Oregon Medicaid Electronic Data Interchange Trading Partner Agreement
o If additional assistance is needed, click here
for complete enrollment instructions
Oregon DHS requires original signatures for both the Trading Partner (provider) and the EDI Submitter (Office
Ally)
Mail the forms to Office Ally with the original signatures in blue ink. Use the following address:
Office Ally
PO Box 872020
Vancouver, WA 98687
The form must be signed in BLUE ink. Forms with signatures not in BLUE ink will be rejected
Standard processing time is approximately 6-8 weeks
Approximately 6-8 weeks after Medicaid receives your form, they will email/mail you an approval letter
If you have not received a letter within 6-8 weeks, please email Support@officeally.com
and request a status
update (include your NPI/Tax ID when requesting an update)
You may also call (888) 690-9888 and ask if your registration packet has been received and if you have been
approved
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 Oregon (ORDHS) EDI Approval
Body of Email:
Please log my EDI approval for Medicaid Oregon.
Provider Name
NPI
Tax ID
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICAID OREGON (ORDHS)
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?
Oregon Medicaid Electronic Data Interchange Trading Partner Agreement OHA 2080 (Rev 7/17) Page 1 of 2
HEALTH SYSTEMS DIVISION
EDI Support Services
*
Trading Partner’s National Provider Identifier (NPI):
List all taxonomy code(s) registered to this NPI:
List the Oregon Medicaid ID(s) associated with this NPI:
Trading Partner Agreement for Electronic Health Care Transactions
When to complete this form: Trading partners must complete and submit this form to:
Sign up to exchange transactions with the Oregon Health Authority (OHA).
Authorize who will exchange these transactions for you.
Make any changes to trading partner or submitter information on file with OHA.
How to complete this form:
If you need to exchange transactions for more than one NPI, complete a TPA for each NPI.
If you need to exchange transactions for multiple Oregon Medicaid ID numbers, y
ou can use one
TPA but only if all locations need the same transactions.
If you need to authorize more than one clearinghouse/submitter, complete a TPA for each one.
Please type or print clearly. Fill in all required fields designated with an asterisk (*). Incomplete
forms will NOT be processed.
Please maintain a copy for your records.
Mail the completed form to: EDI Support Services, 500 Summer St NE, E44, Salem, OR 97301.
Questions? Email DHS.EDISupport@state.or.us.
This TPA (select one): Fully replaces the current TPA on file. This TPA will end all previous
provider/submitter combinations registered under your Oregon Medicaid ID.
Adds information to the current TPA(s).
ONE
Trading partner information
.
This cannot be a billing service.
*Type (select one): Provider Clinic Coordinated Care or Managed Care Organization
*Business name (as enrolled with OHA):
*
Physical address:
*
City, state and ZIP:
*
Phone number/extension:
TWO
Trading partner authorized signer information
The primary signer signs Part 7 of this form.
*Primary signer’s name:
*Phone number/extension: *Title:
*Email address (direct, not group, email):
Secondary signer’s name:
Phone number/extension: Title:
Email address (direct, not group, email):
THREE
Claims contact information
This contact must be a person, not a group.
*Primary contact’s name:
*Phone number/extension: *Email address:
Secondary contact’s name:
Phone number/extension: *Email address:
FOUR
EDI submitter information
If your company intends to exchange transactions directly with OHA,
enter “Self” as the submitter name, and enter your company’s EDI contact information. If your company
intends to use a submitter/clearinghouse, complete this section for the submitter/clearinghouse.
*
Submitter name:
*
Address:
*
City, state and ZIP:
Submitter mailbox # :
MB000
Office Ally
PO Box 872020
Vancouver, WA 98687
329
Oregon Medicaid Electronic Data Interchange Trading Partner Agreement OHA 2080 (Rev 7/17) Page 2 of 2
FIVE
EDI submitter’s contact information
The Business Contact signs Part 8 of this form. OHA will email
the Technical Contact when transaction testing is needed. Do not enter a billing service contact as the
Technical Contact.
*Business contact’s name:
*Phone number/extension:
*Email address (direct, not group, email):
*
Technical contact’s name:
*
Phone number/extension:
Third contact on reverse (if needed)
*
Email address (direct, not group, email):
SIX
Authorized transactions – Check all transactions that OHA should authorize for your EDI submitter.
HIPAA 5010A1 transactions for: FFS provider or CCO/MCO
005010X222A1 837P
Professional Claim Submission
005010X224A2 837D
Dental Claim Submission
005010X223A2 837I
Institutional Claim Submission
005010X221A1 835
Electronic Remittance Advice
005010X279A1 270 and 271:
Batch
Real
-
time
Eligibility Benefits Inquiry and Response
005010X212 276 and 277
:
Batch
Real
-
time
Claims Status Request and Response
005010X218 820
Group Premium Payments
005010X220A1 834
Benefit Enrollment and Maintenance (CCO/MCO only)
NCPDP
1.2/D.0
Request and Response (B1, B2, B3) (CCO/MCO only)
Pharmacy
Rx Carve-Out File (CCO/MCO only)
Status file
CCO Status File (CCO/MCO only)
SEVEN
Trading Partner signature
By signing below, the Trading Partner certifies the following:
I have read the Electronic Data Transmission Oregon Administrative Rules (Chapter 943,
Division 120) at http://arcweb.sos.state.or.us/pages/rules/oars_900/oar_943/943_120.html, and
understand my responsibilities as stated in these rules.
I authorize OHA to transmit to the EDI Submitter listed in Part 4 of this form the return computer
file electronic vouchers of all transactions I have marked in Part 6 of this form.
*Provider, clinic, CCO or MCO name (from Part 1 of this form): *Email address:
*Authorized trading partner signature: *Phone number/extension:
*Date:
Original signature only, of the Primary Signer listed in Part 2
EIGHT
EDI Submitter signature
By signing below, the EDI Submitter certifies the following:
I have read the Electronic Data Transmission Oregon Administrative Rules (Chapter 943,
Division 120) at http://arcweb.sos.state.or.us/pages/rules/oars_900/oar_943/943_120.html, and
understand my responsibilities as stated in these rules.
I agree to protect the confidentiality of the data as required by law.
*Business contact name (from Part 5 of this form): *Email address:
*Authorized EDI submitter signature: *Phone number/extension:
*Date:
Original signature only, of the Business Contact listed in Part 5
Will Morrow
will.morrow@officeally.com
(360) 975-7000 x6284