAT IF I USE A CLEARINGHOUSE/BILLING SERVICE TO SUBMIT THE CLAIMS TO NEW JERSEY MEDICAID ON MY
BEHALF?
Providers who are submitting their claims to New Jersey Medicaid through a Clearing House/Billing Service
must also execute a Submitter/Provider Relationship EDI Agreement (Form EDI–201) with the Clearing
House/Billing Service and the completed agreement must be returned to the DXC Technology EDI Unit for
processing. A separate agreement is required for each New Jersey Medicaid billing/pay-to provider number.
In this case, the Submitter (or the Clearing House who owns the NJ Submitter ID completes Section 1 of the
agreement and the provider completes Section 2 of the agreement.
Section 3 is to be completed by the provider to identify the software that is being used within the provider’s
office to capture the claims data and to then send that claims data to the Clearing House/Billing Service.
Submitter/Provider EDI Agreement
October 2018 Version
Page 3 of 5
Submitter/Provider Relationship EDI Agreement
Agreement
SECTION 1: SUBMITTER INFORMATION
For the MEDICAID, or CHARITY CARE check boxes located at the top of the form, indicate the type of
claims for which you will be submitting electronic claims. Check one box only. A separate New Jersey
Medicaid HIPAA EDI Agreement is required for each provider number you will be electronically submitting
claims for unless the provider is a group practice and the group is responsible for the billing of the individual
providers associated with the provider group.
1. Submitter Name: Enter the name of the Provider or Clearing House/Billing Service Name as registered
with New Jersey Medicaid/DXC Technology.
2. Submitter ID: Enter the Submitter ID as assigned by DXC Technology.
3. Submitter Street Address: Enter the physical street address of the Provider or Clearing House/Billing
Service. This MUST be a physical address. If a P.O. Box is entered in this area, the document will be
rejected and returned for correction.
4. City, State, Zip Code: Enter the city, state and zip code. This MUST be part of the physical address.
5. Submitter Representative’s Signature: This MUST be an original signature of the Provider or Clearing
House/Billing Service. THIS MAY NOT BE STAMPED. This person should have liability authority of the
business.
6. Date Signed: Date signature was placed on this form.
7. Submitter Representative’s Name: PLEASE PRINT CLEARLY and LEGIBLY the person’s name who signed this
form (Item# 5 above).
8. Submitter Representative Telephone Number/Ext: Enter the phone number along with the extension of a
person from your company in the event DXC Technology needs to contact someone in reference to their
electronic file submission.
9. FAX: Enter the FAX number of your place of business.
10. Submitter Representative Email Address: Enter the email address. PLEASE PRINT CLEARLY. This should be a
business email address. This email address will be entered as part of your Submitter file profile. This email
address will be used to contact someone from your company concerning the electronic file submission or
allow you to submit HIPAA electronic claims.
11. 2
nd
Submitter Contact Person: Enter the name of a person in the event DXC Technology needs to contact
someone from your company. This person’s name will be entered as part of your Submitter file profile.
This person’s name will be used to confirm a provider has been linked to your Submitter ID, preferably
someone in the Enrollment Department who handles the EDI Agreement applications.
12. Phone/Ext: Enter the secondary phone number along with the extension of a person from your company
in the event DXC Technology needs to contact someone.
13. 2
nd
Submitter Contact Person Email Address: Enter the email address. PLEASE PRINT CLEARLY. This should
be a business email address. This email address will be entered as part of your Submitter file profile. This
email address will be entered as part of your Submitter file profile. This email address will be used to
confirm a provider has been linked to your Submitter ID, preferably someone in the Enrollment
Department who handles the EDI Agreement applications.
Submitter/Provider EDI Agreement
October 2018 Version
Page 4 of 5
Submitter/Provider Relationship EDI Agreement
Agreement
SECTION 2: PROVIDER INFORMATION
NOTE: THIS INFORMATION SHOULD ONLY BE THE INFORMATION OF A NEW JERSEY MEDICAID PROVIDER. IF YOU
ARE A SECONDARY BILLING SERVICE, PLEASE ADD A SUPPLEMENTARY SECTION 3 AND PLACE BILLING
SERVICE INFORMATION ONLY IN SECTION 3.
14. Action Requested: Please check appropriate box if you are either adding a new provider number to
be linked to your Submitter ID or terminating an existing provider from your Submitter ID.
15. Provider Name: Enter the BUSINESS name of the provider as they are registered with DXC Technology.
16. New Jersey Medicaid Provider Number: Enter the New Jersey Medicaid Provider number assigned to
the provider by DXC Technology. In the case of a GROUP PRACTICE, the New Jersey Medicaid
provider number assigned to the group practice should be used. If a provider practices as a sole
practitioner, then his individual number may be used.
17. NPI Number: Enter the NPI number of the provider as assigned by NPPES and registered with DXC
Technology.
18. Provider Street Address: Enter the physical street address of the provider’s place of business or service
address as it is registered with DXC Technology. This MUST be a physical address. If a P. O. Box is
entered in this area, the document will be rejected and returned for correction.
19. City, State, Zip Code: Enter the city, state and zip code. This MUST be part of the physical address.
20. Provider EDI Contact Person: Enter the name of a person from the provider's place of business in the
event DXC Technology needs to contact someone at the provider level. (This must be someone at
the provider’s place of business. If a provider chooses to use a secondary billing service, the billing
service information should be place in Section 5.
21. Phone/Ext: Enter the phone number along with the extension of a person from the provider's or place
of business in the event DXC Technology needs to contact someone. This phone number is used to
verify a current phone number is on file for the provider.
22. FAX: Enter the FAX number of the provider's place of business.
23. Email Address: PLEASE PRINT CLEARLY. Enter the email address of a contact person from the
provider's place of business in the event DXC Technology needs to contact someone.
24. Provider Representative’s Signature: This MUST be an actual signature of the New Jersey provider
business owner. THIS MAY NOT BE STAMPED. This person should have liability authority of the business.
25. Date Signed: Date signature was placed on this form.
26. Provider Representative’s Name: PLEASE PRINT CLEARLY and LEGIBLY the person’s name who signed
this form (Item# 24 above).
SECTION 3: PROVIDER SOFTWARE VENDOR INFORMATION
27. SOFTWARE VENDOR NAME: Enter the BUSINESS name of the Software Vendor.
28. STREET ADDRESS: Enter the physical street address of the software vendor. This MUST be a physical
address. If a P. O. Box is entered in this area, the document will be rejected and returned for correction.
29. CITY, STATE, ZIP CODE: Enter the city, state and zip code. This MUST be part of the physical address.
Submitter/Provider EDI Agreement
October 2018 Version
Page 5 of 5
Submitter/Provider Relationship EDI Agreement
Agreement
30. SOFTWARE CONTACT PERSON: Enter the name of a person from the software company in the event DXC
Technology needs to contact someone at the software company.
31. PHONE/EXT: Enter the phone number along with the extension of a person from the software company in
the event DXC Technology needs to contact someone at the software company.
32. SOFTWARE CONTACT PERSON EMAIL ADDRESS: Enter the email address of a contact person from the
software company in the event DXC Technology needs to contact someone at the software company
to correspond with for updates, changes, problems, etc., with software.
33. 2
nd
SOFTWARE CONTACT PERSON: Enter the name of a secondary person from the software company in
the event DXC Technology needs to contact someone at the software company.
34. PHONE/EXT: Enter a secondary phone number along with the extension of a person from the software
company in the event DXC Technology needs to contact someone at the software company.
35. 2
nd
SOFTWARE CONTACT PERSON EMAIL ADDRESS: Enter the email address of a second contact person
from the software company in the event DXC Technology needs to contact someone at the software
company to correspond with for updates, changes, problems, etc., with software.
36. FAX: Enter the FAX number of the software company.
37. SOFTWARE PRODUCT NAME: If a software company has multiple products, please enter the name of the
product you are installing for the submission of the HIPAA transaction sets indicated in Section 3 above.
38. SOFTWARE PRODUCT VERSION/RELEASE NUMBER/NAME: Please enter the release number of the software
product you are installing for submission of the HIPAA transaction sets indicated in Section 3 above.
39. SOFTWARE PRODUCT RELEASE DATE: Please enter the release date of the software product you are
installing for submission of the HIPAA transaction sets indicated in Section 3 above.
Return the completed EDI Agreement to DXC Technology at the following address:
Via U.S. Mail
Other Carriers
EDI UNIT
DXC Technology
P.O. Box 4804
Trenton, New Jersey 08650 – 4804
EDI UNIT
DXC Technology
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619
837-I-D-P
Submitter ID
Submitter & Provider Name
E-RA
SIGN
ADD
Date
QA Initials/Date
Provider Group Number
TERM
EDI-201 Page 1 of 3 Submitter/Provider EDI Agreement
October 2018 Version
MEDICAID CHARITY CARE
SECTION 1: SUBMITTER INFORMATION
1.1 SUBMITTER ID/PROVIDER RELATIONSHIP EDI AGREEMENT
Every EDI submitter assigned a Submitter ID by New Jersey Medicaid must complete, sign and submit this New
Jersey Medicaid Submitter/Provider Relationship Agreement before the submitter is authorized to submit
claims for a New Jersey Medicaid Provider.
In some cases the submitter may be a New Jersey Medicaid provider and in other cases the submitter may be
a third party Clearing House/Billing Service. Regardless, New Jersey Medicaid cannot process claims
submitted with a specific Submitter ID for a specific New Jersey Medicaid provider number unless this
agreement has been properly completed and submitted to New Jersey Medicaid or their designated agent.
By signing this agreement the New Jersey Medicaid provider is authorizing the submitter to submit claims
electronically to New Jersey Medicaid on their behalf.
A separate agreement is required for each New Jersey Medicaid Billing Provider Number.
All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the
Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of
Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards
under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and
amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and
State funds and that any false claims, statements, or documents, or concealment of a material fact, may be
prosecuted under applicable Federal or State laws, or both.
1) Submitter Name:
2) Submitter ID:
3) Submitter Street Address:
(P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the physical street address of
the submitter.)
4) City, State, Zip Code:
5) Submitter Representative's Signature (must be original) 6) Date Signed
7) Submitter Representative's Name – Please Print Clearly
8) Submitter Representative Telephone Number/Ext:
( )
/
9)FAX :
( )
10) Submitter Representative Email Address:
11) 2
nd
Submitter Contact Person:
12) Phone/Ext
( )
/
13) 2nd Submitter Contact Person Email Address:
NOTICE: Anyone who misrepresents or falsifies essential information requested by these claims (or in the electronically
produced data) may upon conviction be subject to fine and imprisonment under “State and Federal Law”.
Submitter/Provider Relationship EDI Agreement
Office Ally
9904204
1300 SE Cardinal Court, Suite 190
Vancouver, WA 98683
Brian O'Neill
support@officeally.com
Customer Service
info@officeally.com
360 975-7000
Opt 1
360 896-2151
360 975-7000
Opt 1
EDI-201 Page 2 of 3 Submitter/Provider EDI Agreement
October 2018 Version
Submitter/Provider Relationship EDI Agreement
Provider Name:
Provider #:
SECTION 2: PROVIDER INFORMATION
All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the
Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of
Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards
under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and
amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and
State funds and that any false claims, statements, or documents, or concealment of a material fact, may be
prosecuted under applicable Federal or State laws, or both.
14) Action Requested: Add New Provider Terminate Existing Provider
15) Provider Name:
16) New Jersey Medicaid Provider Number:
17) Provider NPI Number:
18) Provider Street Address:
(P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the
physical street address of the submitter.)
19) City, State, Zip Code:
20) Provider EDI Contact Person:
21) Phone/Ext:
( )
/
22) FAX:
( )
23) Email Address:
24) Provider Representative's Signature (must be original) 25) Date Signed
26) Provider Representative's Name – Please Print Clearly
NOTICE: Anyone who misrepresents or falsifies essential information requested by these claims (or in the
electronically produced data) may upon conviction be subject to fine and imprisonment under “State and
Federal Law”.
SECTION 3: PROVIDER SOFTWARE VENDOR INFORMATION
This section is to identify the third party software vendor practice management system that the provider is
using to exchange information with their third party billing service. This section may also be repeated if a
secondary billing service is being used in addition to a clearing house.
27) SOFTWARE VENDOR NAME:
28) STREET ADDRESS:
(P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box is listed. This must be the
physical street address of the software vendor.)
Office Ally
1300 SE Cardinal Court, Suite 190
EDI-201 Page 3 of 3 Submitter/Provider EDI Agreement
October 2018 Version
Submitter/Provider Relationship EDI Agreement
Provider Name:
Provider #:
29) CITY, STATE, ZIP CODE:
30) SOFTWARE CONTACT PERSON:
31) PHONE/EXT:
( )
/
32) SOFTWARE CONTACT PERSON EMAIL ADDRESS:
33) 2
nd
SOFTWARE CONTACT PERSON:
34) PHONE/EXT:
( )
/
35) SOFTWARE CONTACT PERSON EMAIL ADDRESS:
36) FAX :
( )
37) SOFTWARE PRODUCT NAME:
38) SOFTWARE PRODUCT VERSION/RELEASE NUMBER/NAME:
39) SOFTWARE PRODUCT RELEASE DATE:
*** PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS. ***
Return the completed EDI Amendment to DXC Technology at the following address:
Via U.S. Mail
Other Carriers
EDI UNIT
DXC Technology
P.O.Box 4804
Trenton, New Jersey 08650 – 4804
EDI UNIT
DXC Technology
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619
Vancouver, WA 98683
Customer Service
info@officeally.com
Payer Support
PayerSupport@officeally.com
Proprietary
N/A
N/A
360 896-2151
360 975-7000
360 975-7000
Opt 1
Opt 1
ERA EDI Agreement
Page 1 of 3 October 2018 Version
Electronic Remittance Advice (ERA) EDI Agreement
Electronic Remittance Advice (ERA) EDI Agreement (Form EDI-801)
All New Jersey Medicaid and Charity Care Providers desiring to receive a HIPAA formatted electronic
remittance advice (ERA) must complete a New Jersey Medicaid Electronic Remittance Advice EDI
Agreement. The New Jersey Medicaid HIPAA EDI Agreements and instructions for their completion are
provided later in this section. The Electronic Remittance Advice EDI Agreement must be prior approved and
on file with DXC Technology before an ERA will be made available to the submitter that has been designated
by the requesting provider. DXC Technology will notify the EDI Submitter of New Jersey Medicaid’s approval
for the submitter to receive the ERA.
Submitters who are currently enrolled with DXC Technology and have been approved to receive a HIPAA
Version 4010 electronic remittance advice and have completed and returned the Addendum for 5010 to
the existing EDI Agreement do NOT have to complete the new Electronic Remittance Advice EDI Agreement.
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: HIPAA 837 Claims EDI
Agreement (Form EDI-101) in order to acquire a Submitter ID number. Any New Jersey Medicaid Provider
Number who wishes to send claims for New Jersey Medicaid must complete the Submitter/Provider
Relationship EDI Agreement (Form EDI–201).
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 either
with the HIPAA 837 Claims EDI Agreement (Form EDI-101) or subsequent to the assignment of the Submitter ID
by DXC Technology.
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.
New Jersey Medicaid and Charity Care providers who are submitting claims through 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
EDI–801).
All New Jersey Medicaid HIPAA EDI Agreements MUST be submitted to DXC Technology with ORIGINAL
signatures. Facsimile copies of agreements will NOT be accepted. If the agreement is not properly
completed, DXC Technology will return it.
ERA EDI Agreement
Page 2 of 3 October 2018 Version
Electronic Remittance Advice (ERA) EDI Agreement
Electronic Remittance Advice EDI Agreement: Instructions
WHO SHOULD COMPLETE THIS AGREEMENT?
If you are a New Jersey Medicaid provider who is not already being provided electronic remittance advice
(ERA) and you now wish to receive electronic remittance advice, you must complete the Electronic
Remittance Advice EDI Agreement (Form EDI-801). You must include the designation of the Submitter ID
under which the electronic remittance advice will be made available. The completed agreement must then
be returned to the DXC Technology EDI Unit for processing. DXC Technology will ONLY allow one entity to
receive your electronic remittance data.
For the MEDICAID, or CHARITY CARE check boxes located at the top of the form, indicate the Provider
Type for which you will receive electronic remittance data for. Check one box only. A separate New Jersey
Medicaid Electronic Remittance Advice EDI Agreement is required for each provider number you will be
electronically receiving remittance advice for unless the provider is a group practice and the group is
responsible for the billing of the individual providers associated with the provider group.
SECTION 1: PROVIDER INFORMATION
1. Action Requested: Please check appropriate box if you are either adding a new provider number to be
linked to your Submitter ID or terminating an existing provider from your Submitter ID.
2. Provider Name: PRINT CLEARLY the BUSINESS name of the provider as they are registered with DXC
Technology.
3. Submitter Name: PRINT CLEARLY the BUSINESS name of the entity to receive the electronic remittance
information.
4. Date: Enter the date you wish to begin receiving the electronic remittance information. NOTE: In many
cases it will be a new software product to be installed, so it may be a date in the future. It is best to install
new software after the weekly submission is sent and processed. We recommend a Monday date.
5. Provider Representative's Signature: This should be the signature of the provider business owner or
someone in the business with liability authority.
6. Date: Date signature was placed on form.
7. Provider Representative's Name: PRINT CLEARLY the person's name who signed this form (item # 6
above).
8. Medicaid Provider ID (GROUP ID): Enter the New Jersey Medicaid Provider Number or Group Provider
Number assigned to the provider by DXC Technology. In the case of a GROUP PRACTICE, the New Jersey
Medicaid provider number assigned to the group practice should be used. If a provider practices as a
sole practitioner, then the provider number assigned to the individual should be used.
9. NPI Number: Enter the NPI number of the Provider as assigned by NPPES and registered with DXC
Technology. Please indicate the GROUP NPI if this is a group practice. If a provider practices as a sole
practitioner, then the NPI for the assigned to the individual should be used.
10. Provider Name: Enter the BUSINESS name of the provider as they are registered with DXC Technology.
11. Provider Street Address: Enter the physical street address of the provider’s place of business or service
address as it is registered with DXC Technology. This MUST be a physical address. If a P. O. Box is entered
in this area, the document will be rejected and returned for correction.
ERA EDI Agreement
Page 3 of 3 October 2018 Version
Electronic Remittance Advice (ERA) EDI Agreement
12. City, State, Zip Code: Enter the city, state and zip code. This MUST be part of the physical address.
13. Provider Contact Person: Enter the name of a person from the provider's place of business in the event
DXC Technology needs to contact someone at the provider level.
14. Phone/Ext: Enter the phone number along with the extension of a person from the provider's or place of
business in the event DXC Technology needs to contact someone.
SECTION 2: RECEIVER INFORMATION
15. Submitter Name: Enter the business name of the Provider/Submitter or Billing Service/Submitter who will
be receiving the 835 Health Care Claim Payment/Advice and 277 Health Care Claim Pending Status Information .
16. Submitter ID: Enter the Submitter ID previously assigned by DXC Technology. Doing so will notify DXC
Technology that the Provider Number entered above is to be linked for electronic remittance
information. If a submitter number has not been assigned, please complete the HIPAA 837 EDI
Agreement (EDI-101).
17. Submitter Address: Enter the physical street address of the Provider or Billing Agent/Service receiving the
electronic remittance information. This MUST be a physical address. If a P. O. Box is entered in this area,
the document will be rejected and returned for correction.
18. City, St., Zip: Enter the city, state and zip code. This MUST be part of the physical address.
19. FAX: Enter the FAX number of your place of business.
20. Submitter Contact Person: Enter the name of a person in the event DXC Technology needs to contact
someone from your company.
21. Phone/Ext: Enter the phone number along with the extension of a person from your company in the
event DXC Technology needs to contact someone.
22. Submitter Email Address: Enter the email address. PLEASE PRINT CLEARLY. This should be a business email
address. This email address will be entered as part of your Submitter file profile and used to communicate
technical problems concerning 835 processing.
23. 2
nd
Submitter Contact Person: Enter the name of a person in the event DXC Technology needs to
contact someone from your company.
24. Phone/Ext: Enter the secondary phone number along with the extension of a person from your company
in the event DXC Technology needs to contact someone.
25. 2
nd
Submitter Contact Person Email Address: Enter the email address. PLEASE PRINT CLEARLY. This should
be a business email address. This email address will be entered as part of your Submitter file profile and
used to acknowledge the processing of the EDI AGREEMENT and confirm your submitter profile has been
updated to allow you to receive 835 Electronic Remittance Advice.
Return the completed EDI Agreement to DXC Technology at the following address:
Via U.S. Mail
Other Carriers
EDI UNIT
DXC Technology
P.O. Box 4804
Trenton, New Jersey 08650 – 4804
EDI UNIT
DXC Technology
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619
837-I-D-P
Submitter ID
Submitter & Provider Name
E-RA
SIGN
ADD
Date
QA Initials/Date
Provider Group Number
TERM
EDI–801 Page 1 of 2 ERA EDI Agreement
October 2018 Version
MEDICAID CHARITY CARE
SECTION 1: PROVIDER INFORMATION
All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the
Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of
Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards
under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and
amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and
State funds and that any false claims, statements, or documents, or concealment of a material fact, may be
prosecuted under applicable Federal or State laws, or both.
1) Action Requested: Add New Provider Terminate Existing Provider
2)
hereby authorize
(Provider Name – Print Clearly)
3)
to receive my
(Submitter Name– Print Clearly) (Entity receiving electronic remittance information)
Electronic remittance advice as of 4) Date: ___/___/____ I understand this electronic remittance advice
contains Patient Health Information (PHI) and have taken the necessary steps with the parties named on this
document to maintain the confidentiality of all PHI data.
5)
6) Date:
(Provider Representative's Signature) Must be original
7) Provider Representative's Name
(Please Print Clearly)
8) Medicaid Provider ID (GROUP ID):
9) NPI (GROUP ID)
10) Provider Name:
11) Provider Street Address:
12) City, State, Zip Code:
13) Provider Contact Person:
14) Phone/Ext:
( )
NOTICE: Anyone who misrepresents or falsifies essential information requested by these claims (or in the electronically
produced data) may upon conviction be subject to fine and imprisonment under “State and Federal Law”.
Electronic Remittance Advice (ERA) EDI Agreement
EDI–801 Page 2 of 2 ERA EDI Agreement
October 2018 Version
Electronic Remittance Advice (ERA) EDI Agreement
Provider Name:
Provider Number:
SECTION 2: RECEIVER INFORMATION
15) Submitter Name:
16) Submitter ID:
17) Submitter Address:
18) City, St., Zip:
19) FAX:
( )
20) Submitter Contact Person:
21) Phone/Ext:
( )
22) Submitter Email Address:
23) 2
nd
Submitter Contact Person:
24) Phone/Ext:
( )
25) 2
nd
Submitter Contact Person Email Address:
NOTICE: Anyone who misrepresents or falsifies essential information requested by these claims (or in the electronically
produced data) may upon conviction be subject to fine and imprisonment under “State and Federal Law”
*** PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS. ***
Return the completed EDI Agreement to DXC Technology at the following address:
Via U.S. Mail
Other Carriers
EDI UNIT
DXC Technology
P.O. Box 4804
Trenton, New Jersey 08650 – 4804
EDI UNIT
DXC Technology
3705 Quakerbridge Road, Suite 101
Trenton, New Jersey 08619
Office Ally
9904204
1300 SE Cardinal Court Ste 190
Vancouver, WA 98683
Customer Service
info@officeally.com
Payer Support
payersupport@officeally.com
360 896-2151
360 975-7000 Opt 1
360 975-7000 Opt 1
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MEDICAID NEW JERSEY (MCDNJ) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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